Hemoptysis is defined as the spitting of blood from the lungs or bronchial tubes. It can be classified based on severity from mild to massive. Common causes include infections like tuberculosis, cancers, vascular abnormalities and vasculitis. Initial management focuses on airway protection, oxygenation and circulation. Bronchoscopy helps identify the bleeding site and allows local measures like lavage, vasoconstrictors and tamponade. For persistent or massive bleeding, bronchial artery embolization or surgery may be needed. Precise localization through CT and arteriography guides definitive treatment.

1. HEMOPTYSIS
Dr Nahid Sherbini
Consultant IM & Pulmonary
KFH ,Medina ,SA

2. Definition of Hemoptysis
• The spitting of blood derived from the lungs or
bronchial tubes as a result of pulmonary or
bronchial hemorrhage.
Stedman TL. Stedman’s Medical dictionary. 27th ed. Philidelphia: Lipincott Williams & Wilkins, 2000

3. Severity Classification
GRADE AMOUNT /24 HRS
Mild < 50 ml
Moderate 50 - 200 ml
Severe**/Major* > 200 ml * 150 ml per 12 hrs or**
>400 ml per 24 hrs
Massive > 600 ml
Life-threatening 200 ml/h or 50 ml/h with
respiratory failure.
*Corey R, Hla KM.Am J Med Sci 1987; 294:301–309.
**de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F. Respir Med 2003; 97: 790–795
#Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 1982; 84: 829–833.

4. Massive hemoptysis
• Up to 1000 mL (1)
• Either ≥500 mL of expectorated blood over a 24 h or
bleeding at a rate ≥100 mL/h, regardless of whether
abnormal gas exchange or hemodynamic instability
exists. (2)
(1)Major and massive hemoptysis: reassessment of conservative management.-
Corey R, Hla Am J Med Sci. 1987;294(5):301.
(2)Uptodate.inc

5. Bronchial arteries (90%)
Pulmonary arteries
Source of bleeding
*Remy J, Remy-Jardin M, Voisin C: Endovascular management of bronchial bleeding; in Butler J
(ed): The Bronchial Circulation. New York, Dekker, 1992, pp 667–723.

6. Bronchial arteries
• Systemic pressure
Bronchi, vagus nerve,
posterior mediastinum,
and esophagus.
6
2 Left bron.art
1 Rt.bron.art
T5 -T6

7. Figure 1. Diagrams illustrate the types of bronchial arterial supply: Type I, two bronchial
arteries on the left and one on the right that manifests as an ICBT (40.6% of cases); Type II,
one on the left and one ICBT on the right (21.3%); Type III, two on t...
Yoon W et al. Radiographics 2002;22:1395-1409
©2002 by Radiological Society of North America

8. Pulmonary arterial system
• RV
• Low pressure system
• 8-25mmHg .

9. Causes

11. Infectious
• Tuberculosis
• Fungal infections
• Necrotizing pneumonia and lung abscess
• Bacterial endocarditis with septic emboli
• Parasitic (paragonimiasis, hydatid cyst)
It is the most common cause of hemoptysis worldwide
with 2 billion people infected worldwide with 5-10% developing
disease (Public Health Reports. Vol. 3. New York: World Health Organization; 1996: p. 8–9.)

12. Neoplastic
• Bronchogenic carcinoma
• Endobronchial tumors e.g
carcinoid
• Metastasis
•Bronchiectasis –CF
•Bullous emphysema
•Alveolar hemorrhage
and underlying causes
Pulmonary

13. Vascular
• Pulmonary artery
aneurysm (Rasmussen
aneurysm, mycotic, arteritis)
• Bronchial artery
aneurysm
• PE
• Pulm HTN
• Airway-vascular
fistula
• AV Malformations
• MS
• LVF

14. Vasculitis
• Wegener’s granulomatosis
• Goodpasture’s syndrome
• Behçet’s disease
• SLE
• Coagulopathy /Platelet
disorders
• Uremia/ Platelet
dysfunction
• Anticoagulant therapy
Haematological

16. RISK FACTORS FOR MORTALITY
1. Infiltrates involving 2 or more quadrants on an
admission CXR
2. Bleeding from the pulmonary artery
3. Cancer
4. Aspergillosis
5. Alcoholism
6. Mechanical Ventilation
& Aspiration in to contralateral lung *
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.

17. Predictors of Mortality
 71% in patients who lost =>600 ml
of blood in 4 h
 22% in patients with =>600 ml
within 4–16 h
 5% in those with 600 ml of within
16–48 h
Life-threatening massive : 5 to 15%.
• *Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis. Arch Intern Med
1968;121: 495–498.

18. MANAGEMENT

19. Air way
Breathing
Circulation
Provide suction.
Provide O2
crystalloid solutions
AND blood products

20. INITIAL STEPS
1. IDENTIFY WHICH SIDE IS BLEEDING
2. POSITION THE PATIENT
3. ESTABLISH A PATENT AIRWAY
4. INSURE ADEQUATE GAS EXCHANGE
5. INSURE ADEQUATE CVS FUNCTION
6. CONTROL THE BLEEDING

21. DIAGNOSTIC MODALITIES

22. History
• Does the patient have known pulmonary, cardiac, or renal
disease?- smoke?
• Prior hemoptysis, other pulmonary symptoms, or
infectious symptoms?
• FH of hemoptysis, brain aneurysms, epistaxis, or GI ? a
skin rash?
• Exposed to asbestos?
• Bleeding disorder? DVT risk?
• DRUGS?
• Has the patient had (TB) or been exposed to TB?

23. Physical Examination
• Telangiectasias
• A skin rash,Splinter hemorrhages ,Needle tracks IE
• An audible chest bruit or murmur that increases with
inspiration  a large pulmonary AV malformation.
• P2, TR or PR, or RV lift
• Heart murmurs MS , CHD
• DVT signs

24. Laboratory tests
• Type and cross-matching
• CBC ,COAG
• Electrolytes, BUN
• ABG
• Liver function tests
• Urinalysis
• Special tests

25. CXR
• Site of bleeding in 33–82% *of cases.
• Underlying cause in 35%**.
• Rarely normal
*Khalil A, Soussan M, Mangiapan G, Fartoukh M, Parrot A, Carette MF: Utility of high-resolution chest CT scan in the emergency
management of hemoptysis in the intensive care unit: severity, localization and aetiology. BJR 2007; 80: 21–25.
**Hirshberg B, Biran I, Glazer M, Kramer MR:Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest
1997; 112: 440–444.

26. Bronchoscopy
• Flexible bronchoscopy is the initial diagnostic procedure
of choice :
performed at the bedside, it is readily available, and it is
highly successful at localizing the bleeding site if it is
performed while the patient is bleeding.
• Intubation should be considered .
Massive hemoptysis. Assessment and management. Cahill BC, Ingbar DH
Clin Chest Med. 1994;15(1):147.

27. CT SCAN
• Superior to CXR
• Correct localization in 70–88.5% of cases*
Multidetector CT - bronchial and nonbronchial systemic
arteries .
• Better than bronchoscopy for determining the cause of
bleeding.
*Haponik EF, Britt EJ, Smith PL, Bleecker ER:Computed chest tomography in the evaluation of hemoptysis: impact on diagnosis and
treatment. Chest 1987; 91: 80–85.

28. Figure 9. Bronchial artery.
Yoon W et al. Radiographics 2002;22:1395-1409
©2002 by Radiological Society of North America

29. Figure 8. Bronchial artery.
Yoon W et al. Radiographics 2002;22:1395-1409
©2002 by Radiological Society of North America

30. Arteriography
• Persistent bleeding following bronchoscopy.
• The preceding bronchoscopy may be helpful in
identifying the area of bleeding assisting the
radiologist in locating the precise bleeding site.
• Therapeutic embolization is possible during the
diagnostic arteriography procedure.

31. Figure 10c. Value of preliminary thoracic aortography.
Yoon W et al. Radiographics 2002;22:1395-1409
©2002 by Radiological Society of North America

32. Clues to bronchial artery as the source of
bleeding:
Parenchymal hypervascularity
Vascular hypertrophy
aneurysm

33. The identification of extravasated
dye --INFREQUENT
Bronchopulmonary shunting
Neovasculirization

34. BRONCHOSCOPIC AND
AIRWAY MANAGEMENT

35. • IDENTIFY WHICH SIDE IS BLEEDING
•POSITION THE PATIENT
• ESTABLISH A PATENT AIRWAY
• INSURE ADEQUATE GAS EXCHANGE
• INSURE ADEQUATE CVS FUNCTION
• CONTROL THE BLEEDING

36. Protection of nonbleeding lung
If bleeding side is known
Keep patient at:
-Rest
-Lateral decubitus
-Bleeding side down
Rt.Main bronchus
Left main brochus flooded with blood

37. • IDENTIFY WHICH SIDE IS BLEEDING
• POSITION THE PATIENT
•ESTABLISH A PATENT AIRWAY
• INSURE ADEQUATE GAS EXCHANGE
• INSURE ADEQUATE CVS FUNCTION
•CONTROL THE BLEEDING

38. CONTROL THE BLEEDING
• Non-surgical
Blood products
Bronchoscopic measures
BAE
• Surgery

39. Bronchoscopic Measures
 Endobronchial
>Unilateral lung vent
>Double-lumen ETT
>Balloon tamponade
 Bronchial irrigation
 Vasoconstrictive agents
 Lasers
 Thermal Therapy

40. Selective Intubation
SINGLE LUMEN ETT
Selectively intubate
the non bleeding lung.
Selective intubation of L Main bronchus
in R sided massive hemoptysis

41. Selective Intubation
DOUBLE LUMEN ETT
Specially designed for
selective intubation of
the right or left main
bronchi
Last option in an
asphyxiating pt.

42. FOB - diagnostic
• Identifies the site of
bleeding in 73–93%*
Early versus delayed.
(<24 hrs)
*Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB: Utility of fiberoptic bronchoscopy before bronchial artery
embolization for massive hemoptysis. AJR Am J Roentgenol 2001; 177: 861–867.

43. RIGID BRONCHOSCOPE

44. RIGID
ADVANTAGES
• Larger lumen-
packing/clearing clots
• Improved suctioning
• Better clearance
• Improved visualization
• Continuous OPENING FOR
airway
FLEXIBLE
ADVANTAGES
• Performed at bedside
• Access:UL/distal orifices
• CAN DO Lavage
• Topical anaesthesia

45. DISADVANTAGES
• Poor visibility of
peripheral lesions and
UL
• GA
• DISADVANTAGES
• Poor suction
• Air way patency is not
good
RIGID FLEXIBLE

46. Cold-Saline Lavage
• Lavage: Normal saline at 4 ° C , 50 mL aliquots
• It Stopped the bleeding with massive hemoptysis
obviating the need for emergency thoracotomy.*
Rigid scope is better over FOB
*Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R: Massive hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg
1983; 85: 120–124.

47. Topical VasoconstrictiveAgents
• Topical epinephrine
(1: 20,000)
Effective :
mild to moderate.
Not really useful:
massive bleeding*
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.

48. 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.
Fibrinogen/Thrombin
• Local application
• Immediate arrest of bleeding.
• Initial strategy before BAE.*
• Alternative treatment when
endovascular procedures cannot
be performed.
*Wong LT, Lillquist YP, Culham G, DeJong BP, Davidson AG:
Treatment of recurrent hemoptysis in a child with cystic fibrosis by
repeated bronchial artery embolizations and long-term tranexamic
acid. Pediatr Pulmonol 1996; 22: 275–279

49. Balloon Tamponade
• 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.

50. Advantages:
• Air way protection
• Allows gas exchange
• Supports patient before
embolization or surgery
Disadvantages:
• Ischemic mucosal injury
• Post obstructive pneumonia.

51. EndobronchialAirway Blockade(Silicone Spigot)
Temporary management.
• Silicone spigot is placed endobronchially .
Stabilizes patient before BEA
• *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.

52. A rigid bronchoscope initially allowed aspiration of
blood and removal of clots followed by cold saline
and topical vaso active agents ,clearing the vision
to place spigot
posterior segment
of the right upper lobe
Silicon spigots of various sizes

53. Distal end of flexibe biopsy forceps with
Spigot in place
6-mm silicone spigot
posterior segment
of the right upper lobe
A rigid bronchoscope initially allowed aspiration of
blood and removal of clots followed by cold saline
and topical vaso active agents ,clearing the vision
to place spigot

54. Following this procedure, the patient
underwent BAE, and the spigot
was removed 2 h later.
6-mm silicone spigot in place
posterior segment
of the right upper lobe

55. Bronchoscopy-Guided Topical Hemostatic
Tamponade(THT)
• Oxidized regenerated 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.

56. Bronchoscopy-Guided Topical Hemostatic
Tamponade(THT)
56

57. Bronchoscopy-Guided Topical Hemostatic
Tamponade(THT)
Endobronchial view of a bleeding
subsegmental bronchus before THT
During bronchoscopy guided THT

58. Bronchoscopy-Guided Topical Hemostatic
Tamponade(THT)
Disavantages:
• Not suitable for proximal sites, trachea.
 Patients who cannot tolerate occlusion.
Recurrence of hemoptysis

59. 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)

60. Endobronchial Sealing with Biocompatible Glue
60

61. Laser Photocoagulation
• Nd-YAG laser
• Effective in: Bronchoscopically visible source.
MECHANISM:
• Photocoagulation of the bleeding mucosa with resulting
hemostasis.
 Achieves photoresection and vaporization
*Dumon JF, Reboud E, Garbe L, Aucomte F, Meric B: Treatment of tracheobronchial lesions by laser photoresection.
Chest 1982; 81: 278–284.

62. Argon Plasma Coagulation(APC)
• TYPE : Thermal tissue
destruction
• Non contact electrocoagulation
tool*.
• Used:
In bronchoscopically visible
areas of sources of bleed
62
*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

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

64. • Once desired desiccation (dry) is done ,deeper penetration
and damage to further tissue SHOULD stopped.*
• Used for superficial and spreading lesions.
Advantages of APC over YAG laser.:
• It provides easy access to lesions.
• Allows homogeneous tissue desiccation.

65. Endobronchial Electrocautery
• TYPE: Thermal tissue
destruction
• Coagulation mode: contact
• Readily available
• .
Contact probesElectro cautery machine
Probe through working channel

66. • Indications :
- Bleeding, endobronchial growth &
benign tumours.
• Less expensive alternative to laser.
• Control of haemoptysis using
endobronchial electro cautery was
achieved in 75%* of the cases
Homasson JP: Endobronchial electrocautery. Semin Respir Crit Care
1997; 18: 535– 543

67. 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.

68. BAE
In a study conducted in China
mortality has come down from 15 % (1995-
1999)* to 0 % (2000-2005) with BAE.
*Shigemura N, Wan IY, Yu SCH: Multidisciplinary management of life-threatening massive hemoptysis: a 10-year
experience Ann Thorac Surg 2009; 87: 849–853.

69. INDICATIONS
 To Stabilize patients before surgical resection or medical
treatment
As a definitive therapeutic approach in patients:
 Who refuse surgery
 Who are not candidates for surgery
 Where surgery is contraindicated

70. PROCEDURE
Identification of the bleeding vessel by selective bronchial
artery cannulation.
Injection of particles in to the feeding vessel.
MATERIALS USED
 Catheters
Embolizing materials or particles

71. Figure 2. Right intercostobronchial artery.
Yoon W et al. Radiographics 2002;22:1395-1409
©2002 by Radiological Society of North America

72. Figure 3. Common bronchial trunk.
Yoon W et al. Radiographics 2002;22:1395-1409
©2002 by Radiological Society of North America

73. Catheters:
 Reverse-curved
catheters (Mikaelson,
Simmons I, SOS Omni)
 Forward-looking
catheters (Cobra,
HIH,RC)
 Sizes: 4, 5, or 5.5 Fr
are routinely used.
Mikaelson catheter

74. Cobra type: curved catheter
• Most commonly used
• Microcatheter
• Superselective
catherization
• Less complications
Cobra type catheter

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

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

77. Bronchial artery aneurysm
Hypervascular lesion with aneurysm
Pre embolisation Post embolisationPVA particles
No hypervascular lesion & aneurysm

78. Super selective Embolization of intercostal
artery
Hypervascular areas and a small amount
of pulmonary arterial shunting
Decreased vasularity
POST EMBOLIZATIONPRE EMBOLIZATION
Radicular arteries
INTERCOSTAL ARTERY
Micro catheter passed
beyond radicular artery

79. Left upper lobe bronchial artery
After embolization
Decreased vascularity & hypertrophyTortous and hypertrophied vessel
Before embolization

80. More About Materials
 PVA particles (350-500 mic)
Most common & Safe
• Liquid embolic agents
-ischemic necrosis
 Stainless steel platinum coils
-occlude more proximal vessels.
Particles > 200 to 250 micr.m should be used
IF LESS (Tissue infarction)

81. AVM
• Metallic coils (steel, titanium, or platinum) or detachable
balloons, coils should be 2 mm wider than the feeding
artery .
• If steel coils are used, MRI of the brain DELAYED. 6W
• Other : polyvinyl alcohol, wool coils, and Amplatzer
vascular plugs. Amplatzer plugs are relatively new. In
one study, Amplatzer plugs were used to successfully
occlude 120 out of 161 PAVM (75 %) in 69 patients .

82. Figure 17b. Coil embolization.
Yoon W et al. Radiographics 2002;22:1395-1409
©2002 by Radiological Society of North America

83. BEA
• Success rates : 64% to 100%.
• Recurrent non-massive bleeding :16–46%
• Technical failure: 13%
83

84. Complications of BAE
• Transversemyelitis
• Neurological (Para
paresis)
• Intimal tears
• Chest pain
• Pyrexia
• Haemoptysis
• Systemic embolisation
• Vessel perforation
84

85. Acute Complications of BAE
1. Pleuritic chest pain 5 - 13 %
2. Transient air embolization 5%
3. Radiographic pulmonary infarction 3%
4. TIA 1%
5. Distal migration of the detachable balloon 1%
6. DVT 2ry to the angiography catheter 1.5 %
7. Stroke <0.5 %
8. Reflux of the embolization coil
9. Arterial wall damage with potential perforation .

86. Long-term outcomes
• Stroke and/or cerebral abscess 2%.
• The onset of pulmonary hypertension or the
worsening of prior pulmonary hypertension.

87. SURGICAL MANAGEMENT
• Localized lesions
• Mortality : 1% to 50%
• Mortality :upto 40% (emergency procedure)

88. Indications of surgery
Procedure of choice in:
• Bronchial adenoma
• Aspergilloma
• Hydatid cyst
• Iatrogenic pulmonary rupture
• Chest trauma
• AV malformations

89. Contra indications for Surgery
• Unresectable carcinoma
• Inability to lateralize the bleeding site
• Diffuse disease
• Multiple AVM
• Cystic fibrosis
• Marginal pulm. Reserve
• Non-localizing bronchiectasis

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