Eine Einführung in die pulmonale Hämorrhagie aus Sicht der Pneumologie

Das Spektrum pulmonaler Blutungen reicht von der Erstdiagnose eines Malignoms bis hin zur Manifestation einer lebensbedrohlichen, rasch voranschreitenden Autoimmunerkrankung. Dabei ist ein rasches, geordnetes Handeln geboten, um einen potenziell fatalen Ausgang abzuwenden. Dieser Artikel illustriert anhand eines Fallbeispiels die differenzialdiagnostischen und therapeutischen Überlegungen bei Patient*innen mit einem akuten pulmonalen Blutungsgeschehen aus Sicht der Pneumolog*innen.

Abstract

Hemoptysis resembles a clinical emergency and necessitates a fast and well-coordinated diagnostic and therapeutic approach. While up to 50% of the underlying causes remain unidentified, the majority of cases in the western world can be attributed to respiratory infections and pulmonary neoplasm. While 10% of the patients present with massive, life-threatening hemoptysis, which require a timely airway protection in order to secure a sustained pulmonary gas-exchange, the vast majority presents with non-critical pulmonary bleeding events. Most critical pulmonary bleeding events arise from the bronchial circulation. An early chest imaging is key for identifying the bleeding cause and localization. While chest x-rays are widely implemented in the clinical work-flow and rapidly applicable, computed tomography and computed tomography angiography exhibit the highest diagnostic yield. Bronchoscopy can add diagnostic information especially in pathologies of the central airways, while offering multiple therapeutic options to maintain pulmonary gas exchange. The initial therapeutic regimen comprises early supportive care, but treatment of the underlying etiology is of prognostic relevance and avoids recurrent bleeding events. Bronchial arterial embolization usually is the therapy of choice in patients with massive hemoptysis, while definitive surgery is reserved for patients with refractory bleeding and complex pathologies.

Kernaussagen

• Massive Hämoptysen sind selten, gehen jedoch mit einer hohen Letalität einher.

• Im Fokus stehen anfangs die Sicherstellung des Atemwegs und die Erhaltung des pulmonalen Gasaustausches.

• Die führenden Ursachen für Hämoptysen in der westlichen Welt sind Infektionen der oberen und unteren Atemwege sowie das Bronchialkarzinom.

• Bronchoskopie und Mehrzeilen-Computertomografie sind diagnostisch komplementär und sollten schnellstmöglich zur Verfügung gestellt werden.

• Bei der diffusen, alveolären Hämorrhagie sind eine rasche Diagnose und adäquate Therapie der zugrunde liegenden Erkrankung prognostisch entscheidend.

• Konservative Therapiestrategien verlaufen häufig frustran oder führen zu einem Blutungsrezidiv.

• Für ein erfolgreiches Management eines massiven Hämoptysen/Hämoptoe-Ereignisses bedarf es eines eingespielten interdisziplinären Teams aus Pneumolog*innen, Intensivmediziner*innen, (interventionellen) Radiolog*innen und Thoraxchirurg*innen.

Schlüsselwörter

massive Hämoptysen - nicht massive Hämoptysen - Hämoptoe - Ätiologie - Diagnostik - Therapie

Keywords

massive hemoptysis - non-massive hemoptysis - haemoptoe - etiology - diagnostics - management

Publication History

Article published online:
26 June 2023

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