CRITICAL CARE/RESPIRATORY CARE Approach to Life-Threatening Hemoptysis

The classic concept of massive hemoptysis has been replaced by the newer one of life-threatening hemoptysis (LTH), which means any bleeding from the lower respiratory tract that may cause the death of the patient. Although asphyxia is the usual mechanism of death, hypovolemic shock also plays a role in certain cases. The amount of expectorated blood does not always correlate with the actual volume of bleeding. The underlying state of health, especially basal respiratory function, plays a crucial role when the real consequences of bleeding are considered. The following factors have to be evaluated when a temporary or definitive treatment is chosen: setting of the hemoptysis, presumptive etiology, degree of clinical instability, equipment resources, and personal expertise in different techniques. The most important role of bronchoscopy is its rapid availability when hemoptysis is severe and the patient is not sufficiently stable to be immediately taken to the angiography department. In that situation, orotracheal intubation and bronchoscopy may be lifesaving. Rigid bronchoscopy, in skilled hands, has proven to be superior to flexible bronchoscopy in massive hemoptysis. Fiberoptic bronchoscopy (FOB) is also helpful as an extreme emergency measure to properly place an orotracheal tube contralateral to the bleeding side. Endoscopic local measures may sometimes help to transitorily stop bleeding. If the cause of hemoptysis is itself susceptible to primary surgical treatment and the condition of the patient is sufficiently good in terms of pulmonary reserve, life expectancy, and hemodynamic stability, then surgery is indicated. If the condition of the patient is not good enough, a temporary method to stop hemorrhage and stabilize the patient is then warranted. Although bronchoscopy and bronchial artery embolization (BAE) should be ideally complementary, recent data suggest that BAE may be a more effective temporary measure to stop bleeding.