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A 58-year-old man, a 40-pack-year smoker, presents to the emergency department having coughed up approximately 300 mL of bright-red blood over the past 4 hours. He has lost weight (6 kg in 3 months) and has a chronic cough. He takes warfarin 5 mg daily for atrial fibrillation. On examination he is agitated, respiratory rate 32/min, SpO2 88 percent on room air, BP 96/60, HR 124, and breath sounds are reduced in the right upper zone with crackles. Chest X-ray shows a 4 cm right hilar mass.
Questions
a) Define haemoptysis and classify this presentation by severity, justifying your classification. (2 marks)
Haemoptysis is the expectoration of blood originating from the respiratory tract below the vocal cords. This man has massive (life-threatening) haemoptysis: he has coughed up over 100 mL/24h (300 mL in 4 hours) AND shows signs of airway/gas-exchange compromise (RR 32, SpO2 88 percent, agitation, tachycardia, borderline blood pressure) — meeting both the classical volume threshold and the modern functional definition of any bleed threatening the airway or gas exchange. The probable cause is bronchogenic carcinoma (smoker, weight loss, hilar mass).
b) Outline your immediate resuscitation, including positioning and drug doses. (4 marks)
- Airway and breathing first: high-flow oxygen (target SpO2 94 to 98 percent); vigorous suction to clear blood.
- Position the BLEEDING LUNG DOWN (right side down, lateral decubitus) to protect the good (left) lung from aspiration — death in massive haemoptysis is from asphyxia, not exsanguination.
- Two large-bore IV cannulae; send FBC, coagulation (INR), U&E, group & crossmatch 4 units; balanced crystalloid bolus for the relative hypotension.
- Reverse the warfarin: prothrombin complex concentrate (PCC) 25 to 50 IU/kg IV plus vitamin K 5 to 10 mg IV for rapid reversal (INR elevated on warfarin with life-threatening bleeding); stop the warfarin.
- Tranexamic acid 1 g IV as a pharmacological adjunct.
- Escalate: secure the airway with a large-bore (at least 8 mm) endotracheal tube (or a double-lumen tube / bronchial blocker for selective lung ventilation) if he deteriorates; transfer to ITU; activate bronchoscopy, interventional radiology and thoracic surgery teams in parallel.
c) Outline the stepwise definitive management after resuscitation. (3 marks)
- Rigid bronchoscopy (preferred over flexible in massive bleeding — allows ventilation, large-bore suction and tamponade): options include iced saline lavage, topical adrenaline 1:20 000, balloon (Fogarty/bronchial blocker) tamponade, fibrin glue, argon plasma coagulation (APC) / cryotherapy.
- Bronchial artery embolisation (BAE) — first-line intervention for massive haemoptysis when bronchoscopy cannot control the bleed; a pre-procedure CT angiogram maps the bronchial arteries; immediate success 70 to 99 percent. The team must watch for anterior spinal artery syndrome (paraplegia) from non-target embolisation of the artery of Adamkiewicz.
- Surgery (lobectomy) — last resort, reserved for uncontrolled, localised, surgically resectable bleeding in a fit patient; emergency peri-operative mortality up to 40 percent.
d) Name two serious complications of massive haemoptysis and one feared complication of BAE. (1 mark)
- Complications of massive haemoptysis: asphyxia (the principal mode of death) and hypovolaemic/hyporrhagic shock; also aspiration pneumonia, atelectasis from clot, ARDS.
- Feared complication of BAE: anterior spinal artery syndrome / paraplegia from non-target embolisation of the artery of Adamkiewicz.