The management of hemoptysis depends on the rate of bleeding and the underlying cardiopulmonary status of the patient. In a few cases, bleeding into the airway may be brisk, having the potential to be fatal within minutes. Patients may succumb rapidly, not from exsanguination and shock, but from drowning and asphyxiation. Selecting the appropriate therapeutic maneuvers to institute from the outset requires sound clinical judgment and skill. Practicing the basic maneuvers during training sessions increases the probability of successful management of the airway in the face of massive hemoptysis if the bleeding site is known.
In the face of catastrophic massive hemoptysis, the patient should be positioned with the bleeding lung in a dependent position to protect the normal lung. Once the patient is intubated, the bronchoscope is advanced into the airway in an attempt to keep at least one side of the airway patent and free from occluding clots. In all cases, bronchoscopy is central to the management of these patients. If visualization is completely obscured by blood, the bronchoscope should be passed toward the side opposite from the presumed bleeding. Once passed down to the distal airway, the flexible bronchoscope can serve as a stylet to guide the tip of the ET beyond the carina and to selectively intubate the mainstem bronchus of the nonbleeding lung. The balloon on the ET occludes the unaffected mainstem bronchus, preventing blood from entering the distal airway. In this way, the surgeon establishes control of the patient's airway and breathing. The next step is to support the circulation with IV access and transfused blood as needed.
After the acute situation has been controlled, the patient should be transferred to the OR for additional evaluation and clearance of the airway to the bleeding lung. Once the site of bleeding has been identified, it often can be controlled by suction and clearing of the secretions alone, administration of iced saline lavage through the bronchoscope, or installation of vasoconstrictive agents such as dilute epinephrine. Distal sources of bleeding may require forced installation of saline to dilate the bronchi and permit better visualization or the use of an ultrathin bronchoscope to reach subsegmental bronchi. Bleeding of distal sources also can be controlled by bronchoscopic packing of the distal airway using Surgicel (Ethicon, Inc., a Johnson and Johnson Company, Piscataway, NJ). This is performed by extending the bronchoscopic forceps out of the instrument port and grasping a 2 × 2 cm2 of Surgicel before inserting the bronchoscope into the ET. The Surgicel is then guided into the bleeding airway by the biopsy forceps and held in position.11 Once the bleeding has subsided, obvious abnormalities of the airway can be specifically addressed. Laser coagulation, electrocautery, fibrin glue, or foam tamponade can also be used to achieve emergent hemostasis in the airway.
Once the acute bleeding has been stopped, a rigid bronchoscope is used to clear the airway, provide a conduit for ventilation, and tamponade the source of bleeding. If the bleeding does not stop and the side of origin is known, single-lumen unilateral intubation on the unaffected side alone or in combination with a bronchial blocker to tamponade the bleeding is critical. If the bleeding side cannot be localized because the bleeding is too brisk or visualization is impaired, a double-lumen tube with endobronchial tamponade is a reasonable alternative.
After the patient has been adequately resuscitated, multidetector CT angiography is indicated.12 This technique provides thin-slice images and multiplanar reconstruction of the vessels and bleeding source. Then, interventional radiologists can perform catheter angiography and selective embolization of a bleeding vessel more expeditiously and accurately. Selective embolization has been applied successfully in 79% to 85% of patients at 1 month; however, the recurrence rate is 20% to 33%.13,14 External beam radiotherapy or bronchoscopic brachytherapy can be added to reduce the risk of recurrent bleeding once the diagnosis of cancer has been established. The specific technique chosen to control bleeding will depend on the lesion causing the hemoptysis, the availability of the technique, and the expertise of the operating surgeon.