Aetiology, diagnosis and management of infective causes of severe haemoptysis in intensive care units

Chronic pulmonary aspergillosis complicating sarcoidosis

Chronic pulmonary aspergillosis (CPA) complicating sarcoidosis (SA) is associated with high mortality, and there is a lack of clarity regarding the relative contributions of SA or CPA.

This was a retrospective single-centre study on CPA-SA.

In total, 65 patients (44 men), aged 41.4±13.5 and 48.3±11.9 years at the time of SA and CPA diagnoses, respectively, were included between 1980 and 2015. Of these, 64 had fibrocystic SA, most often advanced, with composite physiological index (CPI) >40 (65% of patients) and pulmonary hypertension (PH) (31%), and 41 patients (63%) were treated for SA (corticosteroids or immunosuppressive drugs). Chronic cavitary pulmonary aspergillosis (CCPA) was the most frequent CPA pattern. Regarding treatment, 55 patients required long-term antifungals, 14 interventional radiology, 11 resection surgery and two transplantation. Nearly half of the patients (27; 41.5%) died (mean age 55.8 years); 73% of the patients achieved 5-year survival and 61% 10-year survival. Death most often resulted from advanced SA and rarely from haemoptysis. CPI, fibrosis extent and PH predicted survival. Comparison with paired healthy controls without CPA did not show any difference in survival, but a higher percentage of patients had high-risk mould exposure.

CPA occurs in advanced pulmonary SA. CPA-SA is associated with high mortality due to the underlying advanced SA rather than to the CPA. CPI, fibrosis extent and PH best predict outcome.

[Severe haemoptysis: indications for triage and admission to hospital or intensive care unit]

Recognition of the criteria of severity and the early admission to a referral center play a critical role in the prognosis of severe haemoptysis. The therapeutic management should be undertaken urgently by providing general supportive care, i.e., optimization of oxygenation and haemodynamic stabilization to prevent recurrence of massive bleeding. Interventional radiology has dramatically improved the initial management of severe haemoptysis. Attempts to control haemoptysis by first-line non-surgical methods are necessary to optimize the operative conditions and improve morbidity and mortality. Surgical lung resection remains the treatment of choice in selected patients with localized lesions complicated by severe and/or recurrent episodes of haemoptysis (bronchiectasis) or lesions associated with a high risk of recurrence of bleeding (mycetoma). Haemoptysis related to pulmonary arterial involvement remains a surgical emergency.