A 67-year-old man who was recently diagnosed with pulmonary tuberculosis and treated with four-drug antituberculous directly observed therapy for the last month presented to the emergency department with hemoptysis.   The patient stated he had small amounts of blood-streaked sputum for the past 2 weeks, but noted that immediately prior to coming to the emergency department he had coughed up approximately “a cup” of bright red blood.  While still in the emergency department, he had a witnessed episode of large volume hemoptysis, estimated to be greater than 250 cc of fresh blood. 

The patient’s past medical history was unremarkable with the exception of longstanding tobacco abuse.  Other than his recent antituberculous therapy he took no regular medications.  He did not regularly use aspirin or other NSAIDs.  He had no history of rash, kidney disease, hematuria, or known autoimmune disease.  Prior to the episodes described above, he had no history of pneumonia or hemoptysis.

The patient smoked one pack of cigarettes per day for the past 45 years.  He did not use alcohol or other recreational drugs.   He emigrated from Ethiopia to the United States 10 years earlier.  The patient was single, living with his brother’s family.   He worked as a carpenter until 2 to 3 months earlier when he became ill.

This man is experiencing massive hemoptysis, variably defined in the literature as hemoptysis resulting in expectorated blood volumes of 200 to 600 ml over a 24 hour period (1).  Although death from hemoptysis is rare, massive hemoptysis represents a life-threatening emergency as blood has the potential to flood the tracheobronchial tree resulting in asphyxiation and respiratory arrest.

The published literature lacks consensus guidelines to assist clinicians in the optimum management of massive hemoptysis.  Despite this, it is generally agreed that the initial care of the patient with massive hemoptysis should be directed towards ensuring adequate ventilation, protection of the unaffected airways and ensuring hemodynamic stability (2).  The patient described above was in clear respiratory distress making immediate intubation and airway control the priority.  Rapid or unrelenting hemoptysis, hemodynamic instability and hypoxemia or severe dyspnea in the setting of supplemental oxygen are all indications for immediate intubation.  Endotracheal tubes with an internal diameter of 8.0 mm or greater should be selected if possible to facilitate future fiberoptic bronchoscopy or other procedures.  If the side of the bleeding is known, the patient should be placed in the lateral decubitus position, with the bleeding side down, to protect the unaffected airways from spillage of blood. 

Selective airway intubation techniques or the use of a double-lumen endotracheal tube may be helpful in the management of massive hemoptysis.  Selective airway intubation involves placing the single-lumen endotracheal tube directly into the right or left mainstem bronchus with the goal of ventilating the nonbleeding lung and simultaneously protecting those airways from blood spillage from the contralateral bleeding lung.  In order for this maneuver to be effective the bleeding site must be known.  The airway anatomy makes selective intubation of the right mainstem bronchus easier compared to the left. However, right mainstem intubation often leads to obstruction of the upper lobe bronchus and resultant lobar collapse.  Substantial experience in this procedure is required. Double-lumen endotracheal tubes, designed for the selective intubation of either the right or left mainstem brochus (3), have also been used to protect the nonbleeding lung from blood spillover.  However, the use of these tubes mandates an experienced operator as numerous drawbacks are described. These include difficulty in placement and ease of misplacement during patient positional changes (4) as well as their smaller intraluminal diameter which could predispose to blood clotting or prohibit the future passage of a bronchoscope. During the acute management of massive hemoptysis both a CT scan and bronchoscopy may localize the site of hemorrhage; however, these options fall secondary to airway control in an unstable patient.  Bronchoscopy carries the additional benefit of having some interventional capability through the placement of a balloon catheter, via direct installation of vasoactive drug in to the bleeding bronchus (epinephrine diluted at 1:20,000), or through electrocautery or cryotherapeutic options.  For these reasons, bronchoscopy should be considered urgently after intubation (2, 5).  Since approximately 90% of all episodes of massive hemoptysis arise from the bronchial artery circulation, bronchial artery angiography and embolization is also a reasonable intervention which could be employed to stop the hemoptysis but this should be considered after the airway is secured.  Finally, patients with massive hemoptysis are at risk of severe hemorrhage and exsanguination, though this is rare.  Immediate transfusion should be considered as an initial measure in any patient who is hemodynamically unstable.

Continuation of the Case:

The patient underwent immediate endotracheal intubation in the emergency department.  A chest radiograph is shown in Figure 1 demonstrating the presence of an endotracheal tube as well as dense opacities mainly present in the right lower and middle lobes.  In addition, there are patchy opacities in the left mid and lower lung zones.  Shortly after intubation, fiberoptic bronchoscopy was performed but was generally unremarkable with the exception of bright red blood in the right middle and lower lobes with slow continued bleeding observed from these areas.