Hemoptysis refers to coughing up blood from the respiratory tract. It can range from a small amount of blood-tinged mucus to life-threatening massive hemorrhage. Common causes include infections, lung cancer, and vascular conditions. Evaluation involves assessing the type and amount of bleeding along with diagnostic tests like chest imaging, sputum analysis, and bronchoscopy. Treatment focuses on stabilizing the patient, stopping the bleeding, and addressing the underlying cause through techniques such as bronchial artery embolization, surgery, or medications. Complications can include asphyxiation, shock, and infection if not properly managed.

1. H e m o p t y s i s Prepared by Dr. Tahany Mahmoud Banha Chest Department Banha University

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4. Hemoptysis Hemoptysis is coughing up blood from the respiratory tract. The blood can come from the nose, mouth, throat, the airway passages leading to the lungs. The word "hemoptysis" comes from the Greek "haima," meaning "blood," and "ptysis," which means "a spitting"

5. Pseudohemoptesis Causes: Blood not from lower respiratory tract it come from above the vocal cords: Mouth Pharynx Nose Aspiration of hematemsis Colonization by grame negative bacteria (seratia blue)‏

6. Massive Hemoptesis: It is the amount of blood that can not be cleared from the dead space (150ml). It is about 600ml blood/24 h X-sanguating Hemoptesis: Rate of bleeding >150ml/h

7. 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.

8. 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.

9. 2- Vascular Mechanisms : Aneurysm formation Vasculitis Pulmonary Embolism Inflammation Broncholithiasis Direct invasion central pulmonary artery trauma

10. Causes Blood-tinged mucus in a healthy nonsmoker usually indicates a mild infection and is generally no cause for concern. Indeed, the most common cause of Hemoptysis is the least serious – a ruptured small blood vessel caused by coughing and/or a bronchitic infection In patients with a history of smoking or who are otherwise at risk for lung disease, however, Hemoptysis is often a sign of serious illness, including cancer

11. Infectious: Chronic bronchitis Bronchiectasis Tuberculosis Nontuberculous mycobacteria Lung abscess Necrotizing pneumonia Mycetoma Cystic fibrosis Common Causes of Hemoptysis

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

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

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

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

16. Evaluation of Hemoptysis 1-Types of Hemoptesis: Blood tinged sputum Blood streaked Red current jully Frank Hemoptesis Rusty sputum 2-Degree of Hemoptysis: Massive Non massive

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

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

19. Causes of Heavy Bleeding into Respiratory tree : Pulmonary Tuberculosis Lung Abscess Bronchiectasis Pulmonary infarction Pulmonary Embolism Bronchogenic Carcinoma Broncholithiasis Mitral Stenosis Actinomycosis Lung Abscess Blastomycosis Lung Abscess

20. Diagnosis History: To differentiate between source of Hemoptysis: Respiratory Gastrointestinal Anticoagulant therapy Mitral valve disease

21. Physical Examination The doctor will examine the patient's nose, throat, mouth, and chest for bleeding from these areas and for signs of chest trauma. The doctor also listens to the patient's breathing and heart beat for indications of heart abnormalities or lung disease .

22. Laboratory Tests Laboratory tests include blood tests to rule out clotting disorders, and to look for food particles or other evidence of blood from the stomach. Sputum can be tested for fungi, bacteria, or parasites .

23. X - Ray and Bronchoscopy Chest x rays and bronchoscopy are the most important studies for evaluating hemoptysis. They are used to evaluate the cause, location, and extent of the bleeding.

24. Value of Bronchoscope 1-Dignostic: Localize site of bleeding F.B aspiration Adenoma 2-Therapeutic: Arrest bleeding Suction and lavage Preservation ventilation of non bleeding lung

25. Type of Bronchoscope The rigid bronchoscope is more preferable than fiber optic one due to it has wide channel for suction of blood and for therapeutic treatment to arrest bleeding.

26. Imaging and other tests Computed Tomography scans (CT scans) are used to detect aneurysms and to confirm x-ray results. Ventilation-perfusion scanning is used to rule out pulmonary embolism. The doctor may also order an angiogram to rule out pulmonary embolism, or to locate a source of bleeding that could not be seen with the bronchoscope . In spite of the number of diagnostic tests, the cause of Hemoptysis cannot be determined in 20-30% of cases .

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

30. Management

31. Three Goals of Therapy : Prevent asphyxiation Stop bleeding Treat primary disease Airway Control Supplemental oxygen Positioning Cough control Endotracheal intubation a. selective intubation Volume Resuscitation

32. Laboratory Evaluation Hematocrit Platelet count Coagulation profile Arterial blood gas, if appropriate Renal function testing Type and cross match blood Smear, culture and cytology of sputum DLCO for pulmonary hemorrhage

33. Consultations Surgical Definitive: resection Medical Antibiotics if indicated Medical management if nonlocalized bleeding, severely impaired pulmonary function, disseminated terminal carcinoma, advanced bilateral pulmonary disease, vasculitis

34. Modalities Bronchial artery Embolization Balloon Tamponade Intracavitary Anti-fungal therapy Mortality Medically managed patients with massive Hemoptysis: 75% Surgically managed patients with massive Hemoptysis: 23%

35. 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