Haemoptysis

Key messages

Definition and prevalence

Haemoptysis, the expectoration of blood from the lower respiratory tract, is often a distressing symptom encountered in palliative care, particularly among patients with advanced pulmonary malignancies. [1,2] This condition may vary from mild blood-streaked sputum to life-threatening massive haemorrhage, necessitating different management strategies depending on its severity. [2] Massive haemoptysis, which is defined as blood loss exceeding 600 mL in 24 hours or 150 mL per hour, is particularly dangerous and requires urgent intervention. [3]

Tumour-related bleeding, including gastrointestinal bleeding and bleeding from haematologic malignancies, is not uncommon in palliative care settings. These bleeding events might be indicative of advanced disease stages, occurring in approximately 10-14% of patients with advanced cancer, with specific rates varying depending on the cancer type and patient population. [4,5] The occurrence of terminal haemorrhage, an event often preceding death, has been reported in 3-12% of these patients. [1]

Assessment

The assessment of haemoptysis and tumour-related bleeding in palliative care generally starts with a comprehensive patient history and physical examination, focusing on the characteristics and impact of the bleeding episodes. [1] Understanding the underlying cause of bleeding, whether due to malignancy, infection, or coagulopathy, is important for determining appropriate management strategies.

Several diagnostic tools are used to assess haemoptysis in palliative care. Bronchoscopy is a key tool, particularly valuable for localising the bleeding source within the bronchial tree, although its use may be limited in more frail patients. [2] Less invasive options, such as chest CT scans, are also important for visualising the extent of tumour involvement and guiding decisions about interventions like bronchial artery embolisation (BAE) or radiotherapy. [3,6]

Assessment often includes evaluating the patient’s coagulation status, especially for those on anticoagulation therapy or with a history of coagulopathy. Standard laboratory tests, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet count, can offer insights into the patient’s haemostatic status and guide clinical decision-making regarding transfusions or other interventions. [1,4] In cases of recurrent or massive haemoptysis, multidisciplinary discussions may be necessary to balance the risks and benefits of potential interventions. [3]

Non-pharmacological treatment

Non-pharmacological approaches are often employed in managing haemoptysis and tumour-related bleeding in palliative care, particularly when the focus is on symptom relief and improving patient comfort. BAE is frequently considered a primary intervention for massive haemoptysis. This minimally invasive procedure involves selectively embolising the bronchial arteries to control or reduce bleeding. Clinical studies report that BAE has a high technical success rate, often cited as high as 97.22%, though recurrence rates can be approximately 21.46%. [3] The procedure is typically performed by an interventional radiologist and is particularly useful when surgical options are not feasible due to the patient's overall health status or advanced disease stage. [1,2]

Palliative Radiotherapy is another non-pharmacological approach commonly utilised to manage tumour-related bleeding, especially in cases where the tumour causes localised erosion or vascular involvement. Radiotherapy works by reducing tumour size, which can subsequently help control bleeding. This approach is generally well-tolerated by patients and can provide substantial symptomatic relief, making it an important option in the palliative care setting. [2,5] The choice between BAE and radiotherapy is typically guided by factors such as the patient's overall condition, tumour characteristics, and care goals. [1,3,5]

Pharmacological treatment

Pharmacological interventions are commonly utilised in palliative care to manage haemoptysis and tumour-related bleeding, with the primary goal being symptom control and enhancing patient comfort. Tranexamic acid is frequently used due to its antifibrinolytic properties, which help stabilise clots by inhibiting the breakdown of fibrin. This medication can be administered through various routes—oral, intravenous, or subcutaneous—depending on the patient's condition and practicality within the palliative setting. Subcutaneous administration is particularly advantageous in situations where other routes are not feasible, offering flexibility in managing bleeding in patients with advanced disease. [1,2] Clinical evidence generally supports its effectiveness, though dosing and duration are often tailored to individual needs and the severity of bleeding. [1]

Platelet transfusions are used in patients with haematologic malignancies or severe thrombocytopenia. The primary goal of platelet transfusions is to raise the platelet count, thereby reducing the risk of bleeding or controlling active haemorrhage. This intervention is especially important in patients at high risk of bleeding due to low platelet levels, such as those undergoing chemotherapy or with bone marrow suppression. [4,6] The decision to use platelet transfusions in palliative care involves weighing the benefits of reducing bleeding against the potential risks, such as transfusion reactions or logistical challenges related to frequent transfusions. [2] This is particularly relevant when considering the patient's overall prognosis and quality of life.

In cases where patients are on anticoagulant therapy and experience bleeding, anticoagulation reversal agents are often employed. Agents such as vitamin K, fresh frozen plasma, and beriplex concentrates are used to counteract the effects of anticoagulants like warfarin. [1,6] The use of these reversal agents requires careful consideration of the risks and benefits, balancing the need to control bleeding with the potential for thrombotic complications. This approach is particularly critical in patients with underlying conditions that require continued anticoagulation. [6]

Equity and access

Access to treatment for haemoptysis and major bleeding in palliative care can vary widely due to geographic, socioeconomic, and cultural factors. Patients in urban areas generally benefit from better access to specialised interventions like BAE and palliative radiotherapy, due to the availability of specialised facilities and healthcare professionals. [1,6] In contrast, those in rural or remote areas, including Aboriginal and Torres Strait Islander peoples, may face delays in accessing these treatments or may not have access to them at all, which can lead to less effective symptom management and poorer outcomes. [6,7] Furthermore, for culturally and linguistically diverse (CALD) communities, cultural and religious differences may affect the acceptability of certain treatments, such as blood products, necessitating a more tailored approach to care. [7]

Socioeconomic barriers also have an influence. Patients from lower-income backgrounds may struggle with the costs associated with travelling to specialised centres or affording necessary treatments. [2,4] These financial challenges can lead to delays in receiving care or an inability to access appropriate treatments, particularly in palliative care settings where maintaining comfort is paramount. [2]

Care context

In palliative care, the management of haemoptysis and major bleeding is significantly influenced by the care setting, whether it be in a hospital, specialist palliative care units or home environment. Each setting presents unique challenges and opportunities for intervention, requiring a tailored approach that should be reflected in goals of care and/or advance care planning discussions to meet the needs of the patient while prioritising comfort and quality of life.

In hospital settings, patients generally have access to a wider range of interventions, including BAE and palliative radiotherapy. These treatments are more feasible in hospitals due to the availability of specialised equipment and trained professionals. [1,6] Hospitals can also offer rapid response to severe bleeding events, with the ability to administer blood products, manage complications, and provide intensive monitoring. However, the decision to pursue these interventions often depends on the patient’s overall prognosis and goals of care, with a careful balance between aggressive treatment and maintaining quality of life. [6]

Home care presents its own set of challenges, particularly due to the limited availability of medical resources and support. In home settings, the management of haemoptysis and bleeding may rely heavily on family caregivers, who may not have medical training. Therefore, treatments must be straightforward and easy to administer, such as oral or subcutaneous medications. [7] Telehealth services, where available, can play an important role in supporting caregivers, offering guidance and monitoring the patient’s condition remotely. However, the feasibility of telehealth varies widely depending on the region and access to digital infrastructure.

In all care settings, the approach to managing haemoptysis and major bleeding should be tailored to the patient’s needs, taking into consideration the resources available in the setting and the primary goal of care—whether it be extending life or ensuring comfort and dignity in the final stages.

Implications for families and carers

Managing haemoptysis and major bleeding in palliative care can place considerable emotional and practical demands on families and carers, particularly in home settings where they may need to handle complex symptoms with limited support. The responsibility of administering medications and responding to sudden bleeding episodes might contribute to increased stress and anxiety, especially when carers feel uncertain about their ability to manage these situations effectively. [7] Access to guidance, education, and telehealth support could assist carers in navigating these challenges, though the availability and effectiveness of these resources may vary.

In hospital and specialist palliative care units settings, families might also experience emotional strain, particularly when faced with witnessing severe symptoms or making decisions about the balance between treatment and comfort care. The importance of clear communication with healthcare professionals in these settings is often highlighted, as it helps ensure that the patient’s wishes are understood and respected, and that families feel supported in their caregiving roles. [6] Providing carers with emotional support and clear information about care options might help alleviate some of the burden during these challenging times. [1]