I think there is a very high risk of cardio genie shock in patients with severe haemoptysis which should be attended to initially and then depending on the results of lab tests, anti coagulation or thrombolysis or embolectomy can be considered
I think the best is to secure the airway and the circulating volume. Once that part is solve, lab tests, X-rays (if you have CT, even better) and physical examination is required.
That is not my cup of tea, but I think in firstly get an stable patient and secondly investigate why is he bleeding and try to solve the problem.
This indeed is a difficult situation to manage.
First and foremost, the patient may need resuscitation. Oxygen, IV fluids, protection of remaining lung from intrabronchial blood. Patient is at risk of asphyxiation.
It is important to identify the cause of haemoptysis.(eg: If it is an AV malformation, it can be embolised. If pulmonary embolism has caused lung infraction which in turn has caused haemoptysis, the lung segment will need excision... and so on).
Similarly, it is also important to classify Pulmonary embolism. Massive acute PE is when there is haemodynamic/ cardiorespiratory collapse. In the setting of massive haemoptysis, you clearly cannot thrombolyse/ heparinise the patient. Therefore, an inflow occlusion (off pump) pulmonary embolectomy might be indicated. This procedure can be further aided with an IVC filter to prevent further emboli.
Once the patient is stabilised, and cause of haemoptysis dealt with, you may be able to anticoagulate this patient.
In case of Chronic PEs, patient may develop pulmonary hypertension. In such patients, pulmonary endarterectomy may be indicated which should be undertaken only in very specialised centres.
Last but not the least, a cause of thromboembolism needs to be identified. The patient should be referred to haemotology for thrombophilia screening.
In patients with pulmonary embolism and bleeding symptoms preventing anticoagulation vena cava filter is an important option with high protection against further embolism. Retrievable vena cava filter that could be taken away or left permanent is an optional possibility.
We recently published a manuscript in JACC demonstrating that the use of a vena cava filter in PE patients with contraindications to anticoagulation (such as the presence of bleeding complications) was associated with increased survival.
in the RIETE registry we have 44 patients with haemoptysis after starting anticoagulant therapy. Is anyone interested to prepare a manuscript on this issue?
Thanks manuel. If you don't mind, would you please send me this article?
J Am Coll Cardiol. 2014 Apr 29;63(16):1675-83. doi: 10.1016/j.jacc.2014.01.058. Epub 2014 Feb 25.
Survival effects of inferior vena cava filter in patients with acute symptomatic venous thromboembolism and a significant bleeding risk.
Muriel A1, Jiménez D2, Aujesky D3, Bertoletti L4, Decousus H4, Laporte S4, Mismetti P4, Muñoz FJ5, Yusen R6, Monreal M7; RIETE Investigators.
Author information
Abstract
OBJECTIVES:
The purpose of this study was to investigate the survival effects of inferior vena cava filters in patients with venous thromboembolism (VTE) who had a significant bleeding risk.
BACKGROUND:
The effectiveness of inferior vena cava filter use among patients with acute symptomatic VTE and known significant bleeding risk remains unclear.
METHODS:
In this prospective cohort study of patients with acute VTE identified from the RIETE (Computerized Registry of Patients With Venous Thromboembolism), we assessed the association between inferior vena cava filter insertion for known significant bleeding risk and the outcomes of all-cause mortality, pulmonary embolism (PE)-related mortality, and VTE rates through 30 days after the initiation of VTE treatment. Propensity score matching was used to adjust for the likelihood of receiving a filter.
RESULTS:
Of the 40,142 eligible patients who had acute symptomatic VTE, 371 underwent filter placement because of known significant bleeding risk. A total of 344 patients treated with a filter were matched with 344 patients treated without a filter. Propensity score-matched pairs showed a nonsignificant trend toward lower risk of all-cause death for filter insertion compared with no insertion (6.6% vs. 10.2%; p = 0.12). The risk-adjusted PE-related mortality rate was lower for filter insertion than no insertion (1.7% vs. 4.9%; p = 0.03). Risk-adjusted recurrent VTE rates were higher for filter insertion than for no insertion (6.1% vs. 0.6%; p < 0.001).
CONCLUSIONS:
In patients presenting with VTE and with a significant bleeding risk, inferior vena cava filter insertion compared with anticoagulant therapy was associated with a lower risk of PE-related death and a higher risk of recurrent VTE. However, study design limitations do not imply a causal relationship between filter insertion and outcome.
Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
KEYWORDS:
deep vein thrombosis; prognosis; pulmonary embolism; survival; vena cava filter; venous thromboembolism
Comment in
Do inferior vena cava filters prevent death from pulmonary embolism? [J Am Coll Cardiol. 2014]
PMID: 24576432 [PubMed - indexed for MEDLINE]
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