Massive Hemoptysis

Tuberculosis is the most common cause of massive hemoptysis which is defined as the production of 600 cc of blood within 24 h. In approximately three quarters of cases, tuberculosis is involved, and most of the rest are carcinoma-related. Massive, life-threatening hemoptysis is associated with tuberculosis with or without superimposed fungal infection, Aspergillus being the most common.

The usual etiology of massive hemoptysis is erosion into a bronchial artery, or less commonly pulmonary arterial bleeding in cavitary tuberculosis resulting from a ruptured Rasmussen's aneurysm.

Emergency management of massive hemoptysis is required. The first emergency step is protecting the airway and adequacy of ventilation of uninvolved lung. This involves patient positioning to minimize aspiration of blood. For example, if the pathology is known to be in the right upper lobe, the patient is placed in the right lateral decubitis position. Bonchoscopy usually is needed to identify the source fo hemoptysis, and then either endobronchial tampenade with isolated Fogarty balloon occlusion or double-lumen endotracheal intubation is established to protect the uninvolved airway. At this point, management of the bleeding usually proceeds using bronchial arterial embolization. In most patients short-term control of hemorrhage is achieved by embolization, and half achieve long-term control by embolization alone. Nonetheless, in the presence of severe tuberculous lung destruction, with or without fungal invovlement, definitive surgical resection usually is required. Using preoperative temporizing angiographic embolization, definitive pulmonary resection can be done on a more elective basis to optimize the patient as a surgical candidate.

Suggested Reading

1. Churchill ED, Klopstock R. Lobectomy for pulmonary tuberculosis. Ann Surg 1943; 117: 641-669.

2. Shields TW. Pulmonary tuberculosis and other mycobacterial infections of the lung In: Shields TW ed. General Thoracic Surgery. 3rd ed, Philadelphia: Lea and Febinger 1989:785-798.

3. Treasure RL, Seaworth BJ. Current role of surgery in mycobacterium tuberculosis. Ann Thorac Surg 1995; 59:1405.

4. Pomerantz M et al. Surgical management of resistant mycobacterium tuberculosis and other mycobacterial pulmonary infections. Ann Thorac Surg 1991; 52:1108.

5. Mouroux J et al. Surgical management of pleuropulmonary tuberculosis. J Thorac cardiovasc Surg 1996; 111:662.

6. Uflacker R et al. Management of massive hemoptysis by bronchial artery embolization. Radiology 1983; 146:627.

7. Crocco JA, Rooney JJ, Fankuahen DS et al. Massive hemoptysis. Arch Intern Med 1968; 121:495-498.

8. Garzon AA, Gourin A. Surgical Management of Massive Hemoptysis, a 10 year experience. Ann Surg 1978; 187:267-271.

9. Rabkin J, Astafjen V, Gothman L, Grigorjev Y. Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 1987; 163:361-365.

10. Garzon AA. Massive hemoptysis: Surgical and tamponade therapy. In: Grillo HC, Austen WG, Wilkins EW, Mathisen DJ, Vlahakes GJ eds. Current Therapy in Cardiothoracic Surgery. St. Louis: C.V. Mosby Company, 1989:174-176.

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