The management of massive haemoptysis and standard haemoptysis differs. Massive haemoptysis management is subdivided into patients for whom active manaegment is indicated (i.e. otherwise good quality of life) versus palliative management.
Management of Massive Haemoptysis
Management depends on the site of origin. Massive haemoptysis is due to involvement of the bronchial arteries in 90% of cases. If active management is indicated, the most effective treatment is bronchial artery angiography and embolisation. This treatment is associated with high success rates and minimal complications (small risk of spinal cord artery embolisation). The invasive nature of this procedure renders it inappropriate in a high number of patients with advanced cancers.
It may be appropriate in non-exanguinating patients to condsider treatments for symptomatic haemoptysis (see below).
The palliative management of exanguination in a patient unable or unsuitable for bronchial artery embolisation is straightforward and must be performed urgently. The patient receives an intravenous or subcutaneous dose of 10-20 mg midazolam (alternatively, PR diazepam may be used).
Management of Symptomatic Haemoptysis
In patients unable or unsuitable for bronchial artery embolisation, and who are not exsanguinating, radiotherapy provides are less invasive option for haemoptysis control. The most commonly used protocol was developed by the MRC:
- 17 Gy in 2 fractions (8.5 Gy per fraction) delivered using opposed anterior/posterior beams
- This method is equivalent to longer fractionation courses for patients with ECOG status of 2 or more
- In patients with a longer life expectancy, increasing the dose and fractions may be appropriate
- Radiotherapy should be used with caution when there is a potential fistula between great vessels and the bronchi, as there may be enlargement of the fistula with radiotherapy treatment leading to exsanguination
Other methods for symptomatic haemoptysis include:
- Bronchial artery embolisation is highly effective but not available in all centres. In some cases the lesion may not be amenable to this procedure
- Endobronchial laser therapy or cryotherapy are both effective strategies but necessitate general anaesthetic
- Chemotherapy often reduces haemoptysis but is the slowest acting of the therapies
- Non-cytotoxic agents such as tranexamic acid may be used; randomised studies have not been performed
