Haemoptysis refers to coughing up blood from the vessels in your respiratory tract below your voice box. Massive haemoptysis accounts for approximately 5% of cases of haemoptysis and is a life-threatening condition because it can result in asphyxiation (lack of oxygen). Because of the severity of the consequences, patients with haemoptysis need to be examined and treated as soon as possible.
Massive haemoptysis refers to when a patient coughs up between 100-1,000 ml of blood in 24 hours, but smaller amounts of blood can also be life-threatening, and so require interventional management.
In 90% of cases, the source of the bleeding is in the bronchi, the airways of the respiratory tract which conduct air into the lungs. In 5% of cases, the source of the bleeding is in the pulmonary system, which is the system that carries de-oxygenated blood away from the heart to the lungs and returns oxygenated blood back to the heart. There are a number of causes for haemoptysis, including tuberculosis, bronchitis and trauma.
The first step for evaluating haemoptysis is a chest radiograph, although the findings appear normal in up to 30% of cases. Another useful diagnostic approach is a bronchoscopy, in which an imaging device is inserted into the airway. CT may be used to find the source of the bleeding and to identify the cause.
The treatment of choice for massive haemoptysis is bronchial artery embolisation, a minimally invasive technique performed by an interventional radiologist. The interventional radiologist inserts a catheter into the patient’s femoral vein (in the upper thigh) using fluoroscopy for guidance. The interventional radiologist then directs the catheter to the bronchial artery and inserts embolisation materials into the branch of the bronchial artery responsible for the bleeding to block the area, stopping the bleeding. The patient will have an angiography after the embolisation procedure to confirm if the procedure has been successful.
The treatment has high rates of immediate clinical success. If the bleeding recurs, the embolisation procedure can be repeated. There are a number of possible complications, including chest pain and difficulty swallowing. The most serious complication is inflammation of the spinal cord, but this only occurs in 1.4-6.5% of cases.
There are surgical treatments available, but these are reserved for cases where the embolisation procedure is unsuccessful or if the condition recurs after multiple embolisation procedures. Surgery has a mortality rate of 14-18%.
Other treatments include endobronchial tamponade, which is the use of an absorbent plug to stop the bleeding, and is used in patients who are not suitable candidates for embolisation or surgery. Another option is rigid bronchoscopy, which may be used to treat patients whose blood flow is impaired or who have breathing problems. Bronchoscopy can be used to clear the airways and aid physicians to carry out treatments.