Iman Galal, MDIman Galal, MD
Assistant Professor Pulmonary MedicineAssistant Professor Pulmonary Medicine
Ain Shams UniversityAin Shams University
E-mail: firstname.lastname@example.orgE-mail: email@example.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
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
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.
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%.
1.1. Bronchial circulation.Bronchial circulation.
2.2. Pulmonary circulation.Pulmonary circulation.
3.3. Anatomizes between pulmonary & bronchial circulation.Anatomizes between pulmonary & bronchial circulation.
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.
Clinical Approach for Management ofClinical Approach for Management of
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
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
Sputum contains hemosedrinSputum contains hemosedrin
laden macrophagesladen macrophages
1)1)Tomography is valuable in selected cases to better show theTomography is valuable in selected cases to better show the
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
Computed Tomographic Scan (CT)Computed Tomographic Scan (CT)
CT ScanCT Scan
CT ScanCT Scan
CT ScanCT Scan
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
4.4. FOB also can provide direct therapy in cases of non massiveFOB also can provide direct therapy in cases of non massive
Instillation of diluted adrenaline.Instillation of diluted adrenaline.
Iced cooled saline.Iced cooled saline.
Wedging & temponadeWedging & temponade →→Fogarty catheter balloonFogarty catheter balloon
Fiberoptic Bronchoscopy (FOB)Fiberoptic Bronchoscopy (FOB)
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,
1.1. Requires general anesthesia.Requires general anesthesia.
2.2. Needs special skills.Needs special skills.
Rigid BronchoscopyRigid Bronchoscopy
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.
1.1. Embolization of Spinal arteriesEmbolization of Spinal arteries →→ paraplegia.paraplegia.
2.2. Needs special skills.Needs special skills.
35. Algorithm for Diagnosing Non-massiveAlgorithm for Diagnosing Non-massive
36. Management of HemoptysisManagement of Hemoptysis
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
Treatment of theTreatment of the
underlying causeunderlying cause
38. Management of MassiveManagement of Massive
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
Emergency resection forEmergency resection for
bronchogenic mass.bronchogenic mass.
Resection of bronchogenicResection of bronchogenic
mass after patientmass after patient
Surgical resection forSurgical resection for
40. Management of MassiveManagement of Massive
Identify:Identify: SSource,ource, RRate & toate & to SSlow (or)low (or) AArrest bleeding.rrest bleeding.
41. Management of MassiveManagement of Massive
42. Management of MassiveManagement of Massive
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
44. Management of MassiveManagement of Massive
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