see [Cameron's haemoptysis](x-devonthink-item://10DC3BB1-027C-40D6-BDB3-4AF0C6B160E6?page=340), [Dunn Haemoptysis](x-devonthink-item://74797ACF-C791-4DF1-8EEC-952E42A35053), [Rosen Hemoptysis](x-devonthink-item://FD8AFBA8-ABE3-4B00-8437-27DB46008A93) > [!TLDR] Key Points > **massive haemoptysis** = life threatening by virtue of airway obstruction or blood loss > - 100-1000 mL/day (usually 300-600mL/24 hours) > > **exsanguinating haemoptysis** = >100mL/hour and loss of >1000 mL **Sources of bleeding** - need to exclude bleeding from nasopharynx or [[Upper GI Bleed|GI tract]] (confirm it is NOT haematemesis!) - bleeding from *bronchial arteries* → usual source of massive haemoptysis - alveolar bleeding less commonly causes massive haemoptysis - 400 mL blood in alveolar space enough to inhibit gas exchange, causes asphyxiation rather than exsangination # Causes **Common causes of massive haemoptysis** - [[Bronchiectasis]] - AVM - tracheo inominate fistula (in pts with [[Tracheostomy#tracheostomy complications|tracheostomy]]) - [[Tuberculosis]] → Rasmussen's artery may form in wall of a cavity leading to haemorrhage - lung carcinoma **other infective** - bronchitis → ==most common cause of minor haemoptysis== - lung abscess - aspirgilliosis **Cardiovascular** - [[Pulmonary Embolism]] (massive haemoptysis rare) - [[Valvular disorders#Mitral Stenosis]] - thoracic aortic aneurysm - [[Pulmonary Hypertension]] **immunologic** - [[glomerulonephritis#Goodpasture's syndrome]] - other vasculitis **congenital** - cystic fibrosis **drug-induced alveolar haemorrhage** - anticonvulsants - antiplatlets - immunosuppressants - chemo - [[Amiodarone]] - PTU - others - idiopathic (50%) - infections (22%) - bronchitis - pneumonia - lung abscess - neoplasm (17%) - bronchial carcinoma - mets - pulm oedema (4.2%) - iatrogenic (3.5%) - ==anticoagulant therapy== - lung bx - R heart catheter - post pulm surg - [[Tuberculosis]] (2.7%) - [[Pulmonary Embolism]] (2.6%) - Aspergillosis 1.1% - vasculitis - Vascular malformation (0.2%) - idiopathic pulm haemosiderosis - coagulopathies - septic emboli/[[Endocarditis]] - Trauma - foreign body # Investigations - CXR - CT - sputum (acid fast), TB, etc - CT angio - +/- bronchoscopy # Treatment ## non-massive haemoptysis - usually mild and self-limiting - tx determined by underlying cause - exclude malignancy - usually d/c on abx and follow up as outpatients ## Massive haemoptysis - \<2% of all cases - 50% mortality - bronchial artery embolisation, espeically if bronchial AVM - bronchoscopy for adrenaline + balloon tamponade - surgery for massive haemoptysis after embolisation controlled bleeding or failed IR # Special considerations - when intubating, use largest ETT size possible (blood can occlude smaller tube) - consider selective lung intubation if severe haemoptysis and side of bleeding known - try to aintain some head up position - if hypoxia, position bleeding patient ==bleeding side down== to prevent aspiration into unaffected lung - if shock, can consider bleeding side up to reduce bleeding (more rare, usually not the right answer)