Massive HaemoptysisMassive haemoptysis may be the result of inflammatory or malignant disease. More rarely it is the result of a congenital defect. The disease divides into surgically remediable and non-surgical disease. This is done on the basis of pulmonary function tests and the assessment of the underlying pulmonary condition as well as the general principles affecting suitability for surgery. In our environment, the commonest causes for massive haemoptysis are active tuberculosis or lung damage from previous tuberculosis. It would appear that haemoptysis is often the result of a superinfection of the tuberculous lung, or the development of an aspergilloma in an old tuberculous cavity. Bronchiectasis may also be complicated by massive haemoptysis. Lung carcinoma may present or complicate by massive haemoptysis.
Management of Massive Haemoptysis
The initial assessment of the patient with massive haemoptysis is to put him into a treatment group, either possibly surgical at presentation, possibly surgical at a later stage or non-surgical disease. Management usually is by bed rest in an ICU, intravenous morphine in a moderately sedative dose to drop the blood pressure and decrease cough which left unchecked commonly causes further episodesof haemoptysis and full tuberculosis cover as well as triple intravenous antibiotics. We usually give a 2nd generation cephalosporin and large dose penicillin. Metronidazole is given initially I.V. but after the first dose may be given either orally or rectally.
Bleeding from branches of the bronchial arteries causes most massive haemoptysis. In inflammatory disease the bronchial arteries not only enlarge and become tortuous. The diseased lung often develops additional feeding vessels from the chest wall. Because of this many cases of massive haemoptysis, especially active tuberculosis and bronchiectasis may initially bemanaged by bronchial artery embolisation. Other feeding arteries may also be embolised at the same sitting with satisfactory results. This service is provided at Inkhosi Albert Luthuli Central Hospital by the Dept. of Radiology with the patients admitted through and cared for by the Dept. of Cardiothoracic Surgery. Unfortunately bleeding caused by aspergilloma is often poorly controlled by embolisation and even if initial control is obtained we favour resection when pulmonary function allows.
Treatment of Carcinoma with massive haemoptysis depends on resectability and often can only be determined by a combination of computerised tomography and bronchoscopy. The final arbiter may be the findings at thoracotomy.