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Hemoptysis Hemoptysis is coughing up blood from the respiratory tract. The blood can come from the nose, mouth, throat, the airway passages leading to the lungs. The word "hemoptysis" comes from the Greek "haima," meaning "blood," and "ptysis," which means "a spitting"
Blood not from lower respiratory tract it come from above the vocal cords:
Aspiration of hematemsis
Colonization by grame negative bacteria (seratia blue)
Massive Hemoptesis: It is the amount of blood that can not be cleared from the dead space (150ml). It is about 600ml blood/24 h X-sanguating Hemoptesis: Rate of bleeding >150ml/h
Pathophysiologic Factors: 1-Dual Circulation: The lungs have a dual blood supply. The pulmonary arterial circulation, a high-compliance, low-pressure system that terminates in the pulmonary capillary bed, is responsible for gas exchange.
In addition, the lungs are supplied by the bronchial arteries, branches of the aorta that bring nutrients to the lung parenchyma and major airways. The bronchial arteries, like all systemic arteries, are a high-pressure system. Most cases of hemoptysis result from disruption of branches of the bronchial arterial tree.
2- Vascular Mechanisms :
Direct invasion central pulmonary artery trauma
Causes Blood-tinged mucus in a healthy nonsmoker usually indicates a mild infection and is generally no cause for concern. Indeed, the most common cause of Hemoptysis is the least serious – a ruptured small blood vessel caused by coughing and/or a bronchitic infection In patients with a history of smoking or who are otherwise at risk for lung disease, however, Hemoptysis is often a sign of serious illness, including cancer
Cardiovascular Severe left ventricular heart failure Mitral stenosis Pulmonary embolism or infarction Septic pulmonary embolism or right-sided endocarditis Aortic aneurysm or bronchovascular fistula
Miscellaneous Idiopathic Pulmonary Hemosiderosis Aspirated foreign body Pulmonary contusion or trauma Posttransthoracic needle biopsy or transbronchial lung biopsy Factitious hemoptysis
Deficiency of vitamin K–dependent factors: prothrombin (II), Stuart factor (X), factor VII, Christmas factor (IX)
Disseminated intravascular coaulation
Fibrinolytic therapy: urokinase , streptokinase.
Evaluation of Hemoptysis
1-Types of Hemoptesis:
Blood tinged sputum
Red current jully
2-Degree of Hemoptysis:
Causes of Blood streaked Sputum :
Upper respiratory inflammation
Nose or Nasopharynx
Severe coughing paroxysms
Causes of Pink Sputum :
Blood and secretions mix in alveoli, small bronchioles
Conditions associated with pink Sputum
Causes of Heavy Bleeding into Respiratory tree :
Actinomycosis Lung Abscess
Blastomycosis Lung Abscess
To differentiate between source of Hemoptysis:
Mitral valve disease
The doctor will examine the patient's nose, throat, mouth, and chest for bleeding from these areas and for signs of chest trauma. The doctor also listens to the patient's breathing and heart beat for indications of heart abnormalities or lung disease .
Laboratory tests include blood tests to rule out clotting disorders, and to look for food particles or other evidence of blood from the stomach. Sputum can be tested for fungi, bacteria, or parasites .
X - Ray and Bronchoscopy
Chest x rays and bronchoscopy are the most important studies for evaluating hemoptysis. They are used to evaluate the cause, location, and extent of the bleeding.
Value of Bronchoscope
Localize site of bleeding
Suction and lavage
Preservation ventilation of non bleeding lung
Type of Bronchoscope
The rigid bronchoscope is more preferable than fiber optic one due to it has wide channel for suction of blood and for therapeutic treatment to arrest bleeding.
Imaging and other tests
Computed Tomography scans (CT scans) are used to detect aneurysms and to confirm x-ray results.
Ventilation-perfusion scanning is used to rule out pulmonary embolism. The doctor may also order an angiogram to rule out pulmonary embolism, or to locate a source of bleeding that could not be seen with the bronchoscope .
In spite of the number of diagnostic tests, the cause of Hemoptysis cannot be determined in 20-30% of cases .
Complication of Hemoptysis
Three Goals of Therapy :
Treat primary disease
Endotracheal intubation a. selective intubation
Arterial blood gas, if appropriate
Renal function testing
Type and cross match blood
Smear, culture and cytology of sputum
DLCO for pulmonary hemorrhage
Antibiotics if indicated
Medical management if nonlocalized bleeding, severely impaired pulmonary function, disseminated terminal carcinoma, advanced bilateral pulmonary disease, vasculitis
Bronchial artery Embolization
Intracavitary Anti-fungal therapy
Medically managed patients with massive Hemoptysis: 75%
Surgically managed patients with massive Hemoptysis: 23%