Massive Haemoptysis - investigations
Bloods
Group and hold and VBG (lactate and Hb) – although remember that the initial haemoglobin is unlikely to reflect true Hb in context of ongoing bleeding)
Platelets (full blood count) and coagulation studies, including D dimber and fibrinogen
Other blood unlikely to help acute management but should be performed: LFTs, EUC, CMP, blood cultures if febrile.
In critical bleeding remember to measure and correct the following parameters:
- temperature
- acid-base status
- ionised calcium
- haemoglobin
- platelet count
- PR/INR
- APRR
- fibrinogen.
CXR
Can be normal
May show possible cause or complications(collapse, consolidation, interstitial changes) from bleed or bloody aspiration into lung
Normal CXR does not exclude focal bronchiectasis
Abnormal CXR in 80-90% of people with a neoplasm as cause for haemoptysis
CT
More effectively delineates abnormalities in peripheral airways
Greater sensitivity in detecting bronchiectasis and nodular lesions (e.g. Ca)
Addition of contrast can demonstrate bleeding points, determine underlying pulmonary pathology and can guide anticipated BAE
Patient may not be stable enough for transfer to CT
Strongly consider intubation prior to CT if any concern about ongoing bleeding.
Bronchoscopy
Can have flexible or rigid bronchoscopy, and may be diagnostic or therapeutic
Flexible if stable, rigid if massive haemoptysis (larger suction channel, device placement)
Early bronchoscopy (during or within 48hr of bleeding) has a higher yield for localising site of bleeding than does delayed bronchoscopy.
Bronchoscopy can be used to extract blood clots, place bronchial blockers, balloon occlude bleeding or attain local control)
Thoracic aortography (+/- bronchial artery embolisation)
- 90% of bleeding is from the higher pressure bronchial arteries.