Massive haemoptysis and desaturation - PowerPoint Presentation

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Massive haemoptysis and desaturation

Or how not to panic when it goes red

Dr

Diana Aguilar - February 2017

OverviewBlood supply of the lungsMassive haemoptysis

Definition

Causes

Management options

Complications of bronchoscopy

Prevention of potential complications

Management of bleeding and other complications

1. Blood supply of the lungs

90% of cases of massive

haemoptysis

Bronchial artery

Bronchial vein

Pulmonary vein

Pulmonary artery

Bronchial arteriesThey supplyLungsVisceral pleural

Oesophagus

In chronic inflammation:

E

nlargement and proliferation of bronchial arteries

Recruitment of vessels from the systemic circulation

Thin walled arteries and more likely to rupture

2. Massive haemoptysisNo established definition, 200-600ml in 24 hoursRate more important than volume

Any bleeding

that

impairs

ventilation and

gas

exchange

B

ronchial artery in aprox

. 90% of casesDeath due to

asphyxiation rather than exsanguination Mortality around 20%

, but up to 80%

CausesMassive haemoptysisBronchiectasisBronchogenic carcinoma

Mycetoma

Lung abscess

Tuberculosis

Eroding cavity

Rasmussen Aneurism (PA)

Non-massive

haemoptysis

AVMPE

Pulmonary hypertensionVasculitisTrauma

Mitral stenosisIatrogenic

Goals of managementResuscitation Localisation

Control Monitor

Airway, breathing, circulation

Consider need for intubation and double lumen ETT

Oxygenation

Nurse the patient with bleeding side down (if known)

Cough suppression may help (morphine, codeine)

IV access, clotting, platelets, X-match

Tranexamic acid

Localise the sourceHistory and examination (?epistaxis/?haematemesis) Imaging

CXR can be normal (20-26%) if source proximal

CT

angiography – bronchial artery

Bronchoscopy (50-93% sensitivity) but can be challenging

Safer after

intubation

Large bore suction channelsRigid bronchoscopy

preferred if skills available

Tamponade via balloon catheter (Fogarty)

Double

-

lumen ETT

3

.

Control the bleeding

:

Isolate bleeding side if bleeding threatens other lung

Bronchial artery embolisation

Localise

and control the bleeding

The most effective 70-90%

20% risk of re-bleed

Complications:

Spinal cord

ischaemia

Chest pain

Dysphagia

Case courtesy of Prof O

Hennessy, Radiopaedia.org, rID: 33694

Surgical approachBest approach if embolisation not possible

Spirometry

(<50%) best predictor of surgical risk

Most suitable treatment/curative for:

Localised

bronchiectasis

AVM

Aneurysm

AspergillomaHydatid

cystMortality 20-30%

Future optionsSurgicel/Surgifoam:

Local

tamponade

I

solation

at the segmental or

sub-segmental

bleeding

siteAbsorption of bloodPromotion of endobronchial

clot formation by induction of fibrin polymerization.

Monitor in HDU/ITUConsider palliation: morphine, diazepamIf

all measures fail

If it is inappropriate to resuscitate the patient (

advanced

disease

,

Advance

D

irective, etc)Support and communication with patient, relatives and junior staff, can be a traumatic experience.

3. Complications of bronchoscopyPlanning and prevention:Thorough patient assessment pre-bronchoscopy:Indication: is it appropriate?

If previous bronchoscopy:

Were there complications?

Dose of sedation needed

Consent

Results: clotting, platelets, renal function, FEV1

Medications: anticoagulation,

antiplatelets

Comorbidities: asthma, COPD, DM, BMI,

arrhtyhmiasAvailable personnel and equipment (OOH FOB)

ComplicationsRespiratory depressionBronchoconstrictionHypoventilation

Hypotension

Syncope

Bleeding (severe bleed <1%)

Endobronchial

biopsy: platelets

>

50,000

/μLMore complex procedures, platelets > 75,000/

μL.

Routine

oxygen

and

CVS monitoring

are

essential in alerting of a deterioration

Bleeding during bronchoscopySuctioning Iced saline irrigation

Adrenaline

Bronchoscopic

tamponade

Balloon

tamponade

– Fogarty balloon

Thrombin or fibrinogen instillationLaser coagulation

Argon plasma coagulator (APC)Electrocautery

Double-lumen ETT tube

Other complicationsHypoxia: usually resolves with oxygenation and termination of the procedure.Brochosconstriction

may require termination of procedure

Respiratory depression, consider need for:

NIV rescue

Flumazenil (should be a “Never event”, so cautious sedation in at risk patients)

Syncope:

standard

observations, ECG, BMs,

etc

SummaryMassive haemoptysis is a medical emergencyStep-wise approach:

Resuscitation

Localisation

Control

Monitor

Team work to help you:

* A&E * Radiology

* ITU * Experienced anesthetist* Endoscopy team * Thoracic surgeons* Palliative care

Thorough preparation pre-bronchoscopyRespiratory Spr saves the day!

The patient & You

When it goes fromthis…. to this… to this…