massive hemoptysis

Specialty: Respiratory.

• massive pulmonary hemorrhage
• large volume lung bleeding

Why it occurs

• Hypertrophic bronchial artery rupture in patients with severe bilateral bronchiectasis (the systemic bronchial circulation handles elevated pressures, resulting in massive bleeding upon rupture)
• Active pulmonary tuberculosis with erosion of the pulmonary artery or Rasmussen aneurysm (aneurysmal dilation of a branch of the pulmonary artery within a tuberculous cavity)
• Intracavitary mycetoma (aspergilloma) that damages the vessels of the cavern wall mechanically and by means of proteolytic enzymes
• Bronchogenic carcinoma with direct aeolian invasion of large caliber pulmonary vessels
• Systemic vasculitis with diffuse alveolar capillaritis (such as granulomatosis with polyangiitis or Goodpasture syndrome).

Initial workup

Immediate cannulation of thick peripheral lines; Urgent chest CT angiography (to locate the bleeding vessel for embolization); Emergency rigid bronchoscopy (allows better control of the airway, isolation of the healthy lung with a Fogarty balloon and aspiration of clots); Blood group and blood cross-matching; Complete coagulation profile (PT, aPTT, INR, platelets).

Standard management

• Tranexamic acid — 10-15 mg/kg slowly intravenously every 8 hours
• Terlipressin — exceptionally prescribed in intensive care units to induce systemic and splanchnic vasoconstriction, closely monitoring coronary perfusion
• Administration of fresh frozen plasma or platelet concentrates if there are severe underlying coagulopathies.