2. Definition of hemoptysis
Definition of hemoptysis
Causes of
of hemoptysis
hemoptysis
Causes
Differential diagnosis of hemoptysis
of hemoptysis
Differential diagnosis
Diagnosis of hemoptysis
of hemoptysis
Diagnosis
Treatment of hemoptysis
of hemoptysis
Treatment
Contents
Contents
3. Pulmonary Bleeding
Pulmonary Bleeding (or pulmonary haemorrhage) is
an acute bleeding from the lung, from the upper respiratory tract and
the trachea, and the alveoli. When evident clinically, the condition is
usually massive.[1] The onset of pulmonary hemorrhage is characterized
by cough productive of blood (hemoptysis) and worsening of oxygenation
leading to cyanosis.[1] Treatment should be immediate and should include
tracheal suction, oxygen, positive pressure ventilation, and correction of
underlying abnormalities (e.g. disorders of coagulation). A blood
transfusion may be necessary.
4. Hemoptysis
Hemoptysis is defined as coughing of blood
is defined as coughing of blood
originating from below the vocal cords.
originating from below the vocal cords.
The word
word "hemoptysis"
The "hemoptysis" comes from
from the
the Greek
Greek
comes
"haima" meaning "blood“ & "ptysis" which means "a
"haima" meaning "blood“ & "ptysis" which means "a
spitting".
spitting".
Hemoptysis can range from
Hemoptysis can range from blood-streaking
blood-streaking ofof
sputum to the presence of gross blood in the absence
sputum to the presence of gross blood in the absence
of any accompanying sputum.
of any accompanying sputum.
Definition
Definition
5. Life threatening
threatening (or)
(or) Massive
Massive hemoptysis
hemoptysis
Life is
is
defined as coughing of blood > 150 ml/time (or)
blood > 150 ml/time (or) > 600
> 600
defined as coughing of
ml/24 hours.
ml/24 hours.
Only 5% of hemoptysis
hemoptysis is
is massive
Only 5% of massive but mortality is
but mortality is 80%.
80%.
Definition
Definition
11. Make sure that this
this is
is True Hemoptysis.
Make sure that True Hemoptysis.
Identify the Severity
Identify the Severity of hemoptysis.
of hemoptysis.
Clinical clues
clues in
in History
Clinical History & Examination.
& Examination.
Diagnostic Investigations.
Diagnostic Investigations.
Appropriate Treatment.
Appropriate Treatment.
Clinical Approach for Management of
Clinical Approach for Management of
Hemoptysis
Hemoptysis
12. Important points to address in History
Important points to address in History
Clinical Clues
Clues
Clinical Suggested Diagnosis
Suggested Diagnosis
Anticoagulant use
use
Anticoagulant Medication effect, coagulation disorder
coagulation disorder
Medication effect,
Association with menses
Association with menses Catamenial hemoptysis
hemoptysis
Catamenial
Dyspnea on exertion, fatigue,
fatigue, orthopnea,
PND, frothy pink sputum
orthopnea,
Dyspnea on exertion,
PND, frothy pink sputum
Congestive heart failure,
failure, Lt
Lt V.
V. dysfunction,
dysfunction, MS
MS
Congestive heart
Fever, productive cough
productive cough
Fever, URTI, acute bronchitis,
acute bronchitis, pneumonia,
pneumonia, lung abscess
lung abscess
URTI,
History of breast,
breast, colon,
colon, or
or renal
renal cancers
cancers
History of Endobronchial metastatic lung disease
metastatic lung disease
Endobronchial
History of chronic lung disease,
chronic lung disease, recurrent
recurrent
History of
LRTI, cough with copious purulent sputum
sputum
LRTI, cough with copious purulent
Bronchiectasis, lung abscess
lung abscess
Bronchiectasis,
Melena, alcoholism,
alcoholism, chronic use of
chronic use of NSAIDs
NSAIDs
Melena, Gastritis, gastric or
gastric or peptic ulcer,
peptic ulcer, esophageal
esophageal varices
varices
Gastritis,
Pleuritic chest pain,
pain, calf tenderness
calf tenderness
Pleuritic chest Pulmonary embolism or infarction
infarction
Pulmonary embolism or
Tobacco use
Tobacco use Acute bronchitis, chronic bronchitis,
chronic bronchitis, lung Ca,
lung Ca, pneumonia
pneumonia
Acute bronchitis,
Toxic symptoms
Toxic symptoms Tuberculosis
Tuberculosis
Weight loss
loss
Weight Emphysema, lung cancer,
lung cancer, TB,
TB, bronchiectasis,
bronchiectasis, lung abscess
lung abscess
Emphysema,
13. True Hemoptysis Versus
Spurious (False) Hemoptysis
True Hemoptysis Versus
Spurious (False) Hemoptysis
True hemoptysis
True hemoptysis False hemoptysis
False hemoptysis
Below vocal cords
cords
Below vocal Above vocal cords
cords
Above vocal
Persists as blood tinged sputum
blood tinged sputum
Persists as Does not persist
not persist
Does
May be mixed with sputum
May be mixed with sputum Not mixed with sputum
Not mixed with sputum
History of cardiopulmonary disease
History of cardiopulmonary disease Obvious by ENT examination
Obvious by ENT examination
CXR may be abnormal
CXR may be abnormal Normal CXR
CXR
Normal
14. Hemoptysis Versus Hematemsis
Hemoptysis Versus Hematemsis
Hemoptysis
Hemoptysis Hematemsis
Hematemsis
Coughing of blood
Coughing of blood Vomiting of blood
Vomiting of blood
History of cardiopulmonary disease
History of cardiopulmonary disease History of GIT disease
History of GIT disease
Bright red in color
red in color
Bright Dark brown in color
Dark brown in color
Sputum remains blood stained
blood stained
after the attack for few days
Sputum remains
after the attack for few days
Usually followed by melena
Usually followed by melena
Mixed with sputum
Mixed with sputum Mixed with gastric contents
contents
Mixed with gastric
Blood is frothy
frothy
Blood is Airless
Airless
Alkaline
Alkaline Acidic
Acidic
Sputum contains hemosedrin
laden macrophages
Sputum contains hemosedrin
laden macrophages
No
No
24. Advantages:
Advantages:
1)Tomography is valuable in selected cases
1)Tomography is valuable in selected cases to better
to better show the
show the
presence
presence
of lung cavities, solid masses,
solid masses, and mediastinal
and mediastinal & hilar
& hilar LDN.
LDN.
of lung cavities,
2)Its
2)Its complementary use with FOB gives
complementary use with FOB gives a greater
a greater positive yield of
positive yield of
pathology & is useful
useful for excluding malignancy in high-risk patients.
for excluding malignancy in high-risk patients.
pathology & is
3)Allows
3)Allows application of special
application of special imaging techniques:
imaging techniques: e.g.,
e.g.,
HRCT (1-3mm thickness section) →Bronchiectasis
HRCT (1-3mm thickness section) →Bronchiectasis
Spiral CT with pulmonary angiography →PE
Spiral CT with pulmonary angiography → PE
Diagnosis
Diagnosis
Computed Tomographic Scan (CT)
Computed Tomographic Scan (CT)
28. Advantages:
Advantages:
1.
1. It is diagnostic
diagnostic for central
for central endobronchial
endobronchial lesions.
lesions.
It is
2.
2. Allows direct visualization of the bleeding site.
direct visualization of the bleeding site.
Allows
3.
3. Permits tissue biopsy,
tissue biopsy, bronchial
bronchial lavage,
lavage, or brushings for pathologic
or brushings for pathologic
Permits
diagnosis.
diagnosis.
4.
4. FOB also can provide direct therapy in cases
therapy in cases of non massive
of non massive
FOB also can provide direct
hemoptysis:
hemoptysis:
Instillation of diluted adrenaline.
Instillation of diluted adrenaline.
Iced cooled saline.
Iced cooled saline.
Wedging & temponade →Fogarty catheter
Wedging & temponade → balloon
Fogarty catheter balloon
Diagnosis
Diagnosis
Fiberoptic Bronchoscopy (FOB)
Fiberoptic Bronchoscopy (FOB)
32. Angiography
Angiography
Advantages
Advantages :
:
1.
1. Gold standard diagnostic tool
tool for
for suspected PE.
suspected PE.
Gold standard diagnostic
2. Diagnosis
2. Diagnosis of
of arteriovenous malformation.
arteriovenous malformation.
3. Allows management
3. Allows management of
of some cases
some cases of
of hemoptysis
hemoptysis using
using
endovascular embolization.
endovascular embolization.
Disadvantages:
Disadvantages:
1.
1. Embolization of Spinal arteries →
Embolization of Spinal arteries → paraplegia.
paraplegia.
2. Needs special skills.
2. Needs special skills.
36. Management ofof Hemoptysis
Hemoptysis
Management
Goal
Goal :
:
1.
1. Evaluate the severity of hemoptysis.
hemoptysis.
Evaluate the severity of
2. Airway protection & patency.
2. Airway protection & patency.
3. Identify the site of
3. Identify the site of bleeding.
bleeding.
4. Protect the contralateral un involved lung.
4. Protect the contralateral un involved lung.
5. Stop the bleeding.
5. Stop the bleeding.
6. Treatment
6. Treatment of
of the cause of
the cause of bleeding.
bleeding.
38. Management of Massive
Massive
Management of
Hemoptysis
Hemoptysis
I.
I. Medical
Medical :
:
Endotacheal tube (single wide bore (or) double lumen).
double lumen).
Endotacheal tube (single wide bore (or)
Position of the patient
the patient sitting (or)
sitting (or) bleeding side down
bleeding side down
Position of
Large bore IV line fluids,
fluids, blood transfusion
blood transfusion (EXCEPT??)
Large bore IV line (EXCEPT??)
Supplemental Oxygen/ Mechanical ventilation.
Mechanical ventilation.
Supplemental Oxygen/
Avoid cough suppressants (if
(if necessary
necessary Benzodiazepine).
Benzodiazepine).
Avoid cough suppressants
Pitressin (Vasopressin) 0.2-0.4 units/min.
0.2-0.4 units/min. IV.
IV.
Pitressin (Vasopressin)
39. Management of Massive
Massive
Management of
Hemoptysis
Hemoptysis
II.
II. Surgical
Surgical :
:
Emergency resection for
Emergency resection for
bronchogenic mass.
bronchogenic mass.
Resection of
of bronchogenic
bronchogenic
Resection
mass after patient
mass after patient
stabilization.
stabilization.
Surgical resection for
Surgical resection for
aspergilloma.
aspergilloma.
40. Management of Massive
Massive
Management of
Hemoptysis
Hemoptysis
III. Endobronchial
III. Endobronchial :
:
Identify: S
Identify: Source, R
ource, Rate & to S
ate & to Slow (or) A
low (or) Arrest bleeding.
rrest bleeding.
43. IV.Endovascular:
IV. Endovascular:
First results of embolization were published in 1973
embolization were published in 1973.
First results of .
In most patients
bronchial arteries
the bleeding originates from
In most patients the bleeding originates from
bronchial arteries rather than pulmonary arteries.
rather than pulmonary arteries.
Transcatheter embolization is effective in immediate
Transcatheter embolization is effective in immediate
control of
of massive hemoptysis
massive hemoptysis (73% -
(73% - 98%).
98%).
control
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.
circulation.
Revascularization through collateral
Progression of basic lung disease.
lung disease.
Progression of basic
Management of Massive
Massive
Management of
Hemoptysis
Hemoptysis
44. Management of Massive
Massive
Management of
Hemoptysis
Hemoptysis
ICU Admission
ICU Admission
Conservative Medical Care
Conservative Medical Care
Rigid Bronchoscope
Rigid Bronchoscope
Hemoptysis stop
Hemoptysis stop
Investigate the cause
Investigate the cause
Hemoptysis did not stop
Hemoptysis did not stop
Surgical/Embolization
Surgical/Embolization
