An 80-year-old female presented with a 2-day history of coughing up blood in multiple episodes of approximately half a cup each time. She had a history of hypertension but no other significant medical history. HRCT chest and CTPA showed a pulmonary arteriovenous malformation (PAVM) on the left side. She was initially managed with bronchial artery embolization (BAE) which failed to control the recurrent massive hemoptysis. She was then treated conservatively with blood products, oxygen supplementation, and medications. When hemoptysis persisted, surgical resection was considered but deemed too high risk. A second attempt at BAE also failed. The patient was eventually discharged after hemoptysis resolved

1. HAEMOPTYSIS
DR MUSTAFA BASHIR

2. CASE HISTORY
80 Year female
Hypertension (on Telmisartan 40 mg OD), Non diabetic
Presented with 2 day history of
• Coughing out of blood
• Multiple episodes, approx. ½ Cup each episode.
• Associated with mild left sided chest discomfort and shortness of
breath.

3. • No History of
 Bleeding from other sites
 Fever , weight loss, Cough, purulent sputum, Wheezing
 Orthopnea,PND
 Swelling of Lower limbs
 Skin rash, arthritis
 Reduced urine output
 PAST History: No history of Pulm-tuberculosis
Similar History 4 weeks back

4. HRCT CHEST

5. CTPA

6. MANAGEMENT
• PATIENT WAS MANAGED WITH BRONCHIAL ARTERY
EMBOLIZATION (BAE)
• HAEMOPTYSIS SETTLED AND PATIENT WAS DISCHARGED HOME
• REPORTED TO EMERGENCY SKIMS WITH RECURRENT
EPISODES OF MASSIVE HAEMOPTYSIS

7. MANAGEMENT
• IN VIEW OF HIGH RISK FOR SURGERY, PATIENT WAS
ATTEMPTED FOR SECOND SESSION OF BAE BUT THAT
FAILED.
• AFTER THE CASE WAS DISCUSSED BY EMERGENCY TEAM
WITH CTVS AND INTERVENTIONAL RADIOLOGIST

8. COURSE IN THE HOSPITAL
• Patient was Shifted to Internal medicine ward
• Had persistent haemoptysis
• Next day had another massive episode of
Haemoptysis

9. CONTD…
In view of Massive haemoptysis
1. Case was discussed CTVS for surgical intervention
2. Radiotherapist for Haemostatic dose of RT
3. SICU for selective Intubation or DLT placement

10. EXAMINATION
PR-110/MIN. GENERAL PHYSICAL EXAM.
BP-140/80 MMHG P +
RR-22/M I
SP02-93%ON ROOM AIR C NIL JVP-N
AFEBRILE TO TOUCH O NO CLUBBING
NO TELANGIECTASIA

11. EXAM. CONT……
CHEST: FINE CREPTS ISA(BILATERAL)
CVS: S1,S2
NO MURMUR.
P/A: SOFT, NT, ND.
CNS: GCS 15/15
NAD.

12. INVESTIGATIONS

13. FURTHER MANAGEMENT
1. LEFT Lateral decubitus position
2. P-RBC support
3. I/V Tranexamic acid
4. Oxygen supplementation
HAEMOPTYSIS SETTLED with conservative management
AFTER 4 days with no episode of haemoptysis patient was discharged
home with advise to follow CTVS in case of Haemoptysis

14. Recurrent Massive Haemoptysis
with left sided Pulmonary AVM
with failed BAE

15. DISCUSSION

16. HEMOPTYSIS
Haemoptysis is defined as
Expectoration of blood
originating from the Lower
respiratory tract (below
Vocal cords)

17. HAEMOPTYSIS SHOULD BE DIFFERENTIATING
FROM

18. DIFFERENCE BETWEEN
HAEMOPTYSIS AND HEMATEMESIS
FEATURES HEMOPTYSIS HEMATEMESIS
Definition Coughing out of blood Vomiting out of blood
Colour & Content Bright red ,mixed with sputum Coffee-ground in colour , with
food particles
Premonitory symptoms Respiratory symptoms GI symptoms
Melena Does not occur Usually with melena
Amount Relatively less High in amount
Reaction Alkaline Acidic

19. SOURCE OF BLEEDING
~90%
Bronchial artery
~10%
Pulmonary artery

20. SITES OF HAEMOPTYSIS
Airways
Parenchyma
Vasculature

21. CAUSES OF HAEMOPTYSIS

22. SEVERITY OF HEMOPTYSIS
Mild • < 100 ml in 24 h
Moderate • 100 -600 ml in 24 h
Massive
• > 600 ml in 24 h or 30 ml/h, with
respiratory failure/Haemodynamic
instability.
Fernando Luiz Cavalcanti J.Bras Pneumol 2010

23. RISK FACTORS FOR MORTALITY
Malignancy
Aspergillosis
Aspirationintocontralaterallung*
Bleedingfromthepulmonaryartery
Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe
hemoptysis.Fartoukh M, Khoshnood B, Parrot A, Khalil A, Carette MF, Stoclin A, Mayaud C, Cadranel J, Ancel PY -
Respiration. 2012;83(2):106.

24. DIAGNOSIS
History
Examination
BronchoscopyImaging
Lab
parameters

25. Clinical features suggestive of cardiac, pulmonary, renal , hepatic or immunological cause

29. MANAGEMENT

30. Air way
Breathing
Circulation
PROVIDE SUCTION.
Provide O2
crystalloid solutions
AND blood products

31. INITIAL STEPS

32. Management
Resuscitation
Identify
Bleeding
Side
Position of
patient
Airway Patency
Control Of
Bleeding

33. PROTECTION OF NON BLEEDING LUNG
Ifbleedingsideisknown
Rest
Lateraldecubitus
-Bleeding side down.

34. SELECTIVE INTUBATION
SINGLELUMENETT
Selectivelyintubate the non
bleeding lung
Selective intubation of L Main bronchus
in R sided massive hemoptysis

35. SELECTIVE INTUBATION
Speciallydesignedforselectiveintub
ationoftherightorleftmainbronchi
• Last option in an
asphyxiatingpt.

36. CONTROL THE BLEEDING
Non
Surgical
• Bloodproduc
ts
(PRP,FFP)
• Bronchosco
picmeasures
• BAE
Surgical
• Lobectomy/
• Pneumonect
omy
• Other
surgical
management
directed to
cause

37. BRONCHOSCOPY
Massive hemoptysis. Assessment and management. Cahill BC, Ingbar DH Clin Chest
Med. 1994;15(1):147.
Flexiblebronchoscopyistheinitialdiagnosticprocedureofchoice:
Performedbedside,andishighlysuccessfulatlocalizi
ng the bleedingsite.
Intubationshouldbeconsidered

38. BRONCHOSPIC MEASURES
Localisation of bleeding
Guide Intubation:
single limen /double lumen intubation
Control of bleeding:
Cold saline lavage
Topical vasoconstrictors like adrenaline,ornipressin
APC/ Electro cautery
BalloonTamponade
Spigot

39. • ADVANTAGES:
• Performedatbedside
• Access: UL/distalorifices
• Can do Lavage
• Topicalanaesthesia.
• DISADVANTAGES:
• Poorsuction
• Airwaypatencyisnotgood
• Merits of rigid bronchoscopy
over flexible:-
• Better airway control
• Larger field of view
• Better suctioning
• Better for therapeutic Interventions
• DISADVANTAGES:
• PoorvisibilityofperipherallesionsandU
L
• GA

40. COLD-SALINE LAVAGE
*Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R: Massive hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg
1983; 85: 120–124.
Lavage:Normalsalineat4°C
ItStopsthebleedingwithmassivehemoptysis
obviatingtheneedforemergencythoracotomy.*
RigidscopeisbetteroverFOB

41. Topical VasoconstrictiveAgents
Topical epinephrine (1:20,000)
Effective :mild to moderate.
Side effects
-Tachyarrythmias
- HTN
• Newer agents: ADH
derivative
- ornipressin
* Cahill BC, Ingbar DH: Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15: 147–167.

42. OTHER
TRANEXAMIC ACID
•ANTIFIBRINOLYTIC DRUG
•ROUTE : PO ,IV & TOPICAL (RECENTLY)
•ENDOBRONCHIAL :*
•DOSE: 500–1,000 MG
•RESPONSE TIME: SECONDS
* Solomonov A, Fruchter O, Zuckerman T,Brenner B, Yigla M: Pulmonary hemorrhage: a novel
mode of therapy. Respir Med 2009; 103: 1196–1200.

43. BalloonTamponade
• Life threatening hemoptysis.
• 4 Fr 100 cm Fogarthy balloon
catheter by FOB.
• Inflated for 24-48 hrs
* Hiebert C: Balloon catheter control of lifethreatening hemoptysis. Chest 1974; 66: 308– 309.

44. EndobronchialAirway Blockade(Silicone Spigot)
Temporary management.
• Silicone spigot is placed
endobronchially .
Stabilizes patient before BAE
• *Dutau H , Palot A, Haas A, Decamps I, Durieux O: Endobronchial embolization with a silicone
spigot as a
temporary treatment for massive hemoptysis. Respiration 2006; 73: 830–832.
posterior segment
of the right upper lobe
Silicon spigots of various sizes

45. BRONCHOSCOPY-GUIDED TOPICAL
HEMOSTATIC TAMPONADE (THT)
• Oxidized cellulose mesh
 Saturates with blood-->brownish or black gelatinous
mass -->clot.
• Successful in life threatening hemoptysis.
• Immediate arrest of bleed: 98%(56 of 57)
*Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC: Bronchoscopy-guided topical hemostatic tamponade
therapy for the Management of life-threatening hemoptysis. Chest 2005; 127: 2113–2118.

46. ENDOBRONCHIAL SEALING WITH
BIOCOMPATIBLE GLUE
• Material: n-butyl cyanoacrylate(adhesive)
• Injected into the bleeding airway through a catheter via a flexible FOB.
• Used in mild hemoptysis.
• * *Parthasarathi Bhattacharyya et al Bronchoscopy Centre, Calcutta, India(CHEST
2002; 121:2066–2069)

47. ARGON PLASMA COAGULATION(APC)
• TYPE : Thermal tissue destruction
• Non contact electrocoagulation
• In bronchoscopically visible areas of
sources of bleed
*Keller CA, Hinerman R, Singh A, Alvarez F: The use of
endoscopic argon plasma coagulation In airway
complications after solid organ transplantation. Chest
2001; 119: 1968–1975.
APC machine

48. 63
Flooding of the
bron.intermed.
Suctioning
airway clearance
visualization
Coagulation and
devascularization
of tissues
Carbonization of
the bleeding site

49. Endobronchial Electrocautery
• TYPE: Thermal tissue destruction
• Contact Electrocoagulation
• Readily available
Contact probesElectro cautery machine
Probe through working channel

50. BRONCHIALARTERY EMBOLIZATION
• Temporary or definitive
• Immediate control: 57–100% of patients**
Embolization : bronchial and nonbronchial
 Long-term control: 70%-88%
*Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann Radiol (Paris)
1974; 17: 5–16.
**Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 33–37.

51. EMBOLIZING MATERIALS:
Absorbable gelatin
sponge
• Gelfoam
• Pledgets (1 to 2 mm)
• Thrombin
• Glue
• Recently approved
-Embospheres,
-Spherical Poly vinyl
alcohol(PVA) particles

52. Right
Left
Abnormal circulation
Pre-embolisation bronchial angiogram
No abnormal circulation
Post embolisation

53. BRONCHIALARTERYANEURYSM
Hypervascular lesion with aneurysm
Pre embolisation Post embolisationPVA particles
No hypervascular lesion & aneurysm

54. LEFT UPPER LOBE BRONCHIALARTERY
After embolization
Decreased vascularity & hypertrophyTortous and hypertrophied vessel
Before embolization

55. INDICATIONS OF
SURGERY
Procedure of choice in:
• Bronchial adenoma
• Aspergilloma
• Hydatid cyst
• Iatrogenic pulmonary rupture
• Chest trauma
• AV malformations

56. PULMONARY AVM
• PULMONARY ARTERIOVENOUS MALFORMATIONS (PAVMS) ARE ABNORMAL COMMUNICATIONS
BETWEEN PULMONARY ARTERIES AND VEINS .
• ALTERNATIVE NAMES INCLUDE PULMONARY ARTERIOVENOUS FISTULAE, PULMONARY
ARTERIOVENOUS ANEURYSMS, CAVERNOUS ANGIOMAS OF THE LUNG, AND PULMONARY
TELANGIECTASES
• STRONG ASSOCIATION BETWEEN PAVM AND HEREDITARY HAEMORRHAGIC TELANGIECTASIA

57. PRESENTATION
• MOST PATIENTS ARE ASYMPTOMATIC, PAVMS CAN CAUSE DYSPNOEA FROM RIGHT-TO-LEFT
SHUNT.
• TRIAD OF DYSPNEA , COUGH & CLUBBING
• BECAUSE OF PARADOXICAL EMBOLI, VARIOUS CENTRAL NERVOUS SYSTEM COMPLICATIONS
HAVE BEEN DESCRIBED INCLUDING STROKE AND BRAIN ABSCESS

58. MANAGEMENT
• CHEST RADIOGRAPHY AND CONTRAST ENHANCED COMPUTED TOMOGRAPHY ARE ESSENTIAL
INITIAL DIAGNOSTIC TOOLS BUT
• PULMONARY ANGIOGRAPHY IS THE GOLD STANDARD.
• CONTRAST ECHOCARDIOGRAPHY IS USEFUL FOR DIAGNOSIS AND MONITORING AFTER
TREATMENT.
• THERAPEUTIC OPTIONS INCLUDE
• ANGIOGRAPHIC EMBOLIZATION WITH METAL COIL OR BALLOON OCCLUSION AND
• SURGICAL EXCISION.

60. 90
Life Threatening hemoptysis
Pulmonary isolation & identification of bleeding source
(Radiological/Bronchoscopic means:CT Chest,Balloon bronchial blockers)
Bronchoscopy
Surgery BAE
(Delayed TREATMENT)
Follow up at OPD
SUCCESS
FAILURE

61. • INVESTIGATIONAL AGENTS —
• STUDIES ARE UNDERWAY USING AGENTS CAPABLE OF ALTERING/INHIBITING THE FUNCTION OF HEPCIDIN
(EG, HEPCIDIN ANTAGONISTS) AND THE HEPCIDIN RECEPTOR (FERROPORTIN) IN ORDER TO ALLEVIATE
THE VARIOUS DISORDERS OF IRON METABOLISM ASSOCIATED WITH INCREASED LEVELS OF HEPCIDIN,
INCLUDING ACD