SUPPLY:--They supply blood to the airways and to lesions within the airways , supply the supporting structures of the lung.
Bronchial arteries and collaterals from axillary, inter coastal(which supply parietal pleura) ,diaphragmatic branches are the main source of bleeding in 90% cases of hemoptysis
Figure 1. Diagrams illustrate the types of bronchial arterial supply: Type I, two bronchial arteries on the left and one on the right that manifests as an ICBT (40.6% of cases); Type II, one on the left and one ICBT on the right (21.3%); Type III, two on the left and two on the right (one ICBT and one bronchial artery) (20.6%); and Type IV, one on the left and two on the right (one ICBT and one bronchial artery) (9.7%).
Divides into rt and lft at level with 5th thoracic ventebra
Infection is the most common cause of hemoptysis, accounting for 60 to 70 percent of cases.
Infection causes superficial mucosal inflammation and edema that can lead to the rupture of the superficial blood vessels.
Bleeding from malignant or benign tumors can be secondary to superficial mucosal invasion, erosion into blood vessels, or highly vascular lesions
Massive hemoptysis is a medical emergency which requires immediate attention…which is shown by the stats shown here…..there is a high mortality of…
BECOZ MOST PATIENTS DIE OF ASPHYXIA DUE TO ASPIRATION AND NOT DUE TO BLOOD LOSS.
2. Provide suction. .
3. Secure airway with ET tube if required. OF size 8.0 or greater
Provide oxygen a: 2–10 L/min by nasal cannula or mask.
5. Monitor O2 saturations and titrate oxygen acc.
6.Monitor BP,Pulse,urine output regularly
7)If in shock or hypotension, begin infusion of crystalloid solutions , a total of 2–3 L of rapid,based on clinical assesment.
SIMULTANEOUSLY ONCE THE PATIENT IS GETTING STABILIZED SEND BLOOD COUNTS.to correct any blood loss and other blood investigations
for any causative lesions or infiltrates resulting from pulmonary haemorrhage.
Figure 9. Bronchial artery. Contrast-enhanced CT scan shows a pathologic left bronchial artery (arrow) that originates from the anterior wall of the descending thoracic aorta.
Figure 8. Bronchial artery. Contrast-enhanced CT scan shows a pathologic right bronchial artery (arrow) that originates from the anteromedial aspect of the thoracic aorta and a hypertrophic left bronchial artery in the aortopulmonary window (arrowheads).
Figure 10c. Value of preliminary thoracic aortography. (a) Descending thoracic aortogram demonstrates two hypertrophic bronchial arteries (solid arrows) and one intervening intercostal artery (open arrow) that supply a hypervascular lesion in the right upper lobe. (b) On a selective upper bronchial angiogram, the bronchial artery that supplies the large hypervascular lesion is seen to have an anomalous origin from the inferior aspect of the aortic arch. Marked bronchopulmonary shunting is also noted. (c) Selective lower bronchial angiogram shows a hypertrophic artery that supplies the hypervascular lesion, along with marked bronchopulmonary shunting. (d) Selective intercostal angiogram shows a hypertrophic artery that supplies the hypervascular lesion, along with bronchopulmonary shunting. The two bronchial arteries and the intervening intercostal artery were selectively embolized with polyvinyl alcohol particles. Postembolization angiograms (not shown) demonstrated occlusion of each vessel, with no opacification of the hypervascular lesion and no pulmonary arterial shunting.
Management of airway is very important because most patients die of asphyxia and not due to blood loss.
in the intial assessment one should be very careful in assessing the the airway patency and resort to procedure or manouveres to maintain it…
In the initial measures,after making the patient lie in lateral decubitus position towards the the side of the lesion and securing the air way….if hemoptysis still persists ,we go for selective lung intubation….
left main stem brochus during a right lung bleed or rt main stem in left lung bleed. Intubating rt is more easier. Risk = blocking R UL bronchus )
Early bronchoscopy gives a higher yield(90%) for localising the site of bleeding.(in 24 -48 hrs)best-24 hrs.
the timing of the procedure did not alter therapeutic decisions or clinical outcome in nonmassive hemoptysis.
RIGID bronchoscope is a rigid metal tube.
Set of stainless steel ventilating and non ventilating rigid tubes ,rigid forceps,rigid bronchoscope with indwelling hopkins lens telescope.(0 DEGREE)
Usage requires expertise and training which most pulmonologists are lacking
I think our ENT colleagues in our hospital have hands on experience….
first case of endobronchial irrigation with cold saline for the early management of hemoptysis in 1980 .
For better suction capacity, thus enabling a better view of the involved area.
following bronchial brushing and biopsy procedures
Because the drug is diluted and washed away.
Because of high plasma level following endobronchial application of epinephrine with significant CVS effects - hypertension and tachyarrythmias
Topical antidiuretic hormone derivatives, such as ornipressin, for their vasoconstrictive effect are being used these days with minimal effects.
Topical administration of TA within the bronchial tree has been described only recently
Mainly used orally or IV for treatment or prophylaxis of mucosal bleeding in patients with bleeding disorders or following major surgery.
Fogarthy balloon catheter-placed through the FOB and is inflated in the segmental and sub segmental bronchus
Control of left sided massive haemoptysis by tracheal intubation, placement, and inflation of a Fogarty catheter in the left main bronchus
Placement of a Fogarty catheter guided by fibreoptic bronchoscopy to control massive bleeding from a segmental bronchus.
Adequate temporary control of bleeding, allowing patients to stabilize before endovascular embolization was achieved
Cold saline and topical vasoactive agents were only partially effective in controlling bleeding.
A rigid bronchoscope initially allowed aspiration of blood and removal of clots in the bronchial tree.
A flexible biopsy forceps was introduced through a flexible FOB, with its distal end out of the bronchoscope, grasping a 6-mm silicone spigot.
The FOB was then inserted into the rigid bronchoscope, and advanced towards the posterior segment of the right upper lobe, where the spigot was left in place under direct vision.
Endobronchial embolization of the posterior segment of the right upper lobe with a silicone spigot as a temporary treatment for massive hemoptysis
(ADD)This procedure was performed in patients with persistent hemorrhage despite bronchoscopic wedging into the bleeding bronchus, coldsaline lavage and local administration of epinephrine. thereby serving as a hemostatic adjunct in the control of bleeding.
After it is saturated with blood, it swells into a brownish or black gelatinous mass that aids in the formation of a clot.
The oxidized regenerated cellulose mesh was grasped with a biopsy forceps in the FOB.
It was then pulled back into the bronchoscope and introduced into the bleeding airway, ranging from lobar to subsegmental bronchi.
In patients who cannot tolerate occlusion of the bleeding airway
since the oxidized regenerated cellulose mesh is absorbed
A catheter (2 mm of outer diameter) meant for passing through the fiberoptic bronchoscopic channel for gluing;
.After catheter was passed through the bronchoscope channel to place it slowly into the bleeding segment.
(B) the bronchoscope in situ, with the catheter tip out from the distal end;
0.5 mL n-butyl cyanoacrylate glue was injected through the catheter.
(c) placement of the catheter in the bleeding subsegment and instillation of the glue endobronchially
The catheter was withdrawn within a few seconds along with the bronchoscope.
procedure was repeated until the hemostasis was achieved.
Achieves photoresection and vaporization of the underlying lesion-DEFINITIVE approach in Mx of hemoptysis
. Indications for malignant tracheobronchial tumors: -Endoluminal tumors presenting with symptomatic airway obstruction and/or bleeding.
Failure of laser therapy to stop the bleeding was often observed in patients with bronchoscopically invisible sites of hemorrhage.
argon plasma is used as medium to conduct high-frequency electrical current through a flexible probe.
needs a special catheter allowing for the argon gas and the electrical current flow
As blood is a good conductor for the high-frequency current, effective dessication of a bleeding bronchus can be performed.
Use of a suction catheter for airway clearance and visualization of active bleeding arising from a bronchial artery.
While suctioning, laser allows simultaneous coagulation and devascularization of tissues surrounding the artery
Most of our colleagues are very much using cautry in OUR OTS.
Like lasers and APC ,heat and tissue interaction TAKES PLACE HERE .
Heat is generated through the application of high-frequency electric currents to coagulate or vaporize tissue depending on the stength of current we use.
contact probe is the medium to conduct the electric current
causing massive or recurrent hemoptysis
of bleeding after embolization range from
(BAE) as first-line therapy was the major change in the recent 5-year period.
Figure 2. Right intercostobronchial artery. On a selective right ICBT angiogram, an intercostal branch (solid arrows) and the right bronchial artery (open arrows) are seen to arise from a common trunk.
Figure 3. Common bronchial trunk. On a selective bronchial angiogram, the right intercostobronchial artery (black arrow) and a pathologic left bronchial artery (white arrow) are seen to arise from a common trunk and supply hypervascular lesions in the left lower lobe.
(Inexpensive, easy to handle, controllable embolic size but resolvable,lack radioopacity)
Selective intercostal angiogram shows hypervascular areas and a small amount of pulmonary arterial shunting (open arrow) at the periphery of the left lower lung field. Note the small radicular artery (solid arrow) that arises from the proximal portion of the intercostal artery.
Postembolization angiogram shows a microcatheter (arrows) that has been advanced into the intercostal artery beyond the origin of the radicular artery.
No ischaemia and no neurologic damage
Used in pulmonary artery aneurysms
to avoid tissue ischemia and neurologic damage
Figure 17b. Coil embolization. (a) Selective right internal mammary angiogram shows small branches that supply a hypervascular staining lesion in the right upper lobe, as well as a pseudoaneurysm (arrow). (b) On a postembolization angiogram obtained after deposition of two coils (arrows) at both the proximal and distal portions of the origin site of the small branches and use of additional polyvinyl alcohol particles, neither the hypervascular lesion nor the pseudoaneurysm is visualized.
Recurrence of hemoptysis may be due to incomplete embolization of the bronchial vessels, recannalization of the embolized arteries, presence of nonbronchial systemic arteries, or development of collateral circulation in response to continuing pulmonary inflammation
Technical failure is caused by non-bronchial artery collaterals from systemic vessels such as the phrenic, intercostal, mammary,(PLEURA) or subclavian Arteries.
1.The most feared complication due to non target occlusion of branches.
When the anterior spinal artery is identified as originating from the bronchial artery, embolisation is often deferred owing to the risk of infaction and paraparesis.
the anterior spinal artery is the blood vessel that supplies the anterior portion of the spinal cord. It arises from branches of the vertebral arteries and is supplied by the anterior segmental medullary arteries, including the artery of Adamkiewicz, and courses along the anterior aspect of the spinal cord
Disruption of the anterior spinal cord leads to bilateral disruption of the corticospinal tract, causing motor deficits, and bilateral disruption of the spinothalamic tract, causing sensory deficits in the form of pain/temperature sense loss
resistant to other treatment.
Dr Nahid Sherbini
Consultant IM & Pulmonary
KFH ,Medina ,SA
2. Definition of Hemoptysis
• The spitting of blood derived from the lungs or
bronchial tubes as a result of pulmonary or
Stedman TL. Stedman’s Medical dictionary. 27th ed. Philidelphia: Lipincott Williams & Wilkins, 2000
3. Severity Classification
GRADE AMOUNT /24 HRS
Mild < 50 ml
Moderate 50 - 200 ml
Severe**/Major* > 200 ml * 150 ml per 12 hrs or**
>400 ml per 24 hrs
Massive > 600 ml
Life-threatening 200 ml/h or 50 ml/h with
*Corey R, Hla KM.Am J Med Sci 1987; 294:301–309.
**de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F. Respir Med 2003; 97: 790–795
#Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 1982; 84: 829–833.
4. Massive hemoptysis
• Up to 1000 mL (1)
• Either ≥500 mL of expectorated blood over a 24 h or
bleeding at a rate ≥100 mL/h, regardless of whether
abnormal gas exchange or hemodynamic instability
(1)Major and massive hemoptysis: reassessment of conservative management.-
Corey R, Hla Am J Med Sci. 1987;294(5):301.
5. Bronchial arteries (90%)
Source of bleeding
*Remy J, Remy-Jardin M, Voisin C: Endovascular management of bronchial bleeding; in Butler J
(ed): The Bronchial Circulation. New York, Dekker, 1992, pp 667–723.
8. Pulmonary arterial system
• Low pressure system
• 8-25mmHg .
• Fungal infections
• Necrotizing pneumonia and lung abscess
• Bacterial endocarditis with septic emboli
• Parasitic (paragonimiasis, hydatid cyst)
It is the most common cause of hemoptysis worldwide
with 2 billion people infected worldwide with 5-10% developing
disease (Public Health Reports. Vol. 3. New York: World Health Organization; 1996: p. 8–9.)
14. RISK FACTORS FOR MORTALITY
1. Infiltrates involving 2 or more quadrants on an
2. Bleeding from the pulmonary artery
6. Mechanical Ventilation
& Aspiration in to contralateral lung *
Early prediction of in-hospital mortality of patients with hemoptysis: an approach to
defining severe hemoptysis.Fartoukh M, Khoshnood B, Parrot A, Khalil A, Carette MF,
Stoclin A, Mayaud C, Cadranel J, Ancel PY -Respiration. 2012;83(2):106.
15. Predictors of Mortality
71% in patients who lost =>600 ml
of blood in 4 h
22% in patients with =>600 ml
within 4–16 h
5% in those with 600 ml of within
Life-threatening massive : 5 to 15%.
• *Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis. Arch Intern Med
17. Air way
AND blood products
18. INITIAL STEPS
1. IDENTIFY WHICH SIDE IS BLEEDING
2. POSITION THE PATIENT
3. ESTABLISH A PATENT AIRWAY
4. INSURE ADEQUATE GAS EXCHANGE
5. INSURE ADEQUATE CVS FUNCTION
6. CONTROL THE BLEEDING
19. DIAGNOSTIC MODALITIES
• Does the patient have known pulmonary, cardiac, or renal
• Prior hemoptysis, other pulmonary symptoms, or
• FH of hemoptysis, brain aneurysms, epistaxis, or GI ? a
• Exposed to asbestos?
• Bleeding disorder? DVT risk?
• Has the patient had (TB) or been exposed to TB?
21. Physical Examination
• A skin rash,Splinter hemorrhages ,Needle tracks IE
• An audible chest bruit or murmur that increases with
inspiration a large pulmonary AV malformation.
• P2, TR or PR, or RV lift
• Heart murmurs MS , CHD
• DVT signs
22. Laboratory tests
• Type and cross-matching
• CBC ,COAG
• Electrolytes, BUN
• Liver function tests
• Special tests
• Site of bleeding in 33–82% *of cases.
• Underlying cause in 35%**.
• Rarely normal
*Khalil A, Soussan M, Mangiapan G, Fartoukh M, Parrot A, Carette MF: Utility of high-resolution chest CT scan in the emergency
management of hemoptysis in the intensive care unit: severity, localization and aetiology. BJR 2007; 80: 21–25.
**Hirshberg B, Biran I, Glazer M, Kramer MR:Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest
1997; 112: 440–444.
• Flexible bronchoscopy is the initial diagnostic procedure
of choice :
performed at the bedside, it is readily available, and it is
highly successful at localizing the bleeding site if it is
performed while the patient is bleeding.
• Intubation should be considered .
Massive hemoptysis. Assessment and management. Cahill BC, Ingbar DH
Clin Chest Med. 1994;15(1):147.
25. CT SCAN
• Superior to CXR
• Correct localization in 70–88.5% of cases*
Multidetector CT - bronchial and nonbronchial systemic
• Better than bronchoscopy for determining the cause of
*Haponik EF, Britt EJ, Smith PL, Bleecker ER:Computed chest tomography in the evaluation of hemoptysis: impact on diagnosis and
treatment. Chest 1987; 91: 80–85.
• Persistent bleeding following bronchoscopy.
• The preceding bronchoscopy may be helpful in
identifying the area of bleeding assisting the
radiologist in locating the precise bleeding site.
• Therapeutic embolization is possible during the
diagnostic arteriography procedure.
38. Selective Intubation
SINGLE LUMEN ETT
the non bleeding lung.
Selective intubation of L Main bronchus
in R sided massive hemoptysis
39. Selective Intubation
DOUBLE LUMEN ETT
Specially designed for
selective intubation of
the right or left main
Last option in an
40. FOB - diagnostic
• Identifies the site of
bleeding in 73–93%*
Early versus delayed.
*Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB: Utility of fiberoptic bronchoscopy before bronchial artery
embolization for massive hemoptysis. AJR Am J Roentgenol 2001; 177: 861–867.
41. RIGID BRONCHOSCOPE
• Larger lumen-
• Improved suctioning
• Better clearance
• Improved visualization
• Continuous OPENING FOR
• Performed at bedside
• Access:UL/distal orifices
• CAN DO Lavage
• Topical anaesthesia
• Poor visibility of
peripheral lesions and
• Poor suction
• Air way patency is not
44. Cold-Saline Lavage
• Lavage: Normal saline at 4 ° C , 50 mL aliquots
• It Stopped the bleeding with massive hemoptysis
obviating the need for emergency thoracotomy.*
Rigid scope is better over FOB
*Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R: Massive hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg
1983; 85: 120–124.
• Antifibrinolytic drug
• Route : PO ,IV & Topical
• Endobronchial :*
DOSE: 500–1,000 mg
• Response time: seconds
* Solomonov A, Fruchter O, Zuckerman T,Brenner B, Yigla M:
Pulmonary hemorrhage: a novel mode of therapy. Respir Med
2009; 103: 1196–1200.
• Local application
• Immediate arrest of bleeding.
• Initial strategy before BAE.*
• Alternative treatment when
endovascular procedures cannot
*Wong LT, Lillquist YP, Culham G, DeJong BP, Davidson AG:
Treatment of recurrent hemoptysis in a child with cystic fibrosis by
repeated bronchial artery embolizations and long-term tranexamic
acid. Pediatr Pulmonol 1996; 22: 275–279
47. Balloon Tamponade
• Life threatening
• 4 Fr 100 cm Fogarthy
balloon catheter by FOB.
• Inflated for 24-48 hrs
* Hiebert C: Balloon catheter control of lifethreatening hemoptysis. Chest 1974; 66: 308– 309.
• Air way protection
• Allows gas exchange
• Supports patient before
embolization or surgery
• Ischemic mucosal injury
• Post obstructive pneumonia.
49. EndobronchialAirway Blockade(Silicone Spigot)
• Silicone spigot is placed endobronchially .
Stabilizes patient before BEA
• *Dutau H , Palot A, Haas A, Decamps I, Durieux O: Endobronchial embolization with a silicone spigot as a
temporary treatment for massive hemoptysis. Respiration 2006; 73: 830–832.
50. A rigid bronchoscope initially allowed aspiration of
blood and removal of clots followed by cold saline
and topical vaso active agents ,clearing the vision
to place spigot
of the right upper lobe
Silicon spigots of various sizes
51. Distal end of flexibe biopsy forceps with
Spigot in place
6-mm silicone spigot
of the right upper lobe
A rigid bronchoscope initially allowed aspiration of
blood and removal of clots followed by cold saline
and topical vaso active agents ,clearing the vision
to place spigot
52. Following this procedure, the patient
underwent BAE, and the spigot
was removed 2 h later.
6-mm silicone spigot in place
of the right upper lobe
53. Bronchoscopy-Guided Topical Hemostatic
• Oxidized regenerated cellulose mesh
Saturates with blood-->brownish or black gelatinous
• Successful in life threatening hemoptysis.
• Immediate arrest of bleed: 98%(56 of 57)
*Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC: Bronchoscopy-guided topical hemostatic tamponade
therapy for the Management of life-threatening hemoptysis. Chest 2005; 127: 2113–2118.
55. Bronchoscopy-Guided Topical Hemostatic
Endobronchial view of a bleeding
subsegmental bronchus before THT
During bronchoscopy guided THT
56. Bronchoscopy-Guided Topical Hemostatic
• Not suitable for proximal sites, trachea.
Patients who cannot tolerate occlusion.
Recurrence of hemoptysis
57. Endobronchial Sealing with Biocompatible
• Material: n-butyl cyanoacrylate(adhesive)
• Injected into the bleeding airway through a catheter via a
• Used in mild hemoptysis.
• * *Parthasarathi Bhattacharyya et al Bronchoscopy Centre, Calcutta,
India(CHEST 2002; 121:2066–2069)
58. Endobronchial Sealing with Biocompatible Glue
59. Laser Photocoagulation
• Nd-YAG laser
• Effective in: Bronchoscopically visible source.
• Photocoagulation of the bleeding mucosa with resulting
Achieves photoresection and vaporization
*Dumon JF, Reboud E, Garbe L, Aucomte F, Meric B: Treatment of tracheobronchial lesions by laser photoresection.
Chest 1982; 81: 278–284.
60. Argon Plasma Coagulation(APC)
• TYPE : Thermal tissue
• Non contact electrocoagulation
In bronchoscopically visible
areas of sources of bleed
*Keller CA, Hinerman R, Singh A, Alvarez F: The use of
endoscopic argon plasma coagulation In airway
complications after solid organ transplantation. Chest
2001; 119: 1968–1975.
Flooding of the
the bleeding site
62. • Once desired desiccation (dry) is done ,deeper penetration
and damage to further tissue SHOULD stopped.*
• Used for superficial and spreading lesions.
Advantages of APC over YAG laser.:
• It provides easy access to lesions.
• Allows homogeneous tissue desiccation.
63. Endobronchial Electrocautery
• TYPE: Thermal tissue
• Coagulation mode: contact
• Readily available
Contact probesElectro cautery machine
Probe through working channel
64. • Indications :
- Bleeding, endobronchial growth &
• Less expensive alternative to laser.
• Control of haemoptysis using
endobronchial electro cautery was
achieved in 75%* of the cases
Homasson JP: Endobronchial electrocautery. Semin Respir Crit Care
1997; 18: 535– 543
65. BronchialArtery Embolization
• Temporary or definitive
• Immediate control: 57–100% of patients**
Embolization : bronchial and nonbronchial
Long-term control: 70%-88%
*Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann Radiol (Paris)
1974; 17: 5–16.
**Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 33–37.
In a study conducted in China
mortality has come down from 15 % (1995-
1999)* to 0 % (2000-2005) with BAE.
*Shigemura N, Wan IY, Yu SCH: Multidisciplinary management of life-threatening massive hemoptysis: a 10-year
experience Ann Thorac Surg 2009; 87: 849–853.
To Stabilize patients before surgical resection or medical
As a definitive therapeutic approach in patients:
Who refuse surgery
Who are not candidates for surgery
Where surgery is contraindicated
Identification of the bleeding vessel by selective bronchial
Injection of particles in to the feeding vessel.
Embolizing materials or particles
Pre-embolisation bronchial angiogram
No abnormal circulation
75. Bronchial artery aneurysm
Hypervascular lesion with aneurysm
Pre embolisation Post embolisationPVA particles
No hypervascular lesion & aneurysm
76. Super selective Embolization of intercostal
Hypervascular areas and a small amount
of pulmonary arterial shunting
POST EMBOLIZATIONPRE EMBOLIZATION
Micro catheter passed
beyond radicular artery
77. Left upper lobe bronchial artery
Decreased vascularity & hypertrophyTortous and hypertrophied vessel
78. More About Materials
PVA particles (350-500 mic)
Most common & Safe
• Liquid embolic agents
Stainless steel platinum coils
-occlude more proximal vessels.
Particles > 200 to 250 micr.m should be used
IF LESS (Tissue infarction)
• Metallic coils (steel, titanium, or platinum) or detachable
balloons, coils should be 2 mm wider than the feeding
• If steel coils are used, MRI of the brain DELAYED. 6W
• Other : polyvinyl alcohol, wool coils, and Amplatzer
vascular plugs. Amplatzer plugs are relatively new. In
one study, Amplatzer plugs were used to successfully
occlude 120 out of 161 PAVM (75 %) in 69 patients .