This document discusses the approach to hemoptysis and epistaxis. It begins by defining hemoptysis as the expectoration of blood from the respiratory tract. For massive hemoptysis, emergent intervention is required. Epistaxis is defined as bleeding from inside the nose. The document then covers the anatomy, etiology, history, physical exam findings, diagnostic studies, and interventions for hemoptysis. It also discusses anterior vs posterior epistaxis, local and general causes of epistaxis, common bleeding sites in the nose, and factors to consider in the management of epistaxis.

1. APPROACH TO
HEMOPTYSIS AND
EPISTAXIS
BY – SHUBHAM KAMDE

2. HEMOPTYSIS
• Hemoptysis is the expectoration of blood from the respiratory tract.
• The first step in evaluation is to ascertain whether the bleeding is coming from the
respiratory tree or instead originating from the nasal cavities (i.e., epistaxis) or the
gastrointestinal tract (i.e., hematemesis) as the therapies for these etiologies will
be significantly different.
• Massive or life-threatening hemoptysis (>400 mL of blood in 24 h or >150 mL at
one time) requires emergent intervention.

5. ANATOMY AND PHYSIOLOGY
• Hemoptysis can arise from anywhere in the respiratory tract; from the glottis to the
alveolus.
• Most commonly, bleeding arises from the bronchi or medium sized airways, but a
thorough evaluation of the entire respiratory tree is often necessary.
• The lungs are supplied with a dual circulation.
• The pulmonary arteries arise from the right ventricle to supply the pulmonary
parenchyma in a low-pressure circuit.
• The bronchial arteries arise from the aorta and carry blood under high systemic
pressure to the airways, blood vessels and visceral pleura.

7. ETIOLOGY
Infections
Most blood-tinged sputum and small-volume
hemoptysis is due to viral bronchitis. Patients with
chronic bronchitis are at risk for bacterial
superinfection with organisms such as
Streptococcus pneumoniae, Haemophilus
influenzae, or Moraxella catarrhalis, increasing
airway inflammation and potential for bleeding.
Similarly, patients with bronchiectasis are prone to
hemoptysis with exacerbations of
disease. Due to recurrent bacterial infection,
bronchiectatic airways are dilated, inflamed, and
highly vascular, supplied by the bronchial
circulation. In several case series, bronchiectasis is
the leading cause of
massive hemoptysis and subsequent death.

10. HISTORY
• A history of repeated small haemoptysis, or blood- streaking of sputum, is highly
suggestive of lung cancer.
• Fever, night sweats and weight loss suggest tuberculosis.
• Pneumococcal pneumonia often causes ‘rusty’-coloured sputum but can cause
frank haemoptysis, as can all suppurative pneumonic infections, including lung
abscess.
• pulmonary thromboembolism is a common cause of haemoptysis and should
always be considered.

11. PHYSICAL EXAMINATION
• Finger clubbing suggests lung cancer or bronchiectasis; other signs of
malignancy, such as cachexia, hepatomegaly and lymphadenopathy, should also
be sought.
• Fever, pleural rub and signs of consolidation occur in pneumonia or pulmonary
infarction; a minority of patients with pulmonary infarction also have unilateral leg
swelling or pain suggestive of deep venous thrombosis.
• Rashes, haematuria and digital infarcts point to an underlying systemic disease,
such as a vasculitis, which may be associated with haemoptysis.

12. DIAGNOSTIC STUDIES
• complete blood count to assess for infection, anemia, or thrombocytopenia,
coagulation parameters.
• Chest imaging is necessary for every patient.
• chest computed tomography (CT) with contrast should be obtained to better
identify masses, bronchiectasis, and parenchymal lesions.

13. INTERVENTION
IN MASSIVE OR LIFE THREATNING
HEMOPTYSIS
• protect the non bleeding lung - Protecting the airway and nonbleeding lung is paramount in
the management of massive hemoptysis because asphyxiation can happen quickly. If the
side of bleeding is known, the patient should be positioned with the bleeding side down to
use gravitational advantage to keep blood out of the nonbleeding lung.
• locate the site of bleeding - A chest radiograph, if it shows new opacities, can be helpful in
localizing the side or site of bleeding, although this test is not adequate by itself. CT
angiography helps by localizing active extravasation. Flexible bronchoscopy may be useful
to identify the side of bleeding.
• control the bleeding - a flexible bronchoscope can be used to suction clot and insert a
balloon catheter or bronchial blocker that occludes the involved airway. Rigid
bronchoscopy, done by an interventional pulmonologist or thoracic surgeon, may allow
therapeutic interventions of bleeding airway lesions such as photocoagulation and cautery

14. EPISTAXIS
-BLEEDING FROM INSIDE THE NOSE IS CALLED EPISTAXIS
• Nose is richly supplied by both the external and internal
carotid systems, both on the septum and the lateral
walls.

15. ANTERIOR VS POSTERIOR EPISTAXIS
• Anterior Epistaxis
When blood flows out from the front of
nose with the patient in sitting position.
• Posterior Epistaxis
Mainly the blood flows back into the
throat. Patient may swallow it and later
have a “coffee-coloured” vomitus. This
may erroneously be diagnosed as
haematemesis.

16. LOCAL CAUSES
- NOSE
1. Trauma - Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of
face and base of skull, hard-blowing of nose, violent sneeze.
2. Infections - (a) Acute: Viral rhinitis, nasal diphtheria, acute sinusitis.
(b) Chronic: All crust-forming diseases, e.g. atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis
septal perforation, granulomatous lesion of the nose, e.g. rhinosporidiosis.
3. Foreign bodies - (a) Nonliving: Any neglected foreign body, rhinolith.
(b) Living: Maggots, leeches.
4. Neoplasms of nose and paranasal sinuses. - (a) Benign: Haemangioma, papilloma.
(b) Malignant: Carcinoma or sarcoma.
5. Atmospheric changes - High altitudes, sudden decompression(Caisson disease).
6. Deviated nasal septum.

17. GENERAL CAUSES
• Cardiovascular system - Hypertension, arteriosclerosis, mitral stenosis, pregnancy (hypertension and
hormonal).
• Disorders of blood and blood vessels - Aplastic anaemia, leukaemia, thrombocytopenic and vascular
purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency and hereditary haemorrhagic
telangectasia.
• Liver disease - Hepatic cirrhosis (deficiency of factor II, VII, IX and X).
• Kidney disease - Chronic nephritis.
• Drugs - Excessive use of salicylates and other analgesics (as for joint pains or headaches),
anticoagulant therapy (for heart disease).
• Mediastinal compression - Tumours of mediastinum (raised venous pressure in the nose).
• Acute general infection - Influenza, measles, chickenpox, whooping cough, rheumatic fever, infectious
mononucleosis, typhoid, pneumonia, malaria and dengue fever.
• Vicarious menstruation - (epistaxis occurring at the time of menstruation).

18. SITE OF EPISTAXIS
1. Little’s area - In 90% cases of epistaxis, bleeding occurs from this
site.
2. Above the level of middle turbinate - Bleeding from above the
middle turbinate and corresponding area onthe septum is often from
the anterior and posterior ethmoidal vessels (internal carotid
system).
3. Below the level of middle turbinate - Here bleeding is from the
branches of sphenopalatine artery. It may be hidden, lying lateral to
middle or inferior turbinate and may require infrastructure of these
turbinates for localization of the bleeding site and placement of
packing to control it.
4. Posterior part of nasal cavity - Here blood flows directly into the
pharynx.
5. Diffuse - Both from septum and lateral nasal wall. This is often seen
in general systemic disorders and blood dyscrasias.

19. MANAGMENT
1. Mode of onset. Spontaneous or finger nail trauma.
2. Duration and frequency of bleeding.
3. Amount of blood loss.
4. Side of nose from where bleeding is occurring.
5. Whether bleeding is of anterior or posterior type.
6. Any known bleeding tendency in the patient or family.
7. History of known medical ailment (hypertension, leukaemia, mitral valve disease, cirrhosis and
nephritis).
8. History of drug intake (analgesics, anticoagulants, etc.).