Approach to patients with hemoptysis.pdf

1. Hemoptysis
Afnan Alawadh
Alanood AlHarthi
Aljoharah Aleisa
Amjad Alrizqi
Anfal Alshimmary
Asma AlHarbi
Deemah AlMazyad
Ebtesam Almajed
Jana Alyousef
Razan Alharthi
Dr. Ebtisam Bakhsh

2. Learning
Objectives
▪ Define Hemoptysis.
▪ Recognize the significance of Hemoptysis.
▪ Discuss the pathophysiology of Hemoptysis.
▪ Enlist the etiologies of Hemoptysis .
▪ Compare between Hemoptysis and hematemesis.
▪ Recognize the Clinical presentation of Hemoptysis.
▪ Identify the diagnostic measures for diagnosing
Hemoptysis.
▪ Outline the management and treatment of
Hemoptysis.
At the end of the presentation, a student should be able to:

4. Hemoptysis
Hema Ptysis
Blood Spitting

5. Definition of Hemoptysis
• Hemoptysis is defined as “the spitting of blood that originated in the lungs
or bronchial tubes.” - American Academy of Family Physicians
• Massive hemoptysis is a term used to describe a
large amount of expectorated blood or rapid rate
of bleeding, ranging from 100 mL/24hr to more
than 1,000 mL/24hr.

6. Significance of Hemoptysis
 Coughing up blood, irrespective of the amount is an alarming symptom.
 It can be a sign of a serious medical condition.
 Appropriate investigation must be done to exclude serious diseases.

7. Pathophysiology of
Hemoptysis

8. Pulmonary Venous Hypertension and Hemoptysis
 Any condition that results in Pulmonary Venous
Hypertension may cause hemoptysis.
 Left ventricular failure leads to increasingly high
pulmonary venous pressures. High pressure
damage venous walls, and manifest clinically as
hemoptysis.

9. Pulmonary Embolism and Hemoptysis
 Pulmonary embolism is responsible for
increase pulmonary vessels pressure by
blocking the pathway of blood flow and it
causes pulmonary infraction which leads the
pulmonary vessel to rupture.

10. Infections and Hemoptysis
 Inflammation of lung tissue can disrupt arterial and venous structures.
 Repetitive cough may damage the pulmonary vasculature.
Airway trauma, foreign body and Hemoptysis
 Airway trauma, and foreign body that causes disruption of blood
vessels may result in Hemoptysis.

11. Etiology of Hemoptysis

12. Causes of Hemoptysis
In developed countries:
• Acute bronchitis
• Bronchiectasis
• Bronchial neoplasms
In contrast, in developing countries,
infections due to
• Mycobacterium tuberculosis
• Paragonimus westermani
• Non-cystic fibrosis (CF)-related bronchiectasis.

13. Causes of non-life-threatening hemoptysis
Airway
diseases
Pulmonary
Parenchymal
diseases
Pulmonary
vascular
disorders
Trauma
and
bleeding
disorders
Miscellane
-ous

14. Bronchiectasis
Tuberculosis
Fungal infections
Bronchogenic carcinoma
Causes of
life-threatening
hemoptysis

16. Risk Factors of Hemoptysis
⁘ History of tobacco use
⁘ Vasculitis
⁘ Immunosuppression
⁘ Venous thromboembolism
⁘ Tuberculosis
⁘ History of coagulopathy
⁘ Use of antiplatelet or anticoagulant
medications
⁘ Exposure to toxins
⁘ Recent history of chest trauma.

17. Hemoptysis vs. Hematemesis?
Hemoptysis Hematemsis
History
- Absense of nausea and vomiting.
- Lung disease.
- Asphyxia is possible.
- Presence of nausea and vomiting.
- Gastric and hepatic disease.
- Asphyxia is unusal.
Sputum
- Frothy.
- Liquid or clotted apperance.
- Bright red or pink.
- Rarely frothy.
- Coffee ground appearance.
- Brown to black.

18. Clinical Presentation

19. Clinical Presentation
• The associated symptoms seen in patients presenting with hemoptysis
can play a major role in diagnosing the underlying disease:
 Weight loss Malignancy and tuberculosis.
 Ankle swelling Pulmonary edema or
heart failure.

20. Clinical Presentation
• The associated symptoms seen in patients presenting with hemoptysis
can play a major role in diagnosing the underlying disease:
 Orthopnea, dyspnea & fatigue Mitral valve stenosis or
congestive heart failure.
 Fever, chills, and chest pain Infection such as pneumonia.
 Dyspnea, pleuritic chest pain & tachycardia Pulmonary embolism.

21. Diagnostic Measures

22. 01
Diagnostic
Measures

23. History Taking
• Personal data
• Chief complaint &duration:
 Start with an Open question
e.g., What brought you here today?
 Coughing of blood, days/weeks

24. History Taking
• History of presenting illness:
 Onset of hemoptysis:
Gradually or suddenly
 Duration of hemoptysis:
Acute /chronic
 Course
 Frequency, Episodes

25. History Taking
• History of presenting illness:
 Character (color, clots):
 Bright red – lung cancer, TB.
 Pink frothy – acute pulmonary oedema.
 Amount:
Mild, moderate or massive >250ml/24h represents medical
emergency (E.g., carcinoma and tuberculosis).

26. History Taking
• Associated symptom:
 SOB
 Wheeze: indicates a respiratory cause bronchiectasis.
 Fever: may indicate infection such as pneumonia or tuberculosis
but low-grade fever can also be seen in cancer.
 Chest pain: mitral stenosis.

27. History Taking
• Associated symptom:
 Weight loss/anorexia: may indicate malignancy
 Night sweats: seen in malignancy and tuberculosis
 Ankle swelling & paroxysmal nocturnal dyspnea: seen in
pulmonary oedema
 Hoarseness of voice: can be due to upper respiratory tract
infection

28. History Taking
• Past medical & surgical history: chronic lung disease , TB , bleeding
disorder
• Medication history, allergies, and blood transfusion: E.g. Anticoagulants
• Travel history: foreign travel may predispose a patient to tuberculosis
• Family history: asthma, TB
• Social history: Smoking, occupation
• Menstrual and gynecological history in female
• Systems reviews
• Thank the patient

29. 02
Diagnostic
Measures

30. True hemoptysis VS pseudohemoptysis
The initial diagnostic evaluation should aim to differentiate between pseudohemoptysis and
hemoptysis.
Pseudohemoptysis can occur when:
1. Hematemesis is aspirated into the lungs.
2. Bleeding from the upper airway or the mouth stimulates a cough reflex
3. Material is expectorated that looks like blood but is not (e.g., Serratia
marcescens infection)

31. True hemoptysis VS pseudohemoptysis
The initial diagnostic evaluation should aim to differentiate between
pseudohemoptysis and hemoptysis.
• Characteristically, hemoptysis tends to be indicated by bright red, frothy
sputum that is alkaline.
• Instead, blood from extrapulmonary sources tends to be darker, may have
admixed food particles, and is acidic.
• Bleeding from the posterior nasal passage or nasopharynx may mimic
hemoptysis without obvious epistaxis.

32. PubMed central, Table II: Singapore Med J. 2016 Aug; 57(8): 415–418. doi: 10.11622/smedj.2016130
Differentials
for
Hemoptysis

33. 03
Diagnostic
Measures

34. Examination
1- General appearance:
 Whether the patient is breathless and then recognize his
breathing type.
 Rate and depth of respiration.

35. Examination
2- Check the vital signs.
3- Examine the eyes and hands:
• Pallor eyes
• Peripheral signs for respiratory disfunction:
− Clubbing.
− Peripheral cyanosis.
6- Lower limbs examination: Looking for edema or pulsations.
7- Back examination of patients with hemoptysis is usually normal.

36. Physical Examination
• The physical examination that consists of:
 Inspection.
 Palpation.
 Percussion.
 Auscultation.

37. Chest Examination
1- Inspection
The following should be assessed:
 The breathing pattern:
(bradypnea, tachypnea, apnea, hyperpnea).
 Abnormalities in the shape of the thorax:
(kyphosis or scoliosis).
 Sputum production or secretions.

38. Chest Examination
2- Palpation:
 Evaluate areas of tenderness.
 Symmetry of chest expansion.
 Check the position of the trachea.

39. Chest Examination
3- Percussion
• Always percuss both sides of the chest at the same level. Often the finding
of asymmetry is more important than the specific percussion note that is
heard.
• Assess diaphragmatic movement.
4- Auscultation:
• Physiological breath sounds( vesicular, tracheal, bronchial and
bronchovesicular breathing).
• Pathological sounds (wheezes, rales, Pleural friction rub or Muffled).

40. 04
Diagnostic
Measures

41. Laboratory studies
• CBC:
− To assess the chronicity and
magnitude of blood loss.
− WBC may suggest infection.

42. • Coagulation profile:
To exclude bleeding
disorders as contributing
factors
Laboratory studies

43. Laboratory studies
• Complete metabolic panel:
−To assess renal function
and screen for pulmonary-
renal syndromes, E.g.,
Goodpasture syndrome.
granulomatosis with
polyangiitis.
− To assess liver function

44. Laboratory studies
• Sputum culture
• TB testing:
−Tuberculin skin test with purified protein derivative (PPD)
−Interferon-gamma release assay (IGRA) with antigens
against Mycobacterium tuberculosis (M. tuberculosis)
−Acid-fast bacilli smear and culture
−Chest imaging
• Serologic testing for specific antibodies:
− if rheumatic disease suspected

45. IMAGING: Chest x-ray
• Purpose:
Localization of the cause of bleeding is it:
 Pneumonia
 Lung abscess
 Bronchial carcinoma
 Acute or chronic pulmonary tuberculosis

46. IMAGING: Chest x-ray
• Findings may include:
 Masses or large pulmonary nodules → suggestive of cancer
 Apical cavities, calcified nodules, or round infiltrates → tuberculosis
 Pulmonary edema → CHF or mitral stenosis
 Consolidation → pneumonia

47. IMAGING: Chest x-ray
Chest radiography in mild hemoptysis with
middle lobe densities from alveolar hemorrhages
• Findings may include:
 Multiple rib fractures → trauma
 Foreign body
 Hemo/pneumothorax
Normal findings (does not exclude life-
threatening conditions)

48. IMAGING: Multislice Computer Tomography
• Purpose:
 To localize the site of bleeding.
 To determine the underlying etiology.
• Indications:
All patients with life-threatening hemoptysis.
Patients with an uncertain diagnosis after chest X-ray.

49. IMAGING: Multislice Computer Tomography
• Etiologies diagnosed by CT:
 Bronchiectasis.
 TB and aspergilloma.
 Lung cancer.
 Vascular disease: fistula, AVM, arterial aneurysm.

50. IMAGING: CT Angiography
• Contrast is injected into the circulation to obtain real-time images.
• Diagnostic purpose:
 Identification of abnormal vascular structures
 Actual visualization of the bleeding (contrast extravasation) is rare.
• Therapeutic purpose:
 Embolization

51. IMAGING: Bronchoscopy
• Minimally invasive procedure using a scope
to visualize the larger airways
• Procedure of choice in most life-threatening
hemoptysis
• Perform within the 1st 12–24 hours of
presentation.

52. IMAGING: Bronchoscopy
Bronchoscope visualization of blood in the left
main bronchus originating from the periphery
of the left lower lobe
• Diagnostic purpose:
 To localize the site of bleeding.
 To determine the underlying etiology.
• Therapeutic purpose:
 To suction blood and thrombi and clear
the airways.
 To stop the bleeding: electrocautery,
laser therapy, epinephrine therapy, or
balloon tamponade.

53. Treatment &
Management

54. Treatment
• Treatment of hemoptysis ranging from outpatient
management to intensive care unit admittance.
• Choice of optimal management depends on the intensity
of bleeding, degree of respiratory compromise, and
severity of underlying cardiorespiratory status.
• The overall goals of hemoptysis management are
threefold: bleeding control, aspiration prevention, and
therapy of the underlying cause.

55. Nonlife threatening or non-massive Hemoptysis
• Treatment for the underlying condition will
usually take care of bleeding that isn’t
dangerous.
• In case of bronchitis, antibiotics and cough
medicine are the best choices, and stop
smoking if the patient is smoker.
• An outpatient assessment by a
pulmonologist should be undertaken
if hemoptysis persists or remains
unexplained.

56. Life threatening or massive hemoptysis
• Massive hemoptysis necessitates a more
vigorous, quick response.
• Intensive treatment and early contact
with a pulmonologist are required for
these patients.
• Diagnosis and treatment must happen at
the same time in cases of massive or life-
threatening hemoptysis.

57. 1) Intubation is a procedure that's used when the
patient can’t breathe to make it easier to get air into
and out of the lungs
2) Ventilation (extra O2)
3) Body position in which the lung with possible
bleeding is lower than the other lung
Treatment & Management of Hemoptysis
Hospitalize the patient in ICU , treatment could include:

58. If the source of bleeding known, try to stop it with:
• Iced saline.
• Medications to narrow blood vessels (vasoconstrictors) like
epinephrine or vasopressin.
• Medicines to help blood clot (coagulants) like tranexamic acid.
• Embolization: aim of the procedure is to stop the blood flowing
into the veins which are causing the hemoptysis whilst also
preserving blood flow to the surrounding area, Small resin
particles (microparticles) or small metal spirals (coils) will be
inserted into the bleeding vessel. This causes the vessel to
become blocked and so stops the bleeding.
Treatment & Management of Hemoptysis

59. • Doctor will treat whatever is causing patient to cough up blood
once he/she is no longer in danger. could get:
Antibiotics for TB or pneumonia
Lung cancer treatment options include chemotherapy and
radiation.
Steroids are used to treat inflammatory disorders.
• Surgery may be required in some circumstances. This could entail:
Removing one lobe (part) of the lung
Taking out the entire lung
Treatment & Management of Hemoptysis

61. Case 1:
• A 50-year-old man with a history of heavy smoking presents with a
cough and blood-tinged sputum for the past week associated with
fatigue, loss of appetite & weight and chest pain.
Which one of these factors would increase risk of hemoptysis?
A. Tobacco use
B. Diabetes Mellitus
C. Ventricular tachycardia

62. The correct answer is A..
Tobacco use

63. Case 2:
• A 46-year-old man presents with a cough that has produced blood-
streaked sputum for the past two days. Associated symptoms include
dyspnea, chest pain, and fever. The medical history is unremarkable. He
has never used tobacco and has not recently traveled or lost weight.
Which of the following is most probably the diagnosis?
A. Lung carcinoma.
B. Pneumonia.
C. Asthma.
D. Pulmonary embolism.

64. The correct answer is B..
Pneumonia

65. Case 3:
• A 41-year-old female presented to an outpatient clinic complaining of
coughing blood. During history taking, the patient said that he had
partial Bladder cystectomy two weeks ago.
Which of the following is the most likely diagnosis?
A. Pneumonia
B. TB
C. Pulmonary embolism
D. Goodpasture syndrome

66. The correct answer is C..
Pulmonary embolism

67. Case 4:
• A 40-year-old man who was recently diagnosed with bronchitis
presented to the emergency department with hemoptysis. The most
appropriate NEXT step in the management of this patient is:
A. Treat the patient with oral antibiotics
B. Vasoconstrictor
C. Embolization

68. The correct answer is A..
Oral antibiotics

69. Thank you!!
Any Qs?

70. References
• www.aafp.org/afp/2005/1001/p1253.html
• www.ncbi.nlm.nih.gov/pmc/articles/PMC5696556/
• www.ncbi.nlm.nih.gov/pmc/articles/PMC5478790/
• www.uptodate.com/contents/etiology-of-hemoptysis-in-adults?search=hemoptysis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#subscribeMessage
• manualofmedicine.com/topics/pulmonology/causes-evaluation-management-hemoptysis/
• www.aafp.org/afp/2015/0215/p243.html
• www.ncbi.nlm.nih.gov/pmc/articles/PMC4993964/
• www.ncbi.nlm.nih.gov/pmc/articles/PMC5478790/
• Clinical examination, Nicholas J Talley
• www.ncbi.nlm.nih.gov/pmc/articles/PMC4463269/
• Bickley L. Bates' Guide to Physical Examination and History-Taking. Lippincott Williams & Wilkins ; 2012
• Suyama, D., 2021. Investigation of hemoptysis (summary) | Radiology Reference Article | Radiopaedia.org. [online] Radiopaedia.org. Available at: <https://radiopaedia.org/articles/investigation-of-
haemoptysis-summary> [Accessed 31 September 2021].
• Shetty, A., 2021. Hemoptysis | Radiology Reference Article | Radiopaedia.org. [online] Radiopaedia.org. Available at: <https://radiopaedia.org/articles/haemoptysis-1?lang=us> [Accessed 31 August 2021].
• www.lecturio.com. 2021. Hemoptysis. [online] Available at: <https://app.lecturio.com/#/article/2861?return=__app__%2Flecture%2Fa%2F37294> [Accessed 31 August 2021].
• www.ncbi.nlm.nih.gov. 2021. The Diagnosis and Treatment of Hemoptysis. [online] Available at: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5478790/> [Accessed 31 August 2021].
• S. Agabegi, S. and D. Agabegi, E., 2019. Step-Up to Medicine. 5th ed. Lippincott Williams&Wilki, 2019, pp.254-256.
• www.ncbi.nlm.nih.gov/pmc/articles/PMC4993964/
• bestpractice.bmj.com/topics/en-us/1039
• www.webmd.com/lung/coughing-up-blood
• www.cirse.org/patients/ir-procedures/embolisation-for-haemoptysis/
• oxfordmedicine.com/view/10.1093/med/9780199600830.001.0001/med-9780199600830-chapter-127