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Hemoptysis

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Hemoptysis causes- Causes of Diffuse Alveolar Hemorrhage

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Hemoptysis

  1. 1. HEMOPTYSIS Dr. J. Roig Pulmonary Division Hospital N. Sra. de Meritxell Andorra
  2. 2. Life threatening hemoptysis (LTH)  LTH better than “massive” hemoptysis  Value of clinical history  Physical findings  Laboratory data  Chest X-ray  Optionally other image techniques  Bronchoscopy
  3. 3. Causes of hemoptysis  Infections  Bronchitis  Tuberculosis  Fungus  Pneumonia  Lung abscess  Bronchiectasis  Tumors  Bronchial cancer  Carcinoid  Cardiovascular  Lung infarct  Mitral stenosis  Trauma  Other  Foreign body  Hemorrhagic diatesis  Goodpasture and other immunological disorders
  4. 4. Orriols R et al. Aetiology of Life-threatening hemoptysis. Eur Resp J 1996;9(S23):315-16  Intubation: 7% (80 cases). Mortality rate 3.4%  Causes: Active tuberculosis 14 (12.1%) Sequels post TBC 22 (18.9%) Bronchiectasis 27 (23.3%) Unsure diagnosis 27 (23.3%) Bullous emphysema 10 (8.6%) Tumors 7 (6.1%) Aspergilloma 6 (5.2%) Mucoviscidosis 2 (1.9%)
  5. 5. Uncommon, sometimes neglected, causes of LTH: infections  Viral lung or bronchial infection (usually associated with disseminated iv coagulation and bleeding diathesis)  Necrotizing bronchial fungal infection  Bacterial endocarditis  Mycotic intrathoracic aneurisms  Hirudo medicinalis (common leech)
  6. 6. S. aureus infection in healthy •Gillet Y. Association between S. aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients. Lancet 2002;359:753- 59. •Boussaud V. Life-threatening hemoptysis in adults with CAP due to PV leukocidin-secreting S. aureus. Intensive Care Med 2003;29:1840-3. •Francis J. Severe Community-onset pneumonia in healthy adults caused by methicillin-resistant S. aureus carrying the PV leukocidin genes.CID2005
  7. 7. Tuberculosis - LTH  Active infection  Rasmussen pulmonary artery aneurism  Sequels post-tuberculosis: Bronchiectasis Broncholitiasis Mycetoma in residual cavities  “Scar carcinoma”
  8. 8. Aspergillus - Hemoptysis  Aspergilloma  Invasive aspergillosis  Chronic necrotizing aspergillosis or semiinvasive  Necrotizing pseudomembranous tracheobronchitis  Stump aspergillosis after lung resection  Bronchocentric granulomatosis
  9. 9. Lung abscess and LTH  Thomas NW. Life-threatening hemoptysis in primary lung abscess. Ann Thorac Surg 1972;14:347 Sequential filling-emptying pattern is a warning sign of massive hemoptysis in lung abscess: urgent surgery must be considered  Philpott NJ. Lung abscess: a neglected cause of life-threatening hemoptysis. Thorax 1993;48:674 Recommends surgery if LTH in chronic abscess
  10. 10. Uncommon, sometimes neglected, causes of LTH: cardiovascular  Eisenmenger syndrome  Mitral stenosis  Left ventricle pseudoaneurysm  Aortobronchial fistulas  Vascular pulmonary abnormalities associated with liver disease
  11. 11. Vascular disease BRONCHIAL CIRCULATION  Angiomes and aneurisms of bronchial arteries  Varicosities in chronic liver disease  Vasculitides  Arterial hypervascularization secondary to:  Inflammatory process  Tumors  Congenital heart disease  Chronic stenosis of pulmonary artery
  12. 12. Vascular disease SYSTEMIC CIRCULATION  Aortic dissection  Systemic Hypervascularization Intercostal arteries Other as mamary artery  Vasculitides
  13. 13. Vascular disease PULMONARY CIRCULATION  Pulmonary disease  Arteriovenous fistula  Tumors (angiosarcoma)  Aneurysms (micotic or not)  Primary pulmonary hypertension  Varicosities in chronic liver disease  Vasculitides
  14. 14. Vascular abnormalities in chronic liver disease  Man KM et al. Pulmonary varices presenting as a solitary lung mass in a patient with end-stage liver disease. Chest 1994;106:294-6.  Schnader J et al. Hemoptysis, hepatopulmonary syndrome and respiratory failure. Clinical conference on management dilemmas. Chest 1997;111:1724-32.  Youssef A et al. Hemoptysis secondary to bronchial varices associated with alcoholic liver cirrhosis and portal hypertension. Am J Gastroenterol 1994;89:1562-3.
  15. 15. Uncommon, sometimes neglected, causes of LTH: vasculitis  Tracheobronchial form of Wegener  Behçet vasculitis  Hughes-Stovin syndrome  Takayasu arteritis
  16. 16. Uncommon, sometimes neglected, causes of LTH: congenital abnormalities  Agenesis of pulmonary artery  Congenital anomalies of large mediastinal vessels, such as hemitruncus  Cystic disease with/without laryngeal papylomatosis  Pulmonary sequestration  Accessory cardiac bronchus
  17. 17. Uncommon, sometimes neglected, causes of LTH: tumors  Some pulmonary metastasis (angiosarcoma and hepatocellular carcinoma)  Some endobronchial metastasis (thyroid papillar carcinoma)  Cystic mediastinal mass  Inflammatory pseudotumor  Pulmonary cavernous hemangiomatosis
  18. 18. Uncommon, sometimes neglected, causes of LTH: other bronchial abnormalities  Broncholithiasis  Tracheopatia osteochondroplastica  Aspiration of foreign body
  19. 19. Causes of Diffuse Alveolar Hemorrhage (DAH) - 1  Bone marrow transplantation, especially autologous  Drug-induced pulmonary hemorrhage  Isolated pulmonary capillaritis with negative antineutrophil cytoplasmic antibodies  Pulmonary arterial fibromuscular dysplasia  DAH associated with high altitude edema  DAH with positive antiglomerular basement membrane antibodies without renal involvement  Idiopathic pulmonary hemosiderosis
  20. 20. Causes of Diffuse Alveolar Hemorrhage (DAH) - 2  Systemic vasculitides, collagen vascular diseases  Negative pressure alveolar hemorrhage  Serious group A streptococcal infections  Ehlers-Danlos syndrome  Crack-cocaine inhalation  Severe bleeding diathesis (DIC)  Trimellitic anhydride inhalation  Primary antiphospholipid syndrome  Lung transplant rejection  Pulmonary-renal syndrome  Pulmonary infection in immunocompromised  Pulmonary veno-occlusive disease
  21. 21. Keypoints in DAH  DAH may be the initial form of presentation  There is no correlation between the amount of expectorated blood and the real volume of alveolar bleeding  If glomerular involvement, deterioration of renal function may be very quick  Value of progressively hemorrhagic BAL  Value of sequential DLCO in non-acute setting
  22. 22. Uncommon, sometimes neglected, causes of LTH: miscellaneaous  Lymphangioleimyomatosis  Uremia  Exogenous lipid pneumonia  Intrathoracic Recklinghausen disease  Extreme breath-hold diving  Bullous emphysema  Broncholitis obliterans organizing pneumonia  Sarcoidosis  Respiratory bronchiolitis associated interstitial lung disease  Subphrenic abscess penetrating the diaphragm
  23. 23. LTH –Miscellaneous (1)  Thoracic trauma  Broncholitiasis  Foreign body  Hemorrhagic diathesis  Vasculitis – alveolar hemorrhage  Old, chronic scars (sequels): Middle lobe syndrome Emphysema (bullae)
  24. 24. LTH - Miscellaneous (2)  Fibrosing mediastinitis  Mediastinal tumors: teratoma  Esophageal cancer  Sarcoidosis  Septal diffuse amiloidosis  Fictitious hemoptysis
  25. 25. General measures in LTH  Immediate intubation and mechanical ventilation if  Asphyxia  Hypovolemic shock  Evaluate admission to the respiratory and ICU  Nothing by mouth  Ipsilateral decubitus lying on the alleged bleeding site  Intravenous line  Evaluate local applicability of the general algorithmic approach  Provision to allow rapid blood replacement  Control of bleeding speed and volume of expectorated blood  Chest radiograph  Routine blood tests: consider specialized tests if indicated  Consider specialized diagnostic procedures if indicated
  26. 26. Hemoptysis, X-ray and FOB  Misdiagnoses if classical criteria are followed  Hemoptysis > 7 days  Age > 40  Smoking habit  FOB in any hemoptysis without diagnosis:  Increasing incidence of tumor even in age < 40  Overall % of cancer on long-term follow-up: 4%  A variety of other non-tumor diagnoses by FOB  LTH is unpredictable  Low morbidity (0.08%) and mortality (0.01) of FOB
  27. 27. LTH: technical aspects of FOB  ENT evaluation is mandatory  Aspiration channel > 2.6 mm of Ø  Avoid FOB-related bleeding iatrogenia: Bronchiectasis Carcinoid tumor Bronchial angiomas Aneurysms of pulmonary artery Removal of old foreign body
  28. 28. Iatrogenic causes of LTH - 1  Surgical corrections of congenital heart disease  Endobronchial brachytherapy  Self-expanding, indwelling airway and esophageal stent- related fistulas  Bronchoscopy-related bleeding complications  Migration to lung of vascular and heart (cardioverter defribillator) patches  Aortobronchial fistula after vascular aortic thoracic graft  Coronary angiography with abciximab infusion  Late bleeding after anticoagulation therapy in pulmonary embolism  Bronchial artery infusion of cytostatic therapy to treat pulmonary metastasis
  29. 29. Iatrogenic causes of LTH - 2  Pulmonary irradiation  Lymphoma and other mediastinal tumors irradiation  Catheter-induced pulmonary artery lesion  Transtracheal aspiration  Percutaneous lung aspiration  Long-standing tracheostomy with tracheoinnominate artery fistula  Thrombolytic therapy, especially with unsuspected cavitary lung disease  Retained intrathoracic old gauze (“gauzeoma”) or sponge
  30. 30. Iatrogenic causes of LTH - 3  Bronchovascular fistula after lung transplantation  Drug-induced bleeding diathesis: DAH  Intravascular migration of fractured sternal wire after median sternotomy  Positive pressure ventilation in patients with cavitary tuberculosis  Bronchovascular fistula after lung transplantation  Bronchial stump aspergillosis in old endobronchial silk thread sutures  Hemoptysis secondary to veno-occlusive pulmonary disease (VOPD) after Glen operation  Pulmonary venous stenosis after catheter radiofrequency ablation
  31. 31. Hellical CT in LTH  Great blood vessels disease  Usually X-ray, FOB and BAE are first options  Often confusing “mass-like” images in lung parenchima  Frequent accumulation of blood at the bottom of both lungs.  Relevance of accurate technique: thin section, “helical CT”,…
  32. 32. General measures in LTH  Immediate intubation and mechanical ventilation if  Asphyxia  Hypovolemic shock  Evaluate admission to the respiratory and ICU  Nothing by mouth  Ipsilateral decubitus lying on the alleged bleeding site  Intravenous line  Evaluate local applicability of the general algorithmic approach  Provision to allow rapid blood replacement  Control of bleeding speed and volume of expectorated blood  Chest radiograph  Routine blood tests: consider specialized tests if indicated  Consider specialized diagnostic procedures if indicated
  33. 33. LTH General measures Transitory measures to stop bleeding Angiography with embolization Identification of the anatomical origin of bleeding Bronchoscopic measures + Is the patient stable and is resection technically feasible? Is surgery 1st ? Appropriate medical treatment Surgery YES NO YES NO
  34. 34. Bronchial artery embolization (BAE)  Anatomic variability both in number and localization  Direct visualization of site of bleeding is very difficult  Sometimes hypervascularized areas are extensive and bilateral  Sometimes origin of bleeding is in collateral systemic circulation  Percentage of origin of bleeding in pulmonary circulation is very low  Risk if anterior spinal artery from bronchial artery (<5%)
  35. 35. Complications of BAE  Spinal complication (paraplegia)  Chest pain  Dysphagia  Main-stem bronchus infarction  Bronchial stenosis  Splenic or other systemic infarct  Bronchial-esophageal fistula  Paradoxic embolization or migration of coil  Pulmonary hypertension (if left-to-right shunt)  Referres pain to the ipsilateral forehead and orbit
  36. 36. Drugs reported to be potentially effective in some causes of LTH  Tranexamix acid, especially in mucoviscidosis*  Vasopressin*  Immunosupressive drugs and steroids in some cases of DAH and vasculitis  Recombinant activated factor VII (rFVIIa)  Percutaneous intracavitary treatment in lung fungal infection  Cidofovir in juvenile laryngeal papillomatosis- related multicystic disease  Anticoagulant therapy in embolism  Hormone: LAM; thoracic endometriosis  Corrective therapy of coaguloptahies * Anecdotal reports and uncontrolled studies

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