Haemoptysis: Endoscopic options
Prof. Dr. Arschang Valipour
Ludwig-Boltzmann-Institute for COPD and Respiratory Epidemiology
Department of Respiratory and Critical Care Medicine
Otto Wagner Hospital
Sanatoriumstr. 2
1140 Vienna
AUSTRIA
[email protected]
AIMS


Understanding the underlying causes of haemoptysis
Understanding the different techniques available to manage haemoptysis with a focus
on interventional pulmonology
SUMMARY
Severe hemoptysis is a life-threatening condition. The presentation delivered at the PG course will
familiarize the auditorium with the underlying causes and definitions of haemoptysis. Therapeutic
strategies such as bronchoscopy, interventional angiography, and/or surgery may need to be applied in
the clinical setting depending on institutional ressources, personal experience, and patients’ condition.
Acute massive hemoptysis is a life-threatening condition associated with a high mortality rate ranging
from 23 – 85% (1). The most frequent causes of life threatening haemoptysis are displayed in Table 1.
The main threat in the acute phase remains asphyxiation resulting from flooding of the airways and
alveoli with blood. Maintenance of airway patency and control of bleeding are therefore the primary
goals, followed by identifying the site and the underlying cause of bleeding. Correctly inserted
double-lumen endotracheal tubes may achieve some of these goals through isolation of the affected
and adequate ventilation of the non-affected lung. However, these tubes carry significant risks (2,3)
and are difficult to place properly (4). In fact, the majority of chest physicians admit a lack of
proficiency with placement of the double-lumen tubes (5). Another disadvantage is that they are easily
obstructed by clots and do not permit passage of bronchoscopes of adequate size to allow toilet under
unobstructed vision (6). Hemoptysis control can also be obtained by using either local iced saline
injections (7) or regional instillation of vasoconstrictive agents (8,9) via bronchoscopy. While this
approach might be useful in mild to moderate hemoptysis, it is insufficient for massive active
bleeding where the agent is diluted and flushed away (1).
Other endoscopic techniques are topical haemostatic tamponade therapy using oxidized regenerated
cellulose (ORC), injections of fibrin-thrombin solutions, tranexamic acid, or (sub) segmental balloon
occlusion to stop the bleeding. Haemostasis with ORC is primarily due to selective tamponade of a
bleeding bronchus (10). A tight blockade is essential for the success of treatment and may require up
to 10 layers of the mesh, which can be customized to suit the needs required. After saturation with
blood, thrombus formation occurs due to the physical properties of the mesh, rather than producing
any alteration of the physiologic clotting mechanism. Oxidized cellulose has caustic activities and
reacts with blood to precipitate an artificial coagulum that provides the substrate for further clotting
(11).
Alternatively, spillage of blood to non-affected functionally intact alveolar areas of the lung can be
prevented by placing a balloon catheter into the bleeding airway (12). Removal of the bronchoscope
over the balloon, however, may be difficult and require different products than those typically used in
endoscopy. Should the bleeding resume despite bronchoscopic interventions, other therapeutic options
such as interventional angiography and/or surgery should be considered. With BAE initial control of
bleeding can be achieved in 60 to 95%. (13,14). A surgical approach in the management of
hemoptysis may be needed for a specific large-vessel bleed, or if there is a parenchymal source that is
resectable. Surgery is, however, associated with a relatively high risk of morbidity and mortality
during the acute episode (3,15).
Table
1.
Most
frequent
causes
(modified from Sakr L, Dutau H. Respiration 2010)
for
life
threatening
haemoptysis
Lung cancer, Carcinoid, Lung metastsis
Pulmonary tuberculosis
Bronchiectasis
Aspergilloma
Pneumonia
Systemic autoimmune disease with pulmonary hemorrhage
(Granulomatosis, Goodpasture Syndrome,…)
Chronic Bronchitis
Iatrogenic (post lung-biopsy, post RFA of lung lesions, post
CT-guided biopsy of lung lesions,….)
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RECOMMENDED READING
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12. Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC. Bronchoscopy-guided topical
hemostatic tamponade therapy for the management of life-threatening hemoptysis. Chest. 2005
Jun;127(6):2113-8.
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