83: Management of Hemoptysis in Lung Cancer

Lung cancer is a silent killer. Symptoms are present in only approximately 40% of patients in a population screened for lung cancer who have radiographic changes.¹ Even in those patients with symptoms, these are usually nonspecific, and clues to the existence of an underlying lung cancer may be gleaned only from the patient's history. A history of long-standing cigarette smoking, age greater than 40 years, significant weight loss, and a chronic cough are clinical pointers worth noting.

Although some degree of hemoptysis may be the presenting complaint in 29% of patients with lung cancer, the degree of hemoptysis varies considerably.² Most commonly, patients report a discrete episode of blood-streaked sputum at least once before seeing a physician. Often this is attributed to chronic bronchitis, especially in the face of a normal recent chest radiograph. Since a chest computed tomography (CT) scan has been shown to be much more sensitive for detecting underlying pulmonary lesions compared with a plain chest radiograph, a chest CT scan should be obtained in all patients with a history of hemoptysis.³

A more severe hemoptysis can be seen with the expectoration of clots after a vigorous coughing episode. It is surprising how many patients will continue to downplay the significance of more severe episodes of hemoptysis or fail to seek urgent medical attention. The expectoration of clots is not considered pathognomonic for lung cancer. Massive hemoptysis (by definition, >200 mL per day), although less common with lung cancer, can occur in up to 20% of patients in whom lung cancer is the cause.⁴ Furthermore, it has been reported to be fatal in up to 50% of patients with lung cancer and demands serious and immediate attention in a hospital setting.⁵

The single most common cause of streaky hemoptysis in the United States is acute bronchitis. The most common cause of the expectoration of clot or massive hemoptysis, however, is lung cancer, especially in patients older than 50 years who have a long-standing smoking history. Other causes of hemoptysis, which cannot be ignored, include tuberculosis, chronic bronchitis, bronchiectasis, pneumonia, pulmonary infarction, lung abscess, aspergilloma, arteriovenous malformation of the lung, mitral stenosis, and bronchial adenoma. Lung cancer should be ruled out before considering other causes.

Massive hemoptysis must be considered a surgical emergency. The potential for imminent loss of life dictates attention first to preservation of the airway, breathing, and circulation (the ABCs of resuscitation). In the face of massive hemoptysis, the patient should be intubated with a single-lumen endotracheal tube (ET). A plain chest radiograph and urgent flexible bronchoscopy frequently can be used to determine which side of the airway is the source of bleeding. If the ET can be guided selectively into the contralateral airway, it can preserve the life of the patient, even if the ipsilateral airway completely fills with blood and clots. Intravenous (IV) access with two large-bore catheters should be established quickly. A large amount of clot in the proximal airway may necessitate urgent tracheotomy to save the patient from drowning and asphyxiation. This maneuver will facilitate the expeditious removal of large clots and blood from the trachea. Once the ABCs of resuscitation are secured, efforts should be directed toward establishing a diagnosis.

A plain chest radiograph should be obtained in any patient presenting with hemoptysis. The simple fact that disease can be seen within one or the other lung field can provide invaluable information for the ongoing care of the patient. It should be noted, however, that up to 5% of patients with a history of hemoptysis and an underlying cancer may have a normal chest radiograph.⁶

Traditionally, flexible bronchoscopy has been considered as the next diagnostic test to perform in a patient who presents with hemoptysis. The likelihood of localizing a bleeding site is considerably higher if bronchoscopy is undertaken during or within 48 hours of an event.⁷ Furthermore, emergency bronchoscopy after intubation can be used to guide the ET into either the left or the right main stem bronchus. In this way, the affected side can be isolated from the healthy lung.⁸ Early bronchoscopy does not guarantee that an endobronchial bleeding site will be identified. In one study, no discrete bleeding source was found in approximately half of patients.⁸

A high-resolution chest CT is an important tool for identifying the source of bleeding and possibly may replace bronchoscopy as the first-line procedure.⁹ In one study, when the chest radiograph was nonspecific, chest CT was found to be diagnostic in 43% and bronchoscopy in only 14% of patients.¹⁰ In this same study, the site of bleeding was localized by chest CT scan in 52% compared with 23% by bronchoscopy. In reality, bronchoscopy and CT scanning should be viewed as complementary studies when used to identify the source of hemoptysis. While CT scan can visualize parenchymal abnormalities in the periphery of the tracheobronchial tree as well as the presence of extraluminal disease, the bronchoscope is better suited for diagnosing endobronchial tumors and subtle airway abnormalities such as mucosal edema. Some of these bronchoscopic findings may not be obvious on a standard chest CT scan. Thus, CT scanning of the chest and bronchoscopy have greater sensitivity and specificity when used in combination.

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.

Emergent surgical intervention is recommended when arterial embolization has failed to control the source of hemoptysis. The mortality and morbidity in patients requiring emergent surgery are high. Surgery should be considered only when the source of bleeding is unilateral and has been clearly identified, and then only in patients with adequate pulmonary reserve.¹⁵ Elective surgery may be entertained in patients with hemoptysis after the bleeding has been controlled and when, from an oncologic standpoint, it is appropriate to remove the underlying tumor.

Brachytherapy

This is a method of delivering direct radiation within or near the affected tissue. Brachytherapy is useful to palliate malignancies in patients who have already received a maximum dose of external beam radiation. This technique is associated with a reduction of hemoptysis. Some studies, however, have reported an increased late risk of perforation or fatal hemoptysis after high-dose brachytherapy in 10.8% of patients.¹⁶

Argon Plasma Coagulation

This technique has been found to be effective in treating hemoptysis from primary and metastatic tumors that originate in the tracheobronchial tree.¹⁶ This procedure can be performed in the outpatient setting or at the bedside in an ICU.

Lung cancer is responsible for 20% of all cases of hemoptysis in the United States. While massive hemoptysis is unusual with lung cancer, the mortality approaches 50%, and it should be considered a medical emergency, demanding immediate attention in a hospital setting. Caregivers should first pay attention to the ABCs of resuscitation and intubate the patient immediately if the airway is compromised. If the plain radiograph fails to demonstrate the site of bleeding, a chest CT scan should be obtained as soon as possible. Urgent flexible bronchoscopy will aid in identifying the side of bleeding and facilitate selective intubation of the unaffected airway to protect the patient from drowning and asphyxia. At this juncture, the patient can either be transferred to the angiography suite for identification of the bleeding source and selective embolization or can go directly to the OR for further evaluation and clearance of clots from the airway. Local maneuvers can be employed through the bronchoscope to stop the bleeding and clear the airway. Emergency open surgery should be considered only if other measures have failed, a unilateral source of bleeding has been identified, and the patient can tolerate resection because of an acceptable pulmonary reserve. Elective surgical resection should be considered only if bleeding has been controlled and it is appropriate to resect the underlying tumor for oncologic reasons.

A 58-year-old woman is presented to the emergency room with a single episode of hemoptysis. She estimated that she had coughed up a half cup of blood in a single cough. She had never had hemoptysis before. Her antecedent history was unremarkable except for smoking one pack of cigarettes a day for the past 40 years and moderate exertional dyspnea over the past 6 months. Physical examination was remarkable for a unilateral wheeze on the right. She had no evidence of blood within the nares, but traces of blood could be seen in the oral cavity. Her vital signs were normal. Portable chest radiograph showed a right hilar mass.

While under evaluation in the emergency ward, the patient again coughed and produced 200 mL of bright red blood. Her heart rate increased to 110 beats per minute, and her systolic blood pressure fell to 90 mm Hg, with a mean arterial pressure of 70 mm Hg. The patient was urgently intubated in a controlled manner, but the ET quickly filled with blood. A flexible bronchoscope was placed down the ET, although nothing but blood could be seen through the scope. The bronchoscope was guided in a blind manner toward the left of the ET and trachea while the patient's head was turned to the right. In this manner, the bronchoscope would have a high probability of advancing into the left main bronchus. The ET was advanced as far as possible over the bronchoscope and selectively intubated the left main bronchus. The balloon was inflated, and additional blood no longer filled the tube. Large-bore IV lines were placed for blood and fluid resuscitation, and an arterial line was placed while the bronchoscope was used to clear the distal left mainstem bronchus. Although a clear narrow passage was created down to the secondary carina between the left upper lobe and the left lower lobe, a large amount of organized clot remained in the airway and could not be removed readily by the flexible bronchoscope.

The patient was taken to the OR. She was still bringing up copious amounts of clot through the ET, and her arterial saturations were in the mid-80% range. A decision was made to perform a tracheotomy to more effectively clear the airway. With the flexible bronchoscope within the lumen of the ET, the balloon was deflated. There was no sign of current bleeding. The ET was withdrawn to the level of the tracheotomy. A Yankauer suction tip and O-ring forceps were passed through the tracheotomy incision into the trachea to remove the organized clot from the airway. A tracheostomy tube was inserted, and the balloon was inflated. Bronchoscopy of the right main airway now was possible, and a soft, friable tumor was seen at the level of the right upper lobe takeoff. A no. 6 Fogarty arterial catheter was passed through the tracheostomy and placed deflated in the right mainstem bronchus. Biopsies and brushings of the tumor were obtained.

Hemoptysis is a dreaded disorder that is often managed emergently. Maintaining a patent airway, even at the expense of obstructing the diseased airway, is paramount. Although flexible fiberoptic bronchoscopy can be used to guide the ET into the uninvolved bronchus, it may be impossible to do so in the face of true massive hemoptysis. In this situation, rigid bronchoscopy remains a reasonable alternative and is the only way to provide adequate suction to maintain a patent airway. Therapeutic intervention in this setting includes using all available modalities. If a discrete endobronchial lesion is seen, laser or argon plasma coagulation (APC) can be used acutely. Generally, most patients will undergo bronchial artery embolization. This can then be followed by definitive treatment such as resection or external beam radiation.