Hemoptysis
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Hemoptysis Presentation Transcript

  • 1. HEMOPTYSISHEMOPTYSIS ByBy Iman Galal, MDIman Galal, MD Assistant Professor Pulmonary MedicineAssistant Professor Pulmonary Medicine Ain Shams UniversityAin Shams University E-mail: dr.imangalal@gmail.comE-mail: dr.imangalal@gmail.com
  • 2. Definition of hemoptysisDefinition of hemoptysis Causes of hemoptysisCauses of hemoptysis Differential diagnosis of hemoptysisDifferential diagnosis of hemoptysis Diagnosis of hemoptysisDiagnosis of hemoptysis Treatment of hemoptysisTreatment of hemoptysis ContentsContents
  • 3. HemoptysisHemoptysis is defined as coughing of bloodis defined as coughing of blood originating from below the vocal cords.originating from below the vocal cords. The wordThe word "hemoptysis""hemoptysis" comes from the Greekcomes from the Greek "haima""haima" meaning "blood“ &meaning "blood“ & "ptysis""ptysis" which means "awhich means "a spitting".spitting". HemoptysisHemoptysis can range fromcan range from blood-streakingblood-streaking ofof sputum to the presence ofsputum to the presence of gross bloodgross blood in the absencein the absence of any accompanying sputum.of any accompanying sputum. DefinitionDefinition
  • 4. Life threatening (or) Massive hemoptysisLife threatening (or) Massive hemoptysis isis defined as coughing of blood > 150 ml/time (or) > 600defined as coughing of blood > 150 ml/time (or) > 600 ml/24 hours.ml/24 hours. Only 5% of hemoptysis isOnly 5% of hemoptysis is massivemassive but mortality is 80%.but mortality is 80%. DefinitionDefinition
  • 5. Tracheobronchial causes:Tracheobronchial causes: 1. Bronchitis (acute & chronic).1. Bronchitis (acute & chronic). 2. Bronchiectasis.2. Bronchiectasis. 3. Foreign body.3. Foreign body. 4. Tumor (e.g., bronchial carcinoma, tracheal & laryngeal tumors).4. Tumor (e.g., bronchial carcinoma, tracheal & laryngeal tumors). 5. Bronchial telangectasia.5. Bronchial telangectasia. Cardiovascular causes:Cardiovascular causes: 1.1. Left Ventricular Failure.Left Ventricular Failure. 2. Mitral stenosis.2. Mitral stenosis. 3. Aortic aneurism.3. Aortic aneurism. Cause of HemoptysisCause of Hemoptysis
  • 6. Pulmonary:Pulmonary: 1. Tuberculosis.1. Tuberculosis. 2. Tumor.2. Tumor. 3. Pneumonia.3. Pneumonia. 4. Abscess.4. Abscess. 5. Infarction.5. Infarction. 6. Trauma.6. Trauma. 7. Vasculitis & collagen disorders.7. Vasculitis & collagen disorders. 8. Cystic fibrosis.8. Cystic fibrosis. 9. Alveolar hemorrhage.9. Alveolar hemorrhage. 10.Arteriovenous malformation10.Arteriovenous malformation Other causes:Other causes: 1. Blood diseases.1. Blood diseases. 2. Anticoagulant therapy.2. Anticoagulant therapy. Cause of HemoptysisCause of Hemoptysis Cont.Cont.
  • 7. Cause of HemoptysisCause of Hemoptysis
  • 8. 1.1. Pulmonary tuberculosis.Pulmonary tuberculosis. 2.2. Pulmonary infarction.Pulmonary infarction. 3.3. Bronchiectasis.Bronchiectasis. 4.4. Cystic fibrosisCystic fibrosis 5.5. Lung abscess.Lung abscess. 6.6. Necrotizing pneumonia.Necrotizing pneumonia. 7.7. Mitral stenosis.Mitral stenosis. 8.8. Pulmonary arteriovenous malformation.Pulmonary arteriovenous malformation. Causes of Massive HemoptysisCauses of Massive Hemoptysis
  • 9. Sources:Sources: 1.1. Bronchial circulation.Bronchial circulation. 2.2. Pulmonary circulation.Pulmonary circulation. 3.3. Anatomizes between pulmonary & bronchial circulation.Anatomizes between pulmonary & bronchial circulation. Mechanisms:Mechanisms: 1.1. Vessel engorgement.Vessel engorgement. 2.2. Erosion (or) rupture of vessels.Erosion (or) rupture of vessels. 3.3. Mucosal ulceration.Mucosal ulceration. 4.4. Vascular granulation tissue.Vascular granulation tissue. Mechanism & Sources of HemoptysisMechanism & Sources of Hemoptysis
  • 10. Make sure that this isMake sure that this is True Hemoptysis.True Hemoptysis. Identify theIdentify the SeveritySeverity of hemoptysis.of hemoptysis. Clinical clues inClinical clues in HistoryHistory && Examination.Examination. DiagnosticDiagnostic Investigations.Investigations. AppropriateAppropriate Treatment.Treatment. Clinical Approach for Management ofClinical Approach for Management of HemoptysisHemoptysis
  • 11. Important points to address in HistoryImportant points to address in History Clinical CluesClinical Clues Suggested DiagnosisSuggested Diagnosis Anticoagulant useAnticoagulant use Medication effect, coagulation disorderMedication effect, coagulation disorder Association with mensesAssociation with menses Catamenial hemoptysisCatamenial hemoptysis Dyspnea on exertion, fatigue, orthopnea,Dyspnea on exertion, fatigue, orthopnea, PND, frothy pink sputumPND, frothy pink sputum Congestive heart failure, Lt V. dysfunction, MSCongestive heart failure, Lt V. dysfunction, MS Fever, productive coughFever, productive cough URTI, acute bronchitis, pneumonia, lung abscessURTI, acute bronchitis, pneumonia, lung abscess History of breast, colon, or renal cancersHistory of breast, colon, or renal cancers Endobronchial metastatic lung diseaseEndobronchial metastatic lung disease History of chronic lung disease, recurrentHistory of chronic lung disease, recurrent LRTI, cough with copious purulent sputumLRTI, cough with copious purulent sputum Bronchiectasis, lung abscessBronchiectasis, lung abscess Melena, alcoholism, chronic use of NSAIDsMelena, alcoholism, chronic use of NSAIDs Gastritis, gastric or peptic ulcer, esophageal varicesGastritis, gastric or peptic ulcer, esophageal varices Pleuritic chest pain, calf tendernessPleuritic chest pain, calf tenderness Pulmonary embolism or infarctionPulmonary embolism or infarction Tobacco useTobacco use Acute bronchitis, chronic bronchitis, lung Ca, pneumoniaAcute bronchitis, chronic bronchitis, lung Ca, pneumonia Toxic symptomsToxic symptoms TuberculosisTuberculosis Weight lossWeight loss Emphysema, lung cancer, TB, bronchiectasis, lung abscessEmphysema, lung cancer, TB, bronchiectasis, lung abscess
  • 12. True Hemoptysis VersusTrue Hemoptysis Versus Spurious (False) HemoptysisSpurious (False) Hemoptysis True hemoptysisTrue hemoptysis False hemoptysisFalse hemoptysis Below vocal cordsBelow vocal cords Above vocal cordsAbove vocal cords Persists as blood tinged sputumPersists as blood tinged sputum Does not persistDoes not persist May be mixed with sputumMay be mixed with sputum Not mixed with sputumNot mixed with sputum History of cardiopulmonary diseaseHistory of cardiopulmonary disease Obvious by ENT examinationObvious by ENT examination CXR may be abnormalCXR may be abnormal Normal CXRNormal CXR
  • 13. Hemoptysis Versus HematemsisHemoptysis Versus Hematemsis HemoptysisHemoptysis HematemsisHematemsis Coughing of bloodCoughing of blood Vomiting of bloodVomiting of blood History of cardiopulmonary diseaseHistory of cardiopulmonary disease History of GIT diseaseHistory of GIT disease Bright red in colorBright red in color Dark brown in colorDark brown in color Sputum remains blood stainedSputum remains blood stained after the attack for few daysafter the attack for few days Usually followed by melenaUsually followed by melena Mixed with sputumMixed with sputum Mixed with gastric contentsMixed with gastric contents Blood is frothyBlood is frothy AirlessAirless AlkalineAlkaline AcidicAcidic Sputum contains hemosedrinSputum contains hemosedrin laden macrophagesladen macrophages NoNo
  • 14. ExaminationExamination Clinical CluesClinical Clues Suggested DiagnosisSuggested Diagnosis Cachexia, clubbing, hoarseness, Cushing's syndrome,Cachexia, clubbing, hoarseness, Cushing's syndrome, hyperpigmentation, Horner's syndromehyperpigmentation, Horner's syndrome Bronchogenic carcinoma, SCLCBronchogenic carcinoma, SCLC ClubbingClubbing Lung cancer, bronchiectasis, lung abscessLung cancer, bronchiectasis, lung abscess Dullness to percussion, fever, crepitationsDullness to percussion, fever, crepitations PneumoniaPneumonia Fever, tachypnea, hypoxia, working accessory respiratoryFever, tachypnea, hypoxia, working accessory respiratory muscles, barrel chest, intercostal retractions, pursed lipmuscles, barrel chest, intercostal retractions, pursed lip breathing, rhonchi, distant heart soundsbreathing, rhonchi, distant heart sounds COPD, Lung cancer, pneumoniaCOPD, Lung cancer, pneumonia Gingival thickening, saddle nose, nasal septum perforationGingival thickening, saddle nose, nasal septum perforation Wegener's granulomatosisWegener's granulomatosis Mid diastolic rumbling murmurMid diastolic rumbling murmur MSMS LN enlargement, cachexia, violaceous skin lesionsLN enlargement, cachexia, violaceous skin lesions Kaposi's sarcoma 2ry to HIVKaposi's sarcoma 2ry to HIV Tachypnea, tachycardia, dyspnea, S1Q3T3, pleural frictionTachypnea, tachycardia, dyspnea, S1Q3T3, pleural friction rub, unilateral leg pain & edemarub, unilateral leg pain & edema Pulmonary thromboembolismPulmonary thromboembolism Orofacial & mucous membrane telangiectasia, epistaxisOrofacial & mucous membrane telangiectasia, epistaxis Osler-Weber-Rendu diseaseOsler-Weber-Rendu disease Tachycardia, tachypnea, hypoxia, congested neck veins, S3Tachycardia, tachypnea, hypoxia, congested neck veins, S3 gallop, bilateral fine basal crepitationsgallop, bilateral fine basal crepitations CHF caused by Lt V. dysfunction or MSCHF caused by Lt V. dysfunction or MS
  • 15. DiagnosisDiagnosis Laboratory InvestigationsLaboratory Investigations TestTest Diagnostic FindingsDiagnostic Findings WBCs with differentialWBCs with differential ↑↑WBCs count & shift to the left in URTI & LRTIWBCs count & shift to the left in URTI & LRTI Hemoglobin & hematocritHemoglobin & hematocrit ↓↓ in anemiain anemia Platelet countPlatelet count ↓↓ in thrombocytopeniain thrombocytopenia PT, INR & PTTPT, INR & PTT ↑↑ in anticoagulant use, disorders of coagulationin anticoagulant use, disorders of coagulation ABGsABGs Hypoxia, hypercarbiaHypoxia, hypercarbia d-dimerd-dimer ↑↑ in pulmonary embolismin pulmonary embolism Sputum Gram stain, culture,Sputum Gram stain, culture, AFB smear & cultureAFB smear & culture Sputum Gram stain, culture, AFB & cultureSputum Gram stain, culture, AFB & culture Sputum cytologySputum cytology NeoplasmNeoplasm Tuberculin TestTuberculin Test PositivePositive in TBin TB ESRESR ↑↑in infection, autoimmune disorders (e.g., Wegener'sin infection, autoimmune disorders (e.g., Wegener's syndrome, SLE, Goodpasture's syndrome) & malignancysyndrome, SLE, Goodpasture's syndrome) & malignancy
  • 16. DiagnosisDiagnosis Chest X Ray (CXR)Chest X Ray (CXR) Chest RadiographChest Radiograph Suggestive DiagnosisSuggestive Diagnosis Cardiomegaly, increasedCardiomegaly, increased pulmonary vascular distributionpulmonary vascular distribution Chronic heart failure, mitral valve stenosisChronic heart failure, mitral valve stenosis Cavitary lesionsCavitary lesions Lung abscess, TB, necrotizing carcinomaLung abscess, TB, necrotizing carcinoma Diffuse alveolar infiltratesDiffuse alveolar infiltrates Chronic heart failure, pulmonary edema, aspirationChronic heart failure, pulmonary edema, aspiration Hilar adenopathy or massHilar adenopathy or mass Carcinoma, metastatic disease, infectionCarcinoma, metastatic disease, infection HyperinflationHyperinflation COPDCOPD Lobar or segmental infiltratesLobar or segmental infiltrates Pneumonia, thromboembolism, obstructing carcinomaPneumonia, thromboembolism, obstructing carcinoma Mass lesion, nodules, granulomasMass lesion, nodules, granulomas Carcinoma, metastatic disease, Wegener'sCarcinoma, metastatic disease, Wegener's granulomatosis, septic embolism, vasculitidesgranulomatosis, septic embolism, vasculitides Patchy alveolar infiltratesPatchy alveolar infiltrates Bleeding disorders, idiopathic pulmonaryBleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture's syndromehemosiderosis, Goodpasture's syndrome
  • 17. DiagnosisDiagnosis CXRCXR
  • 18. DiagnosisDiagnosis CXRCXR
  • 19. DiagnosisDiagnosis CXRCXR
  • 20. DiagnosisDiagnosis CXRCXR
  • 21. DiagnosisDiagnosis CXRCXR
  • 22. DiagnosisDiagnosis CXRCXR
  • 23. Advantages:Advantages: 1)1)Tomography is valuable in selected cases to better show theTomography is valuable in selected cases to better show the presencepresence of lung cavities, solid masses, and mediastinal & hilar LDN.of lung cavities, solid masses, and mediastinal & hilar LDN. 2)2)Its complementary use with FOB gives a greater positive yield ofIts complementary use with FOB gives a greater positive yield of pathology & is useful for excluding malignancy in high-risk patients.pathology & is useful for excluding malignancy in high-risk patients. 3)3)Allows application of special imaging techniques: e.g.,Allows application of special imaging techniques: e.g., HRCT (1-3mm thickness section)HRCT (1-3mm thickness section) →→BronchiectasisBronchiectasis Spiral CT with pulmonary angiographySpiral CT with pulmonary angiography →→PEPE DiagnosisDiagnosis Computed Tomographic Scan (CT)Computed Tomographic Scan (CT)
  • 24. DiagnosisDiagnosis CT ScanCT Scan
  • 25. DiagnosisDiagnosis CT ScanCT Scan
  • 26. DiagnosisDiagnosis CT ScanCT Scan
  • 27. Advantages:Advantages: 1.1. It is diagnostic for central endobronchial lesions.It is diagnostic for central endobronchial lesions. 2.2. Allows direct visualization of the bleeding site.Allows direct visualization of the bleeding site. 3.3. Permits tissue biopsy, bronchial lavage, or brushings for pathologicPermits tissue biopsy, bronchial lavage, or brushings for pathologic diagnosis.diagnosis. 4.4. FOB also can provide direct therapy in cases of non massiveFOB also can provide direct therapy in cases of non massive hemoptysis:hemoptysis: Instillation of diluted adrenaline.Instillation of diluted adrenaline. Iced cooled saline.Iced cooled saline. Wedging & temponadeWedging & temponade →→Fogarty catheter balloonFogarty catheter balloon DiagnosisDiagnosis Fiberoptic Bronchoscopy (FOB)Fiberoptic Bronchoscopy (FOB)
  • 28. DiagnosisDiagnosis (FOB)(FOB)
  • 29. AdvantagesAdvantages:: 1.1. Wide suction channel.Wide suction channel. 2.2. Ensures ventilation.Ensures ventilation. 3.3. Allows Interventional procedure application in cases ofAllows Interventional procedure application in cases of massive hemoptysis e.g., Laser, Electrocautery,massive hemoptysis e.g., Laser, Electrocautery, Cryotherapy.Cryotherapy. Disadvantages:Disadvantages: 1.1. Requires general anesthesia.Requires general anesthesia. 2.2. Needs special skills.Needs special skills. DiagnosisDiagnosis Rigid BronchoscopyRigid Bronchoscopy
  • 30. DiagnosisDiagnosis Rigid BronchoscopyRigid Bronchoscopy
  • 31. AngiographyAngiography AdvantagesAdvantages:: 1.1. Gold standard diagnostic tool for suspected PE.Gold standard diagnostic tool for suspected PE. 2.2. Diagnosis of arteriovenous malformation.Diagnosis of arteriovenous malformation. 3.3. Allows management of some cases of hemoptysis usingAllows management of some cases of hemoptysis using endovascular embolization.endovascular embolization. Disadvantages:Disadvantages: 1.1. Embolization of Spinal arteriesEmbolization of Spinal arteries →→ paraplegia.paraplegia. 2.2. Needs special skills.Needs special skills.
  • 32. AngiographyAngiography
  • 33. AngiographyAngiography
  • 34. Ventilation/Perfusion Lung ScanVentilation/Perfusion Lung Scan (V/Q scan)(V/Q scan)
  • 35. Algorithm for Diagnosing Non-massiveAlgorithm for Diagnosing Non-massive HemoptysisHemoptysis
  • 36. Management of HemoptysisManagement of Hemoptysis GoalGoal:: 1.1. Evaluate the severity of hemoptysis.Evaluate the severity of hemoptysis. 2.2. Airway protection & patency.Airway protection & patency. 3.3. Identify the site of bleeding.Identify the site of bleeding. 4.4. Protect the contralateral un involved lung.Protect the contralateral un involved lung. 5.5. Stop the bleeding.Stop the bleeding. 6.6. Treatment of the cause of bleeding.Treatment of the cause of bleeding.
  • 37. Management of HemoptysisManagement of Hemoptysis Non-MassiveNon-Massive MassiveMassive Treatment of theTreatment of the underlying causeunderlying cause MedicalMedical SurgicalSurgical EndobronchialEndobronchial EndovascularEndovascular
  • 38. Management of MassiveManagement of Massive HemoptysisHemoptysis I.I. MedicalMedical:: Endotacheal tube (single wide bore (or) double lumen).Endotacheal tube (single wide bore (or) double lumen). Position of the patient sitting (or) bleeding side downPosition of the patient sitting (or) bleeding side down Large bore IV line fluids, blood transfusionLarge bore IV line fluids, blood transfusion (EXCEPT??)(EXCEPT??) Supplemental Oxygen/ Mechanical ventilation.Supplemental Oxygen/ Mechanical ventilation. Avoid cough suppressants (if necessary Benzodiazepine).Avoid cough suppressants (if necessary Benzodiazepine). Pitressin (Vasopressin) 0.2-0.4 units/min. IV.Pitressin (Vasopressin) 0.2-0.4 units/min. IV.
  • 39. Management of MassiveManagement of Massive HemoptysisHemoptysis II.II. SurgicalSurgical:: Emergency resection forEmergency resection for bronchogenic mass.bronchogenic mass. Resection of bronchogenicResection of bronchogenic mass after patientmass after patient stabilization.stabilization. Surgical resection forSurgical resection for aspergilloma.aspergilloma.
  • 40. Management of MassiveManagement of Massive HemoptysisHemoptysis III.III.EndobronchialEndobronchial:: Identify:Identify: SSource,ource, RRate & toate & to SSlow (or)low (or) AArrest bleeding.rrest bleeding.
  • 41. Management of MassiveManagement of Massive HemoptysisHemoptysis
  • 42. Management of MassiveManagement of Massive HemoptysisHemoptysis
  • 43. IV.IV.Endovascular:Endovascular: First results of embolization were published in 1973First results of embolization were published in 1973.. In most patients the bleeding originates fromIn most patients the bleeding originates from bronchial arteriesbronchial arteries rather than pulmonary arteriesrather than pulmonary arteries.. Transcatheter embolization is effective in immediateTranscatheter embolization is effective in immediate control of massive hemoptysis (73% - 98%).control of massive hemoptysis (73% - 98%). Recurrence may be caused by:Recurrence may be caused by: Incomplete embolization of artery.Incomplete embolization of artery. Recanalization of previously embolized artery.Recanalization of previously embolized artery. Revascularization through collateral circulation.Revascularization through collateral circulation. Progression of basic lung disease.Progression of basic lung disease. Management of MassiveManagement of Massive HemoptysisHemoptysis
  • 44. Management of MassiveManagement of Massive HemoptysisHemoptysis ICU AdmissionICU Admission Conservative Medical CareConservative Medical Care Rigid BronchoscopeRigid Bronchoscope Hemoptysis stopHemoptysis stop Investigate the causeInvestigate the cause Hemoptysis did not stopHemoptysis did not stop Surgical/EmbolizationSurgical/Embolization