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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.

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