clinical scenarios included Imam Medical college

1. Hemoptysis
Firas Alhijli
Moath Alkeaid
Meshal Albeshr
Yaser Alotaibi

2. Objectives:
• Definition
• All bloody coughs are hemoptysis, true or false?
• Classification
• Diffuse alveolar hemorrhage
• Causes
• Causes of massive hemoptysis
• Work up
• Management

3. Definition
Firas Alhijli

4. Definition:
• Is the spitting of blood that originated in the
lungs or bronchial tubes
• The patient’s history should help determine the
amount of blood and differentiate between
hemoptysis, pseudo hemoptysis and
hematemesis
• physical examination can lead to the diagnosis in
most case

5. Mechanism of cough

6. All bloody cough are
hemoptysis?

7. All bloody cough are hemoptysis?
• Respiratory tract: often looks bubbly because it is
mixed with air and mucus. It is usually bright red
• Gastrointestinal: blood is dark and contains bits of
food or what look like coffee grounds .
• Peptic ulcer
• Gastropathy (alcohol, aspirin and NSAIDs)
• Esophagitis
• Mallory-Weiss tear
• gastro- esophageal varices.

8. All bloody cough are hemoptysis?
• Oropharynx:
Gingivitis
Bleeding ulcer
Dislodged teeth
Leukemia
Thrombocytopenia
Hemophilia

9. Diffrential diagnosis:
• We differentiate hemoptysis from other causes
like URT bleeding and upper GI bleeding by:
• Alkaline pH, presence of pus and the frothy
appearance of the blood.

10. How to differentiate?
Hemoptysis Hematemesis
Cough Nausea and vomiting
Frothy and might be mixed with
sputum
No air
Might be mixed with food
Bright red Bright red or dark brown
Alkaline pH Acidic pH
Hx of respiratory disease Hx of liver disease or peptic ulcer
No history of melena History of melena may present
Investigated with bronchoscoby Investigated with endoscopy

11. Diffrential diagnosis:
• common causes:
• Bronchitis
• Lung cancer
• TB
• Bronchiectasis
• Pneumonia
• Idiopathic
• Other causes:
• Goodpasture's
syndrome
• PE
• Aspergilloma
• Hemophilia

12. Classification
Moath Alkeaid

13. Classification
• Based on blood loss:
• Mild hemoptysis: blood loss is less than 50 ml/day
• Moderate hemoptysis: blood loss is 50-200 ml/day
• Severe hemoptysis: blood loss is more than 200 ml/day
• Massive hemoptysis: blood loss is more than 600 ml/day
• Life threatening hemoptysis: 200ml/hour or 50ml/hour
with respiratory failure.

14. Patient’s history:
• Is there a history of lung, cardiac or renal disease?
• History of cigarettes smoking?
• History of bleeding disorder?
• History of liver disease?
• History of recent infections, pulmonary symptoms or
prior hemoptysis?
• TRAVEL HISTORY
• DRUG HITSORY

15. Physical exammination
• skin rash
• Splinter hemorrhage
• Clubbing
• Audible chest bruit or murmur that increase
with inspiration
• Hepatomegaly
• Cachexia
• Legs

16. Diffuse alveolar hemorrhage:
• It’s life-threatening and medical emergency that can be
caused by numerous disorders and presents with
hemoptysis, anemia, and diffuse alveolar infiltrates.
• Originates from the pulmonary microcirculation, including
the alveolar capillaries, arterioles, and venules and is
usually diffuse.
• Early bronchoscopy with bronchoalveolar lavage is usually
required to confirm the diagnosis and to rule out infection.
• Most cases of DAH are caused by systemic vasculitis
associated with systemic autoimmune diseases.

17. Causes of inflammatory DAH
• Systemic vasculitis is one of the most common causes of DAH
and can be pathologically defined by the presence of cellular
inflammation, vessel destruction, tissue necrosis, and
eventually, organ dysfunction.
• ANCA-associated vasculitis
• Goodpasture’s syndrome
• SLE

18. Presentation of inflammatory DAH
• The clinical presentation of the disease underlying DAH is
highly variable, the identification of a cause is very difficult
• The diagnosis of DAH relies on the clinician’s recognition
combined with clinical, laboratory, radiologic, and pathologic
features.
• The clinical features of each patient's disease are determined
by the site, size, and type of vessel involved.

19. Diagnosis of DAH
• It’s confirmed by biopsy, where we can see RBCs, fibrin,
hemosiderin-laden macrophage in the alveolar space
• This can help us in distinguishing DAH from surgical trauma.
• Mild interstitial thickening, organizing pneumonia, or diffuse
alveolar damage can also be seen.

20. Treating DAH
• Biopsy of involved sites can help to identify the cause and to
direct therapy.
• Therapy for DAH consists of treating both the autoimmune
destruction of the alveolar capillary membrane and the
underlying condition. Corticosteroids and immunosuppressive
agents remain the gold standard for most patients.
• What if immune complex was the cause of DAH?

21. Causes
Meshal Albeshr

23. Causes:
• Infection: TB, Lung abscess, Bronchiectasis,
Pneumonia, Fungal
• Neoplasm: Carcinoma, adenoma, Metastatic
• Congenital: Bronchial cyst, Sequestration of lung
• Traumatic, Iatrogenic, Bleeding disorder
• Cardiovascular: Mitral stenosis, Pulmonary HTN,
Aortic aneurysm, AV malformation, PE
• Collagen Vascular Disease: Vasculitis, Wegner’s
granulomatosis, Good pasture’s syndrome

24. Bronchial Disorders – Cancer:
• The most common type is small cell carcinoma (SCC)
• Can be presented in various ways:
1. If it arises in a large bronchus, symptoms will arise
early.
2. It it arises in a peripheral bronchus, the tumor may
grow large without showing any symptoms
• Local spread may occur at mediastinum and invade
or compress the pericardium, esophagus, superior
vena cava, trachea, or phrenic or left recurrent
laryngeal nerves.

25. Paranchymal Disorders – TB
• TB is caused by an infection with Mycobacterium
tuberculosis (MTB), which is part of a complex of organisms
that also includes M. bovis, which comes from drinking
non-sterilized milk and M. africanum (from humans)
• M. Tuberculosis is spread by the inhalation of aerosolized
droplet nuclei from other infected patients

26. Cardiovascular disorders –
Mitral Stenosis:
• Condition that is rheumatic in origin
• Valve orifice is slowly diminshed by progressive
fibrosis, leaflet calcification and fusion of the
cusps
• Restricted blood flow from left atrium to left
ventricle causes a rise in left atrial pressure,
leading to pulmonary venous congestion and
breathlessness.

27. Cardiovascular disorders –
Mitral Stenosis:

28. Blood disorders – Leukemia:
• A group of malginant disorders of
haematopoietic stem cells
• Associated with increased number of white
blood cells within the bone marrow and
peripheral blood

29. Massive hemoptysis:
• Bronchioectasis
• TB
• Aspergilloma
• Cryptogenic
• SCC

30. Table 1
Underlying etiology of massive hemoptysis in previous studies
Study Country Patients (n)
Underlying cause of hemoptysis (%)
Bronchiectasis Tuberculosis Lung cancer Mycetoma Infection/abscess Cryptogenic Other
Fartoukh et al [2012] France 1087 20 25 17 6 – 18 20
Shigemura et al [2009] China 62 23 55 6 8 6 – 2
Valipour et al [2005] Austria 57 8.5 23 35 – – 16 17.5
Fartoukh et al [2007] France 195 40 14 17 7 3 – 9
Ong and Eng [2003] Singapore 29 66 10 7 14 – – 3
Hsiao et al [2001] USA 28 57 7 14 – – 7 14
Revel et al [2002] France 80 31 19 11 7.5 – 10 21.5
Mal et al [1999] France 46 9 50 4 2 4 22 9
Knott-Craig et al [1993] South Africa 120 – 73.3 5 6 2.5 8.3 –
Crocco et al [1968] USA 67 10 73 8 – 9 – –
Gourin and Garzon [1974] USA 62 11 73 3.2 – 6.5 – –
McCollum et al [1975] USA 15 20 33 6.7 13.3 – 6.7 –
Yang and Berger [1978] USA 20 15 50 15 5 – 10 –
Garzon et al [1982] USA 24 17 46 13 – 8 8 –
Conlan et al [1983] South Africa 123 30 38 4.9 3.3 4.9 – –
Uflacker et al [1985] Brazil 75 1.3 76 – 16 2.6 – –
Johnston and Reisz [1989] USA 22 4 18 4 9 4 – 26
Hirshberg et al [1997] Israel 29 21 – 13.8 – 24 – –
Reisz et al [1997] USA 23 – 22 43 – 4 – 4
Tanaka et al [1997] Japan 47 17 53 10 – – 8.5 10

31. Massive hemoptysis:
• 90% arise from high pressure bronchial circulation
• 5% arise from the aorta or non-bronchial systemic
circulation (intercostal arteries, coronary arteries,
thoracic arteries originating from the axillary and
subclavian arteries, and the upper and inferior
phrenic arteries)
• 5% arise from pulmonary vessels

32. Bronchoectasis:
• Chronic airway inflammation causes hypertrophy
as well as tortuosity of the bronchial arteries
that are with the regional bronchial trees
• expansion of the submucosal and peribronchial
plexus of blood vessels
• Rupture of either the tortuous vessels or the
capillary plexus results in rapid bleeding subject
to systemic blood pressure in these vessels

33. Tuberculosis – Active TB:
• Massive hemoptysis may develop as a consequence
of either active or prior TB
• In active TB, massive hemoptysis may occur in a
cavitary or non-cavitary disease
• This will result in bronchiolar ulceration with necrosis
of the adjacent blood vessels
• Bleeding is usually from the bronchial arterial
circulation
• However, in some occasions, active TB may cause
rupture of a Rasmussen’s aneurysm, which is a
derivative of the pulmonary arterial circulation

34. Tuberculosis – Prior TB:
• The causes in this are usually a consequence of
either:
1. erosion of a calcified lymph node, through a
bronchial artery and into an airway
2. bronchiectasis secondary to structural damage
from prior TB
3. mycetoma formation in a lung cavity from prior
infection with TB

35. Aspergilloma (IPA):
• Serious and possibly fatal condition
• Immunocomprimised
• Suspected in patients with supparitive
pneumonia and has not responded to antibiotics

36. Cryptogenic massive hemoptysis:
• Despite the efforts made in advancing the field,
20% of cases that were presented with
hemoptysis, no overt cause was found
• Any case that were found not have a cause to
their condition, were categorised as Cryptogenic
• However most cases reported, were found to
have a positive history of smoking.

37. Squamous cell carcinoma:
• Some lung cancer patients, will experince hemoptysis
at some point
• However, a fewer number may report having massive
hemoptysis
• The presence of large, centrally located tumors with
cavitation.
• Especially squamous cell carcinoma, where it is
associated with massive hemoptysis
• The majority of cancer patient with massive
hemoptysis due to malignancy, have a positive
history of small bleeding episodes during the past
few weeks

38. Clinical
presentation
Yaser Alotaibi

39. Clinical presentation:
• Some lung cancer patients, will experince hemoptysis
at some point
• However, a fewer number may report having massive
hemoptysis
• The presence of large, centrally located tumors with
cavitation.
• Especially squamous cell carcinoma, where it is
associated with massive hemoptysis
• The majority of cancer patient with massive
hemoptysis due to malignancy, have a positive
history of small bleeding episodes during the past
few weeks

40. Clinical presentation:
Acute Bronchitis:
productive cough, malaise, difficulty breathing,
and wheezing.
Bronchiectasis:
Productive cough, dyspnea, pleuritic chest pain,
wheezing, fever, weakness, and weight loss.
Pneumonia:
Productive cough, fever, SOB, loss of appetite.

41. Clinical presentation:
• Malignancy:
Productive progressive cough, loss of appetite,
unintentional weight loss, SOB, chest pain.
• TB:
Cough, Weight loss, Fever, Night sweats, history
of travel, chest pain, Fatigue.

42. Investigations

43. Investigations:

44. Investigations:

45. How to Manage?

46. Management:

47. Management:

48. Management:
Acute management:
• vitals
• Oxygenation.
• Position of the patient.
Massive hemoptysis:
• ABC.
• Bronchoscopy.
• BAE.

49. Clinical scenariospresented by all of us:)

50. Clinical cases
A 60-year-old man has had cough and sputum for over
15 years. Now he complains that his sputum is blood
tinged, particularly when he first awakens in the
morning. His chest X-rays show “tram-lines” at both
lung bases. These findings suggest:
A. Carcinoma of the lung
B. Bronchiectasis
C. Interstitial lung disease
D. Heart failure

51. Bronchiectasis: “tram-lines”

52. Clinical cases
• A 56-year-old man, former cigarette smoker, complains of
cough and sputum production, which has become blood-
streaked. Chest X-rays and chest CT show a 5 cm mass lesion in
the anterior segment of the right upper lobe. The diagnostic
procedure of choice is:
A. Sputum cytology
B. Bronchoscopy
C. Video-assisted thorascopic surgery (VATS)
D. Body scan

53. Bronchoscopy

54. Clinical cases
• A 27-year-old male presents to clinic complaining of coughing up
small amounts of blood daily for the past week. He denies smoking,
sick contacts, or recent travel. Chest radiographs demonstrates
interstitial pneumonia with patchy alveolar infiltrates suggestive of
multiple bleeding sites. Urinalysis is positive for blood and protein. A
positive result is returned for anti-glomerular basement membrane
antibody (anti-GBM Ab). What is the most likely diagnosis?
A. SLE
B. Granulomatosis with polyangiitis “Wegner’s disease”
C. Churg-Strauss syndrome
D. Goodpasture disease

55. Goodpasture disease:
• Also known as anti-glomerular basement membrane
disease, is a rare autoimmune disease in which
antibodies attack the basement membrane in lungs
and kidneys, leading to bleeding from the lungs
and kidney failure.

56. Clinical cases
• A 60-year-old man presents to the ER with pleuritic chest pain. He recently
returned from a vacation in Germany and noticed he felt short of breath
and had chest pain the following morning. The patient is generally healthy
but did have surgery on his ankle 3 weeks ago and has been less
ambulatory. His temperature is 37.2°C, BP is 137/88, HR 120/min, RR
22/min, and O2 is 96% on RA. Physical exammination is notable for a warm
and swollen lower extremity. Which of the following findings would warrant
further workup with a CT angiogram?
A. Bilateral wheezing
B. Hemoptysis
C. Increased breath sounds over area of the lung
D. Green sputum

57. Hemoptysis :)

58. Resources:
• Davidson’s principles and practice of medicine
• Harrison’s principles of internal medicine
• Medscape
• PubMed
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651925/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5696556/
• https://epomedicine.com/medical-students/respiratory-
examination-hemoptysis/
• https://radiopaedia.org/cases/tram-track-sign-on-chest-
radiograph
• MCQs:
• https://www.tcd.ie/medicine/Emedicine/pul-hem/mcq1.htm
• https://step2.medbullets.com/pulmonary/120670/hemoptysi
s

59. THANK YOU!