- Hemoptysis is the expectoration of blood from the respiratory tract below the level of the vocal cords. It can range from blood-streaked sputum to gross blood. It is classified as minor (<20mL/day), moderate (20-100mL/day), or massive (100-600mL/day). - The bronchial arteries, which arise from the aorta, are responsible for 95% of hemoptysis cases as they have higher systemic pressure. The pulmonary arteries have lower pressure and carry only a small portion of cardiac output. - Common causes of hemoptysis include tuberculosis, bronchiectasis, mycetoma, lung abscess, mitral stenosis, and

1. HEMOPTYSIS
Dr. ZAKIR HUSSAIN

2. HEMOPTYSIS – definition
HEMOPTYSIS
• Expectoration of blood from da resp tract below da level
of vocal cords.
• can range from blood-streaking of sputum to the presence
of gross blood.
• Depending on da amount of blood loss, it has been
categorized… as minor, moderate, n massive.

3. Classification of hemoptysis
 MINOR HEMOPTYSIS - bloodloss is 20ml/day
 MODERATE HEMOPTYSIS – 20-100 ml/day
 MASSIVE HEMOPTYSIS - 100- 600 ml/day
MASSIVE HEMOPTYSIS : bleeding is potentiallly life
threatening & blood loss is significant to compromise
resp function.

4. Anatomy
PULMONARY ARTERY :
entire cardiac output Low-pressure pulmonary
arteries & arterioles oxygenated in the pulmonary
capillary bed…………… Pulm @ only 5% of hemoptysis
BRONCHIAL ARTERY: higher systemic pressure but carry a
small portion of the cardiac output. Arise from aorta.
Nutitional source to airways, n lungs.
95% of hemoptysis.

5. D/D of HEMOPTYSIS
diff, from hemoptysis from other causes …
R/o NON PULMONARY like upper resp tract bleeding,
Bleeding from GI tract.
Alkaline pH, frothy, or the presence of pus may sometimes
suggest the lungs as the primary source of bleeding
differenciate hemoptysis from hemetemisis

6. HEMOPTYSIS vs HEMETEMESIS

7. Past HISTORY
 Is there a history of prior lung, cardiac, or renal disease?
 Is there a history of cigarette smoking?
 Has the patient had prior hemoptysis, other pulmonary
symptoms, or infectious symptoms?
 Is there a family history of hemoptysis or brain aneurysms
(suggesting hereditary hemorrhagic telangiectasia)?
 Is there a history of skin rash? (Vasulitis, SLE)
 What is the patient's travel history?

8. Previous HISTORY
 Is there a history of bleeding disorders or use of
aspirin, NSAIDS, or anticoagulants?
 Is there a history of upper airway or upper G.Icomplaints
or diseases?
 Is pt having any liver disease.

9. Physical Examination
 Skin rash -- vasculitis, systemic lupus erythematosus, fat
embolism, or infective endocarditis.
 Telangiectasias -- hereditary hemorrhagic telangiectasia
 Splinter hemorrhages -- endocarditis or vasculitis.
 Clubbing is nonspecific, since it can occur in many chronic

10. Physical Examination
Audible chest bruit or murmur that increases with
inspiration -- large pulmonary AV malformations .
Cardiac murmurs -- congenital heart disease,
endocarditis with septic emboli, or mitral stenosis.
Legs should be examined carefully for possible deep
venous thrombi.

11. Evaluation

12. Causes of HEMOPTYSIS

13. Tuberculosis
Active tubercular pneumonitis-
bronchiolar erosion
 Rupture of Rasmussen’s aneurysm
(pulm. art)
 Healed calcified LNE-eroding through
bronchial arteries into airway
 Scar carcinoma
 Development of bronchiectasis
 Mycetoma formation

14. Bronchiectasis
 Pathologically it is destruction of the
cartilaginous support of bronchial wall
and bronchial dilatation owing to
parenchymal retraction from alveolar
fibrosis
 ANATOMICAL CHANGES:
o Bronchial artery hypertrophy
o Expansion of peribronchial & sub
mucosal bronchiolar arteriolar plexus
o Augmentation of anastomoses with
the pulmonaryarterial bed

15. MYCETOMA

16. MYCETOMA
Mechanical trauma of the vascular
granulation tissue by the movement of
the fungal ball in the cavity
 Vascular injury from aspergillus
associated endotoxin
 Aspergillus related proteolytic activity
 Vascular damage from a type 3
hypersensitivity reaction

17. Fungal ball

19. Lung abscess
Due to necrotizing effect of primary
infection and the inflammation that
involves pulmonary vasculature

20. MITRAL STENOSIS
Before valvotomy and mitral valve
replacement hemoptysis occurred in
20-50% of patients
 In M.S - Lt atrial pressure – pulm veins
-pulmonary capillary bed-if pressure
exceeded inthe rt. atrial pressure-
blood flows in the retrograde direction
in the bronchial veins through the
bronchopulmnary anastomosis

21. carcinoma
83% with hemoptysis – squamous ca.
centrally located ,48% cavitate
 Mechanism:
necrosis and inflammation of vessels
within tumour bed
Direct tumor invasion of the pulmonary
vasculature is rare

22. LOCALIZATION
o Physical examination
o CXR
o CT chest
o Bronchoscopy
o Arteriography
o RBC scan
o Bronchography

23. LOCALIZATION
o Physical examination and chest x-ray
were equivocal and not helpful in 55%-
60% of patients
o This poor localization of bleeding
reflects the fact that blood may be
widely distributed in the lung by
coughing

25. LOCALIZATION
Early bronchoscopy :(48 hrs)
o Diagnostic yield is higher
o Likely hood of localizing site is more
o Accurate localization may direct
therapeutic interventioin
CT chest during active bleeding may be
misleading because aspirated blood
may mask underlying pathology or
incorrectly appear as a parenchymal
mass

26. CT Scan
o Use of early chest CT to help localize
the bleeding site and diagnose the
cause of hemoptysis
o The advantage of CT –diagnosing
bronchiectasis, lung abscess, and mass
lesions, including cancer, mycetomas,
and AVM’S
o The disadvantage of chest CT
diff in shiftin pt from ICU

27. LOCALIZATION
RBC SCAN
o Tc 99m-sulfur colloid isotope-labeled
RBC
o Reserved for the patients in whom
bronchoscopy couldn’t be performed
BRONCHOGRAPHY: replaced by HRCT

28. bronchoscopy vs HRCT
o Fiberoptic bronchoscopy and HRCT , each with
specific advantages in certain clinical situations
o HRCT picks all tumors seen by bronchoscopy
as well as several which were beyond
bronchoscopic range. On the other hand, HRCT
could not detect bronchitis or subtle mucosal
abnormalities which could be seen by
bronchoscopy
o HRCT was useful in diagnosing bronchiectasis
and aspergillomas, while bronchoscopy was
diagnostic of bronchitis and mucosal lesions
such as Kaposi's sarcoma

29. MANAGEMENT
o Adequate airway protection, ventilation,
and cardiovascular function
o Intubate if pt. has poor gas exchange,
rapid ongoing hemoptysis, hemodynamic
instability, severe SOB.
o protection of the nonbleeding lung
o Spillage of blood into the non-bleeding
lung can either block the airway with clot
or fill the alveoli and prevent gas
exchange.
o Need to know site of bleeding

30. MANAGEMENT
o Place bleeding lung in the dependant
position
o Selectiely intubate the nonbleeding
lung.
o Placement of a double lumen ETT
specially designed for selective
intubation of the right or left mainstem
bronchi

31. MANAGEMENT

32. MANAGEMENT
 BRONCHOSCOPIC MEASURES:
BRONCHIAL IRRIGATION
VASOCONSTRICTIVE AGENTS
TOPICAL COAGULANTS
LASERS
 ENDOBRONCHIAL BLOCKADE
BALOON TAMPONADE
UNILATERAL LUNG VENTILATION
DOUBLE-LUMEN ET TUBES
 EMBOLOTHERPY
 SURGERY

33. Bronchoscopic measures
BRONCHIAL IRRIGATION:
o Cold saline lavage (4c)
o Colon et al studied 25 pts
Bleeding stopped in 23 patients,,
2 patients rebleed
 VASOCONSTRICTIVE AGENTS:
o Topical epinephrine (1:2000)
o Intravenous vasopressin

34. Bronchoscopic measures
 ELECTROCAUTERY
 ARGON PLASMA COAGULATION
 BRONCHOSCOPIC BRACHYTHERAPY
 TOPICAL COAGULANTS:
o Tsukamoto et al- 19 pts-
o 60% hemostasis with topical thrombin
o 100% - fibrinogen-thrombin solution
(re bleeding in 1 pt)

35. LASER COAGULATION
o Nd –YAG laser therapy for endobronchial
tumors
o Thermal effects vaporizes the superficial
layers and coagulate the deeper layers
o Seal vessels upto 1.5mm in diameter but
larger vessels maynot be adequately
controlled
o Even highly vascular tumors have a
propensity to bleed when subjected to
laser therapy

36. BALLOON TAMPONADE
o 4 Fr 100 cm Fogarthy balloon catheter
placed by the fibreoptic bronchoscope
and is inflated in the segmental and
sub segmental bronchus
o Inflated for 24-48 hrs
Advantages:
o Allows gas exchange
o Supports patient before embolization
or surgery

37. BALLOON TAMPONADE
o Disadvantages:
Ischemic mucosal injury
Post obstructive pneumonia
o Saw et al- 6/10 patients effective .
No rebleeding for 6wks- 9 months
o Swersky et al- 4/4 pts- effective.
Rebleeding in 2 pts

38. Title

39. EMBOLIZATION
Alternative to surgery in pts with
bilateral disease, multiple bleeding
sites and borderline pulmonary reserve
o Halted active bleeding and stabilized
patients in 84-100%
o Long-term control of bleeding after
embolization range from 70%-88% with
f/u period of 1- 60 m

40. EMBOLIZATION
COMPLICATIONS:
o Chest pain-(24-91%)
o Dysphagia-(0.7-18.2%)
o Subintimal dissection of aorta or
bronchial artery
o Bronchoesophageal fistula
o Reflux of embolic material into systemic
circulationnecrosisofsmallbowel,occlusion
ofanterior tibial artery,seizure

41. SURGERY
• Conservative management of massive
hemoptysis carries a mortality rate of
50-100%
o Mortality rate for surgery performed
for massive hemoptysis- 7.1-18.2%
o However mortality rate increases
significantly upto 40% when surgery is
undertaken as an emergency procedure

42. SURGERY
SURGERY IS PROCEDURE OF CHOICE
o BRONCHIAL ADENOMA
o ASPERGILLOMA RESISTANT OT OTHER
TREATMENT
o HYDATID CYST
o THORACIC VASCULAR INJURY

43. Sx - contraindications
o Unresectable carcinoma
o Inability to lateralize the bleeding site
o Diffuse disease
Multiple AVM
Cystic fibrosis
o Arterial hypoxia
o Co2 retention
o Dyspnea at rest

44. Sx - complications
o Morbidity-23-54%
o Post- op BPF-10-14%
o Empyema
o Hemorrhage requiring re-exploration
o Hemothorax
o Resp insufficiency req proloned vent
o Mortality-10-50%
o -Gourin & garzon’s study:37% of active
bleeding died in comparision with 8%

47. THANK YOU