Management of hemoptysis

1. HEMOPTYSIS
By
Dr Opeyemi C. M

2. Definition of hemoptysis
Causes of hemoptysis
Differential diagnosis of hemoptysis
Diagnosis of hemoptysis
Treatment of hemoptysis
Contents

3. Hemoptysis is defined as coughing of blood
originating from below the vocal cords.
The word "hemoptysis" comes from the Greek
"haima" meaning "blood“ & "ptysis" which means "a
spitting".
Hemoptysis can range from blood-streaking of
sputum to the presence of gross blood in the absence
of any accompanying sputum.
Definition

4. Life threatening (or) Massive hemoptysis is
defined as coughing of blood > 150 ml/episode (or) >
600 ml/24 hours.
Worldwide, the most common cause of hemoptysis is
tuberculous infection
The cause of hemoptysis cannot be determined in 20-30% of
cases.
Only 5% of hemoptysis is massive but mortality is 80%.
Definition

5. 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.

6. 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.

7. 2- Vascular Mechanisms:
• Aneurysm formation
• Vasculitis
• Pulmonary Embolism
• Inflammation
• Broncholithiasis
• Direct invasion of central pulmonary artery
• Trauma

8. Sources:
1. Bronchial circulation.
2. Pulmonary circulation.
3. Anatomizes between pulmonary & bronchial circulation.
Mechanisms:
1. Vessel engorgement.
2. Erosion (or) rupture of vessels.
3. Mucosal ulceration.
4. Vascular granulation tissue.
Mechanism & Sources of Hemoptysis

9. •Infectious:
Chronic bronchitis
Bronchiectasis
Tuberculosis
Nontuberculous mycobacteria
Lung abscess
Necrotizing pneumonia
Mycetoma
Common Causes of Hemoptysis

10. Neoplastic
Lung cancer
Bronchial adenoma
Metastatic disease (osteogenic sarcoma,
choriocarcinoma)
•Vasculitic
Wegener's granulomatosis
Systemic lupus erythematosus
Churge Strauss syndrome

11. Cardiovascular
Severe left ventricular heart failure
Mitral stenosis
Pulmonary embolism or infarction
Septic pulmonary embolism or right-sided
endocarditis
Aortic aneurysm or bronchovascular fistula

12. Miscellaneous
Idiopathic Pulmonary Hemosiderosis
Aspirated foreign body
Pulmonary contusion or trauma
Posttransthoracic needle biopsy or
transbronchial lung biopsy
Factitious hemoptysis

13. Bleeding Diathesis
 Anticoagulant therapy
 Deficiency of vitamin K–dependent factors:
prothrombin (II), Stuart factor (X), factor VII,
Christmas factor (IX)
 Disseminated intravascular coagulation
 Fibrinolytic therapy: urokinase,
streptokinase.

14. Tracheobronchial causes:
1. Bronchitis (acute & chronic).
2. Bronchiectasis.
3. Foreign body.
4. Tumor (e.g., bronchial carcinoma, tracheal & laryngeal tumors).
5. Bronchial telangectasia.
Cardiovascular causes:
1. Left Ventricular Failure.
2. Mitral stenosis.
3. Aortic aneurysm.
Cause of Hemoptysis

15. Pulmonary:
1. Tuberculosis.
2. Tumor.
3. Pneumonia.
4. Abscess.
5. Infarction.
6. Trauma.
7. Vasculitis & collagen disorders.
8. Cystic fibrosis.
9. Alveolar hemorrhage.
10.Arteriovenous malformation
Other causes:
1. Blood diseases.
2. Anticoagulant therapy.
Cause of Hemoptysis Cont.

16. Cause of Hemoptysis

17. 1. Pulmonary tuberculosis.
2. Pulmonary infarction.
3. Bronchiectasis.
4. Cystic fibrosis
5. Lung abscess.
6. Necrotizing pneumonia.
7. Mitral stenosis.
8. Pulmonary arteriovenous malformation.
Causes of Massive Hemoptysis

18. Make sure that this is True Hemoptysis.
Identify the Severity of hemoptysis.
Clinical clues in History & Examination.
Diagnostic Investigations.
Appropriate Treatment.
Clinical Approach for Management of
Hemoptysis

19. True Hemoptysis Versus
Spurious (False) Hemoptysis
True hemoptysis False hemoptysis
Below vocal cords Above vocal cords
Persists as blood tinged sputum Does not persist
May be mixed with sputum Not mixed with sputum
History of cardiopulmonary disease Obvious by ENT examination
CXR may be abnormal Normal CXR

20. Hemoptysis Vs Hematemesis
Hemoptysis Hematemesis
Coughing of blood Vomiting of blood
History of cardiopulmonary disease History of GIT disease
Bright red in color Dark brown in color
Sputum remains blood stained
after the attack for few days
Usually followed by melena
Mixed with sputum Mixed with gastric contents
Blood is frothy Airless
Alkaline Acidic
Sputum contains hemosedrin
laden macrophages
No

22. Important points to address in History
Clinical Clues Suggested Diagnosis
Anticoagulant use Medication effect, coagulation disorder
Association with menses Catamenial hemoptysis
Dyspnea on exertion, fatigue, orthopnea,
PND, frothy pink sputum
Congestive heart failure, Lt V. dysfunction, MS
Fever, productive cough URTI, acute bronchitis, pneumonia, lung abscess
History of breast, colon, or renal cancers Endobronchial metastatic lung disease
History of chronic lung disease, recurrent
LRTI, cough with copious purulent sputum
Bronchiectasis, lung abscess
Melena, alcoholism, chronic use of NSAIDs Gastritis, gastric or peptic ulcer, esophageal varices
Pleuritic chest pain, calf tenderness Pulmonary embolism or infarction
Tobacco use Acute bronchitis, chronic bronchitis, lung Ca, pneumonia
Toxic symptoms Tuberculosis
Weight loss Emphysema, lung cancer, TB, bronchiectasis, lung abscess

23. Examination
Clinical Clues Suggested Diagnosis
Cachexia, clubbing, hoarseness, Cushing's syndrome,
hyperpigmentation, Horner's syndrome
Bronchogenic carcinoma, SCLC
Clubbing Lung cancer, bronchiectasis, lung abscess
Dullness to percussion, fever, crepitations Pneumonia
Fever, tachypnea, hypoxia, working accessory respiratory
muscles, barrel chest, intercostal retractions, pursed lip
breathing, rhonchi, distant heart sounds
COPD, Lung cancer, pneumonia
Gingival thickening, saddle nose, nasal septum perforation Wegener's granulomatosis
Mid diastolic rumbling murmur MS
LN enlargement, cachexia, violaceous skin lesions Kaposi's sarcoma 2ry to HIV
Tachypnea, tachycardia, dyspnea, S1Q3T3, pleural friction
rub, unilateral leg pain & edema
Pulmonary thromboembolism
Orofacial & mucous membrane telangiectasia, epistaxis Osler-Weber-Rendu disease
Tachycardia, tachypnea, hypoxia, congested neck veins, S3
gallop, bilateral fine basal crepitations
CHF caused by Lt V. dysfunction or MS

24. Diagnosis
Laboratory Investigations
Test Diagnostic Findings
WBCs with differential ↑WBCs count & shift to the left in URTI & LRTI
Hemoglobin & hematocrit ↓ in anemia
Platelet count ↓ in thrombocytopenia
PT, INR & PTT ↑ in anticoagulant use, disorders of coagulation
ABGs Hypoxia, hypercarbia
D-dimer ↑ in pulmonary embolism
Sputum Gram stain, culture,
AFB smear & culture, fungi
stain & culture
Sputum Gram stain, culture, AFB & culture
Sputum cytology Neoplasm
Tuberculin Test Positive in TB
ESR
↑in infection, autoimmune disorders (e.g., Wegener's
syndrome, SLE, Goodpasture's syndrome) & malignancy

25. Diagnosis
Chest X Ray (CXR)
Chest Radiograph Suggestive Diagnosis
Cardiomegaly, increased
pulmonary vascular distribution
Chronic heart failure, mitral valve stenosis
Cavitary lesions Lung abscess, TB, necrotizing carcinoma
Diffuse alveolar infiltrates Chronic heart failure, pulmonary edema, aspiration
Hilar adenopathy or mass Carcinoma, metastatic disease, infection
Hyperinflation COPD
Lobar or segmental infiltrates Pneumonia, thromboembolism, obstructing carcinoma
Mass lesion, nodules, granulomas
Carcinoma, metastatic disease, Wegener's
granulomatosis, septic embolism, vasculitides
Patchy alveolar infiltrates
Bleeding disorders, idiopathic pulmonary
hemosiderosis, Goodpasture's syndrome

26. Diagnosis
CXR

27. Advantages:
1) Tomography is valuable in selected cases to better show the presence
of lung cavities, solid masses, and mediastinal & hilar LDN.
2) Its complementary use with FOB gives a greater positive yield of
pathology & is useful for excluding malignancy in high-risk patients.
3) Allows application of special imaging techniques: e.g.,
HRCT (1-3mm thickness section) Bronchiectasis
Spiral CT with pulmonary angiography PE
Diagnosis
Computed Tomographic Scan (CT)

28. Diagnosis
CT Scan

29. Diagnosis
CT Scan

30. Value of Bronchoscopy
1-Diagnostic:
 Localize site of bleeding
 Foreign Body aspiration
 Adenoma
2-Therapeutic:
 Arrest bleeding
 Suction and lavage
 Preservation ventilation of bleeding lung

31. Advantages:
1. It is diagnostic for central endobronchial lesions.
2. Allows direct visualization of the bleeding site.
3. Permits tissue biopsy, bronchial lavage, or brushings for pathologic
diagnosis.
4. FOB also can provide direct therapy in cases of non massive
hemoptysis:
Instillation of diluted adrenaline.
Iced cooled saline.
Wedging & tamponade Fogarty catheter balloon
Diagnosis
Fiberoptic Bronchoscopy (FOB)

32. Diagnosis
(FOB)

33. Advantages:
1. Wide suction channel.
2. Ensures ventilation.
3. Allows Interventional procedure application in cases of
massive hemoptysis e.g., Laser, Electrocautery,
Cryotherapy.
Disadvantages:
1. Requires general anesthesia.
2. Needs special skills.
Diagnosis
Rigid Bronchoscopy

34. Diagnosis
Rigid Bronchoscopy

35. Angiography
Advantages:
1. Gold standard diagnostic tool for suspected PE.
2. Diagnosis of arteriovenous malformation.
3. Allows management of some cases of hemoptysis using
endovascular embolization.
Disadvantages:
1. Embolization of Spinal arteries  paraplegia.
2. Needs special skills.

36. Angiography

37. Angiography

38. Ventilation/Perfusion Lung Scan
(V/Q scan)

39. Management of Hemoptysis
Goal:
1. Evaluate the severity of hemoptysis.
2. Airway protection & patency.
3. Identify the site of bleeding.
4. Protect the contralateral un involved lung.
5. Stop the bleeding.
6. Treatment of the cause of bleeding.

40. Management Principles
• Airway control
– Supplemental Oxygen
– Positioning
– Cough control
– Endotracheal intubation or Selective
intubation
• Volume resuscitation
– Crystalloids
– Blood

41. Evaluation of Hemoptysis
1-Types of Hemoptysis:
 Blood streaked
 Frank Hemoptysis
 Rusty sputum
2-Degree of Hemoptysis:
 Massive
 Non massive

42. Causes of Blood streaked Sputum:
 Upper respiratory inflammation
 Nose or Nasopharynx
 Gums
 Larynx
 Severe coughing paroxysms
 Trauma

43. Causes of Pink Sputum :
 Blood and secretions mix in alveoli, small
bronchioles
 Conditions associated with pink Sputum
– Pneumonia
– Pulmonary edema

44. Management of Hemoptysis
Non-Massive Massive
Treatment of the
underlying cause
Medical
Surgical
Endobronchial
Endovascular

45. Algorithm for Diagnosing Non-massive
Hemoptysis

46. Management of Massive
Hemoptysis
I. Medical:
Position of the patient sitting (or) bleeding side down
Large bore IV line fluids, blood transfusion
Supplemental Oxygen/ Mechanical ventilation.
Endotracheal tube (single wide bore (or) double lumen).
Cough suppressants
Pityressin (Vasopressin) 0.2-0.4 units/min. IV.

47. Management of Massive
Hemoptysis
II. Surgical:
Emergency resection for
bronchogenic mass.
Resection of bronchogenic
mass after patient
stabilization.
Surgical resection for
aspergilloma.

48. Management of Massive
Hemoptysis
III.Endobronchial:
Identify: Source, Rate & to Slow (or) Arrest bleeding.

49. Management of Massive
Hemoptysis

50. Management of Massive
Hemoptysis

51. IV.Endovascular:
First results of embolization were published in 1973.
In most patients the bleeding originates from
bronchial arteries rather than pulmonary arteries.
Transcatheter embolization is effective in immediate
control of massive hemoptysis (73% - 98%).
Recurrence may be caused by:
Incomplete embolization of artery.
Recanalization of previously embolized artery.
Revascularization through collateral circulation.
Progression of basic lung disease.
Management of Massive
Hemoptysis

52. Management of Massive
Hemoptysis
ICU Admission
Conservative Medical Care
Rigid Bronchoscope
Hemoptysis stop
Investigate the cause
Hemoptysis did not stop
Surgical/Embolization

53. Complication of Hemoptysis
 Asphyxia
 Shock
 Anemia
 Renal failure
 Atelectasis
 Pulmonary infection

54. Mortality
• Medically managed patients with massive
hemoptysis: 75%
• Surgically managed patients with massive
Hemoptysis: 23%

55. Role of Surgery in Hemoptysis
Surgery is indicated in the following situations:
• Leaky thoracic aneurysm
• Chest trauma
• A-V fistula
• Localized bronchiectasis
• Chronic lung abscess