Massive Haemoptysis - management aims
- Protect pulmonary gas exchange – preserve ventilation and oxygenation
- Aggressive resuscitation / Haemodynamic stabilisation
- Identify and treat the source of bleeding
- Correction of any underlying coagulopathy – primary or induced
Optimal patient position
- Bleeding lung placed downwards to protect the non-bleeding lung from blood spillage – limited by the fact that you will normally not know which lung is affected
- If patient awake/ vomiting – encourage sitting up right with continuous suctioning.
Bilateral lung ventilation
- May be unable to tell origin of blood loss, best to ventilate both lungs initially
- Single lumen ETT (largest size able to be passed), or
- Double lumen ETT with proximal cuff inflated - if immediately available in hands skilled in its use.
Unilateral lung ventilation
Identify side of bleeding if possible:
- Determines optimal patient position
- Difficult on clinical examination alone
- Imaging may assist decision making.
There are various strategies mooted for unilateral lung ventilation. Here we present some techniques, which may be helpful in the ED setting:
Single lumen ETT:
- Insert the largest possible, single-lumen ETT into the mainstem bronchus. If this is ventilating the "good" lung, leave it in place and call for expert help and advice.
- If you find that you are ventilating the haemorrhaging lung, pass a foley catheter and inflate it in the main bronchus.
- Place foley down suction port elbow prior to feeding down ETT
- Withdraw the ETT tube to above the carina and ventilate, leaving the foley catheter in place in the mainstem bronchus. Await expert, anaesthetic help.
Double-lumen ETT :
These tubes are not currently recommended for use in massive haemoptysis as the smaller lumens will not pass an adult bronchoscope, this limits the ability to suction blood clots that have spilled into the good lung.
(Usually not available and expertise is limited in the ED. They are either ‘left’ or ‘right’-sided)
- This device has a tracheal tube with short lumen and cuff that sits in the distal trachea and a bronchial tube with longer lumen and cuff
- The bronchial tube generally placed in left main bronchus (to avoid RUL collapse) and can isolate left lung when cuff inflated. Inflation of cuff also protects this lung from blood spillage from contralateral lung.
- Small diameter of each lumen renders them prone to blockage and can present difficulty in passing a bronchoscope with effective-sized suction channel.
Adequate Gas Exchange
- No unique ventilatory strategies.
- Volume replacement – if needs volume, give blood
- Early activation of massive transfusion protocol
- Early and repeated measurement of all paramaters of transfusion (pH, plts, iCa, temp, fibrinogen, Hb, coags)
- High potential for haemodynamic instability if requires urgent intubation.
- Non-surgical: bronchoscopy, arteriography
- Surgical: Lobectomy / pneumonectomy
- Other surgical treatments directed at underlying cause.
Further References and Resources
Davidson K (2020): Managing Massive Hemoptysis: Chest 2020 Jan;157(1):77-88. doi: 10.1016/j.chest.2019.07.012. Epub
Department of anaesthesia and intensive care. Endotracheal tubes [internet]. Fong: Chinese University of Hong Kong; 2009 [cited 2014 Jun 10]. [Figure], Right and left sided double lumen tubes. Available from Chinese University of Hong Kong.
A 10 minute video using a model airway demonstrating how to use a double lumen ETT and standard ETT with a bronchial blocker.