This document discusses hemoptysis (coughing up blood). It defines hemoptysis and outlines its severity based on blood loss. The most common causes are tuberculosis, bronchiectasis, and lung cancers. A diagnostic evaluation involves history, physical exam, chest imaging like x-ray and CT, and bronchoscopy. Management depends on the severity, ranging from watchful waiting for mild cases to airway stabilization, bronchial artery embolization, and surgery for massive hemoptysis when more conservative options have failed. Endoscopic techniques like laser, electrocautery and hemostatic agents can help control bleeding locally.

1. Hemoptysis
Dr Dileep MD
Asst. Professor
Pulmonary Medicine
Mediciti Medical College
Hyderabad

2. • DEFINITION
• ETIOLOGY
• PATHOGENESIS
• DIAGNOSTIC EVALUATION
• MANAGEMENT

3. Definition
• Expectoration of blood ,the source of bleeding being below
the vocal cords, either from tracheobronchial tree or lungs
• It represents 6.8% of chest clinic visits & 11% of thoracic
surgical admissions

4. SEVERITY
Based on amount of blood lost during episode
• MILD <5cc in 24 hrs
• MODERATE 5-600cc in 24 hrs
• MASSIVE >600cc in 24 hrs
-Requires blood transfusion
-Hemodynamically unstable

5. • Mortality: 7- 30%( in non massive hemoptysis)
80% (in massive)
• Origin: in 90 % cases arises from bronchial arteries
5% cases from pulmonary arteries
5% cases from non bronchial systemic arteries

6. Etiology

8. Pathogenesis
TUBERCULOSIS: Bleeding may result from
a)Direct extension of infection into bronchial & pulmonary
arterioles
b)Bronchiectasis (post tubercular)
c)Rasmussen’s aneurysm(neovascularisation in large
parenchymal cavities d/t secondary infection with
mycetomas
d)Pressure of a calcified hilar lymph node on a bronchus

9. • BRONCHIECTASIS: bronchial arteries become enlarged,
tortuous ,ectatic & form extensive collateral vessels which
are prone to spontaneous rupture
• PULMONARY MALIGNANCIES:
may result in endobronchial involvement ,mucosal tumor
invasion ,tumor necrosis, secondary infection caused by
obstructing tumor

10. • MYCETOMAS: typically aspergillus may secondarily infect
cavitary lung disease,they cause bronchial artery dilatation
& invade the vascular intima
• LUNG ABSCESS: necrotising inflammation of lung
parenchyma eroding bronchial & pulmonary vessels

11. DIAGNOSTIC EVALUATION
HISTORY
PHYSICAL EXAMINATION
INVESTIGATIONS

12. HISTORY
• Differentiate true from pseudo hemoptysis and
hematemesis
• Pseudohemoptysis: Aggressive sinus &posterior nasal
bleeds typically results in aspiration of blood in to airway
• Hematemesis: Bleeding from the GIT

13. HISTORY(cont..)
• AGE: bronchiectasis or valvular lesions occur in pts <40yrs age
>40yrs with h/o smoking more likely it is d/t bronchogenic
neoplasm
• SYMPTOMS:
- Acute hemoptysis with chest pain: pulmonary embolism
- chr.cough with occasional hemoptysis: neoplasm,tb,etc..
- hemoptysis with fever &chills: pneumonia
- sob,edema,cardiomegaly: CHF
- purpura or bleeding from other sites: systemic disease
or coag. disorder

14. History(cont..)
• H/o episodic bleeding:
1)benign conditions
2)acute bronchitis superimposed on chr.br.
3)bronchial adenoma
4)bronchiectasis
• H/o accompanying kidney involvement:
1) Wegener’s granulomatosis
2) Good pastures syndrome
3) Collagen vascular diseases
• PAST H/O: Tuberculosis
Bronchiectasis

15. PHYSICAL EXAMINATION
• Clubbing , adenopathy and localised wheeze may represent
underlying malignancy
• Clubbing, copious sputum, coarse crackles: bronchiectasis
• Valvular heart lesions may typically be auscultated-murmurs
• Nasal septal ulcerations and cartilaginous deformities :WG
• Mucocutaneous telangectasia: osler-weber-rendu syndrome
• Petechiae: coagulopathy

16. LABORATORY EVALUTATION
• Initial work up : CBP, urine analysis, sputum for AFB smear, culture
& sensitivity, chest x-ray
-Platelet count, clotting profile,Hb
-BGT, cross matching, ABG
-RFT,LFT
• If pulm. embolism is suspected: ABG analysis, V/Q scan, pulm
angiography
• CHF : ECG, 2D ECHO

17. Chest radiographs
• Important for diagnosing and lateralisation of source of bleeding
• Malignancies,tb,bronchiectasis ,lung abscess can be strongly
suspected
LIMITATIONS: SEVERAL CAUSES MAY BE
RADIOGRAPHICALLY SILENT
(endobronchial malignancy, carcinoid tumor, bronchiolith, aorto
bronchial fistula, pulmonary embolism)

18. CT-CHEST
• It should be done for those cases where chest x-ray &
bronchoscopy did not diagnose or localise the pathology

20. Diagnostic bronchoscopy
• Early bronchoscopy :(48 hrs)
• Diagnostic yield is higher
• Likelyhood of localizing site is more
• Accurate localization may direct therapeutic
interventioin

21. MANAGEMENT
• NON MASSIVE
• MASSIVE

23. MANAGEMENT OF MASSIVE HEMOPTYSIS
• AIR WAY STABILISATION
• ENDOSCOPIC THERAPEUTICS
• TOPICAL AGENTS
• LASER BRONCHOSCOPY
• ELECTROCAUTERY
• BRONCHIAL ARTERY EMBOLISATION
• SURGERY

24. • 1)POSITION THE PATIENT :with bleeding site down
to protect the unaffected lung
• 2)Volume resuscitation
• 3)Anti tussive agents &sedatives: role is
controversial (use cautiously)
• 4)Hemostatic agents: tranexemic acid

25. AIR WAY STABILISATION
• Intubate and protect the “good lung”
• Isolate the bleeding lung
• Tamponade the source of bleeding

26. Airway techniques : 4 major strategies
1) Single lumen ET directed in to good lung

27. 2) Single lumen tube with a ballon blocker

28. 3) Single lumen tube & then bronchoscopically placed ballon
catheter in the bleeding lung

29. 4)Robertshaw’s double lumen ET

30. ENDOSCOPIC THERAPEUTICS
• Bronchoscopy is an imp. tool for evaluation &management of
these patients

31. • Rigid bronchoscope:
-b/c of large barrel size all therapeutic techniques may be easily
performed
-barrel itself can be used to core out tumors after
the blood supply has been adequately coagulated
Limitations- requires GA, inspection is limited to central airways
• Flexible bronchoscope: routinely performed, easily at bedside using
conscious sedation, detailed distal airway inspection is possible, can
be used along with rigid bronchoscopy

32. TOPICAL AGENTS
• Endoscopically applied topical agents that are
used to control the bleeding source
 Vasoconstrictive
 Procoagulant agents
these agents are injected in to the bleeding segment using
a bronchoscope

33. • Vasoconstrictive agents: cold saline lavage
(500ml)
epinephrine
• Pro coagulants: fibrin,fibrin precursors,fibrin-
thrombin glue preparations&
fibrinolytic inhibitors

34. LASER BRONCHOSCOPY
• CO2 LASER
• Nd:YAG laser – delivery fiber is small& flexible, hence used
through both rigid &flexible bronchoscope
• Limitations:
• 1)may ignite flammable structures such as
bronchoscopes,Ettubes,suction catheters etc.
2)Limited to those patients with focal endobronchial pathologies
3)There is no role for bronchoscopic laser therapy in hemoptysis
secondary to bronchiectasis, pulmonary AVMs,etc.

35. ELECTROCAUTERY
• Argon plasma coagulation(APC) is a non contact form of e.
cautery used to coagulate bleeding foci in airways

36. Bronchial artery embolisation
• Indications
• Anatomy
• Technique
• Embolic materials
• complications

37. INDICATIONS FOR BAE
 Bronchial embolization and non bronchial systemic
artery embolization
 Bilateral, advanced disease
 Vital capacity < 40%
 Inability of localize site of bleeding
 Non resectable Br CA with distant metastases
 Recurrent hemoptysis after traumatic or resective
surgery
 Refusal by patient for surgical intervention

38. BAE(CONT..)
• Anatomy: bronchial arteries arise from descending
thoracic aorta mc b/w T5-T6 vertebra
• Most common pattern is 2 on the left& one on right

39. • Technique of BAE:
• Preliminary descending thoracic aortogram
• Evaluate number & origin sites of bronchial arteries
• After catherisation of bronchial artery bronchial angiography
is performed by manual injection of contrast medium

40. BAE
• Angiographic findings in massive hemoptysis:
 hypertrophic &tortous bronchial arteries
 neovascularisation
 shunting into pulm. Artery or vein
 extravasition of contrast medium
 bronchial artery aneurysm

41. EMBOLIC AGENTS
 Gelatin sponge (GelfoamR)
 Polyvinyl alcohol(PVA)
 Microspheres
 Coils
 Spongel
 Polyurethane or velour plus albumin
 Macroaggregates plus sclerosing agents
 Gelatin sponge plus bucrylate
 Gelatin sponge plus coils
 Polyvinyl alcohol plus coils
 Polyvinyl alcohol plus gelatin sponge

42. CATHETERS
• Cobra type curved catheters are most
commonly used
• Simmons- 1
• Headhunter
• Yashoro-type
• Microcather

43. Embolisation using Coil and also poly vinyl alcohol

44. Tortuous rt intercostal artery
PRE POST

45. BAE(complications)
• Chest pain(ischemia)
• Dysphagia
• Spinal cord ischemia d/t occl. Of spinal arteries
(most disastrous complication)
• Pulmonary infarction
• Non target organ embolisation(ex:ischemic colitis)
• Recurrence may occur d/t recanalisation ,revascularisation
by collaterals,non bronchial systemic arterial supply
• In this sense BAE is a bridge procedure

46. Surgery
INDICATIONS:
1)Uncontrolled massive hemoptysis when the site of bleed has been
lateralised and localised to a segment or lobe
2)When embolisation is not available or not succesful
3)When bleeding from a known site with in a lung is assoc. with
persistent haemodynamic instability and resp.compr.
4)As definitive therapy in patients whose haemoptysis has stopped

47. SURGICAL TREATMENT
• GENERALLY THE LOBE CONTAINING THE BLEEDING
SITE IS IDENTIFIED
• IF MORE THAN ONE BLEEDING SITE EXISTS OR THE
REMAINING LUNG IS ALREADY DISEASED THE
WHOLE LUNG IS REMOVED
• IN NUTSHELL EITHER A LOBECTOMY OR A
PNEUMONECTOMY IS DONE

48. • Contraindications:
1)Arterial hypoxemia & co2 retention
2)Poor pulmonary reserve
3)Bilateral lung disease
4)lnability to localise the site of bleeding
5)Diffuse disease
6)Pulmonary hypertension(mpp>30mm Hg)

49. SURGERY COMPLICATIONS
• Morbidity-23-54%
• Post- op BPF-10-14%
• Empyema
• Hemorrhage requiring re-exploration
• Haemothorax
• Respiratory insufficiency req. proloned ventilation
• Mortality-10-50%

50. Thank You