Pulmonary Hemorrhage

Pulmonary Hemorrhage is a topic covered in the Pocket ICU Management.

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First Things First (assess & treat for the following)

  • FIRST: Protect the airway.
    • Any patient with massive hemoptysis should be admitted to a monitored setting.
    • Death from hemoptysis usually results from asphyxiation rather than exsanguination.
    • Intubation: clinical judgment based on volume & rate of bleeding as well as patient’s cardiopulmonary reserves
    • Remember, anatomic dead space only 100-200 ml.
    • Use largest ETT possible (8.0 ETT or larger) to facilitate therapeutic bronchoscopy.
    • Temporizing measures for specific iatrogenic hemorrhage
      • Tracheostomized pt? Apply anterior/downward pressure on tracheal cannula and over-inflate cuff (tracheo-arterial fistula).
      • PA catheter balloon recently inflated? (PA rupture): Withdraw catheter slightly and re-inflate balloon to compress bleeding vessel more proximally.
  • SECOND: Localize/lateralize the site of bleeding with CXR or FOB.
    • Stable vs. unstable pt will alter algorithm.
    • CXR may mislead; fails to localize source in 20-50%.
    • Urgent bronchoscopy for massive hemoptysis
    • Protect non-bleeding lung by positioning patient with bleeding side dependent.
    • Unilateral lung intubation may protect non-bleeding lung.
    • If R-sided source can selectively intubate L lung over bronchoscope
    • If L-sided source can selectively intubate R lung, but risk obstruction of RUL orifice
    • If L-sided source can selectively ventilate R lung by intubating trachea and then occluding LUL bronchus with 14 Fr Fogarty balloon catheter
    • Use double-lumen ETT only if skilled & knowledgeable practitioner is available; serious consequences with poor positioning.
      • Double-lumen ETT will hamper therapeutic bronchoscopy and suctioning due to smaller-diameter lumen.
  • THIRD: Resuscitate, supportive care
    • Supplemental oxygen
    • Volume resuscitation, evaluate need for transfusion
    • Correct coagulopathy
    • Sedation
    • Cough suppression: codeine sulfate
    • Immediate pulmonary & surgical evaluation
    • Rule out pseudohemoptysis.
      • Upper GI bleeding
      • Nasopharynx or oral cavity bleeding
      • Evaluate posterior pharynx & upper larynx.
      • Hematemesis usually dark, frequently acidic, may be mixed with food particles
      • Hemoptysis usually bright red, frothy, alkaline pH
  • FOURTH: Provide definitive and specific treatment (see General Management Principles)
  • FINALLY: Prevent recurrent bleeding.

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Last updated: April 29, 2010