Approach to haemoptysis

1. HAEMOPTYSIS
• Presenter : dr milan rabadiya
• Moderator: dr khatija jhumkawala

2. INTRODUCTION
Hemoptysis is the expectoration of blood.
Severity ranges from mild to severe, and it can be difficult to stop. The
challenge is to stabilize the patient while simultaneously determining
the source and providing treatment.
The definition of massive hemoptysis varies, with reported ranges
from 100 mL per 24 hours to >1000 mL per 24 hours,and a midpoint
value of 600 mL per 24 hours accepted by many.

3. PATHOPHYSIOLOGY
• Hemoptysis results from disruption of blood vessels within the
walls of the airways, from trachea to bronchi, bronchioles, and
the lung parenchyma .
• The pulmonary arteries account for 99% of the blood flow to
the lungs but are a low-pressure system involved in gas exchange
and rarely the source of massive hemoptysis.
• The bronchial arteries accounts for only 1% of the blood flow to the
lungs but 90% of the cases of hemoptysis because it is a high-
pressure system.
• Bronchial arteries typically branch off the thoracic aorta at thoracic
vertebrae levels 5 and 6 and are responsible for supplying oxygen
and nutrients.

4. • Approximately one third of the time, they are ectopic and originate
from other parts of the aorta.
• Extensive anastomoses occur between the bronchial and pulmonary
arteries, producing a physiologic right-to-left shunt composing 5%
of cardiac output.
• In general, hemoptysis develops from either airway, parenchymal, or
cardiovascular processes.
• For example, coughing in the setting of transient airway
inflammation (e.g., acute bronchitis) can lead to minor bleeding in
otherwise healthy lungs.
• However, the most common causes of potentially massive
hemoptysis are parenchymal in origin, such as tuberculosis,
mycetoma, neoplasm, and bronchiectasis.

5. • In chronic inflammatory states (e.g., chronic obstructive pulmonary disease),
the bronchial arteries proliferate to enhance the delivery of blood to the
alveoli, and this neoangiogenesis creates thin-walled, fragile vessels prone to
rupture
• Chronic inflammatory State Lead to bronchiectasis (chronic bronchial wall
inflammation), resulting in destruction of the cartilaginous support
predisposing blood vessels to rupture.
• In the case of infection (e.g., Aspergillus and tuberculosis), there can be
necrotic destruction of tissue resulting in cavitary lesions. Neoangiogenesis
can occur in the cavity walls and bridge them.
• A Rasmussen’s aneurysm is a false aneurysm of dilated blood vessels
crossing the wall of a tuberculosis cavity

6. CAUSES OF HEMOPTYSIS

8. CLINICAL FEATURES
• HISTORY
a.Risk factor
b.Food history
c.Travel history
d.Drug history
e.Surgical history
• PHYSICAL EXAMINATION
• DIAGNOSIS

9. IMAGING
• Chest radiography is the initial imaging modality, yielding a diagnosis
up to 50% of the time1; in massive hemoptysis, the radiograph is rarely
normal
• Diffuse alveolar hemorrhage manifests as scattered alveolar infiltrates
on chest radiograph, whereas focal alveolar hemorrhage, infiltrates,
masses, and cavitation are potential sources of hemoptysis.
• Multidetector CT can be performed during a single breath hold using a
16-detector row or greater scanner
• Multidetector CT is preferred in evaluating massive hemoptysis.

10. TREATMENT: MILD HEMOPTYSIS

13. TREATMENT: SEVERE HEMOPTYSIS

16. • AIRWAY CONTROL:
In patients with more severe bleeding, assessing and ensuring the
airway patency and ongoing oxygenation are key.
If the patient has a tracheostomy, look for a trachea-innominate
fistula; control this with direct digital pressure on the anterior
portion of the trachea against the posterior aspect of the sternum
using the tracheostomy as the point of access.

17. • If the patient does not have a tracheostomy and requires airway
control, proceed immediately with rapid sequence intubation,10 using
a largerdiameter endotracheal tube to allow for bronchoscopy.
• Once intubation is successful, place the patient so the affected lung is
in a dependent position to prevent spilling of blood into the
unaffected side
• If bleeding is uncontrollable, you may preferentially intubate the
main bronchus of the unaffected lung. Alternatively, to stop bleeding,
some use a Fogarty catheter (14F/100 cm) to tamponade the
bronchus of the affected lung.

18. • The latter can be accomplished by passing the Fogarty catheter
adjacent to the endotracheal tube once the patient is intubated . If
attempts at intubation fail, cricothyrotomy is an option.

21. • BRONCHOSCOPY
• Urgent bronchoscopy can identify the origin of bleeding and provide
stabilizing treatment. . Awake flexible, fiberoptic bronchoscopy
provides visualization of the more peripheral and upper lobes but
does not provide optimal suctioning and does not allow for local
treatment.
• Rigid bronchoscopy usually requires general anesthesia but is
possible with deep sedation; it allows for improved airway control.
• Rigid bronchoscopy cannot fully view the upper lobes and peripheral
lesions, but it offers greater suctioning ability than fiberoptic
bronchoscopy and can provide treatment, such as the passage of
Fogarty balloon catheters for tamponade of bleeding, epinephrine
instillation, and ice water lavage.

22. THANK YOU