hemoptysis

HEMOPTYSISHEMOPTYSIS

Dr. Daniela Bartoş, Ph. D.

Definition

• Hemoptysis means coughing-up blood originating from the subglottic airways.

• In large amounts, hemoptysis can have an unfavourable vital prognostic and requires emergency treatment.

• In small amounts, the disease should not be overlooked, since it can relapse to a serious form or can conceal a pulmonary disease.

Anatomy

• Bronchial arteries derive from the descending thoracic aorta at level T4-T8. Their number varies, but most frequently there are the right bronchial artery and two left bronchial arteries, and possibly many anatomic variants.

• There may also be an ectopic bronchial artery, originating in other ramifications of the aorta, most frequently in the internal mammary, subclavian, inferior thyroid artery.

• Bronchial arteries are between 0.5 and 2 mm wide.• Bronchial arteries can create an anastomosis

between them.

Physiopathology

Hemoptysis can occur via several mechanisms:

• Blood vessel breakage – is a seldom occurrence, being the origin of massive hemoptysis

• detectable in arterial and venous pulmonary aneurysms• if the carcinoma eroded the walls of arteries• seldom in case of tuberculosis (Rasmunsen’s pseudo-aneurysm

close to a cavern)

• Sanguine leak from pulmonary capillaries into alveoli• this mechanism explains the hemoptysis in the acute pulmonary

oedema and partly that in acute infectious diseases• alteration of the alveolar basement membrane via immunologic

disorders (Goodpasture syndrome) increases permeability and enables sanguine leak

Physiopathology

• Change in capillary circulation with systemic hyper-vascularisation. This mechanism is manifest in:

• inflammatory or acute infectious diseases (pneumonia, abscess, tuberculosis)

• disabling processes (dilated bronchi – Bronchiectasis) or aspergillomas

• diffuse angiomatosis

Diagnosis

• Clinical signs of hemoptysis: expectoration of red blood with air bubbles while coughing

• There can be prodromes:• retro-sternal heat• anxiety• a sensation of tickling in the throat• syncope

Diagnosis

• Judging by the amount, hemoptysis can be:• foudroyant: leading to death within minutes by losing

blood and asphyxiation by flooding the airways• massive, abundant: more than 500 ml of blood. It is

accompanied by signs of acute anaemia (pallor, tachycardia, falling blood pressure or hemorrhagic shock, consciousness disorders), thus requiring urgent therapeutic steps.

• NB: The same clinical significance have the repeated hemoptyses in which the expectorated blood volume is equal to or higher than 500 ml per day or higher than 150 ml per hour.

Diagnosis

• Medium: expectorated blood ranging from 300 to 400 ml. It can be a therapeutic emergency owing to the risk of repeating itself with unpredictable severity

• Mild: most often it consists only in some blood clots or coughing up of blood-stained sputum. It is most of all a diagnosis-related emergency.

• Respiratory clinical examination in case of hemoptysis can only detect less worthy elements:

• subcrepitant and bronchial rales• crepitant rales in case of pneumonia

Differentiated diagnosis

Hemoptysis should be distinguished primarily from:• Hematemesis

• Ejection after emesis effort

• Dark-coloured blood mixed with food particles

• In this context, stomach ache or gastric ulcer pain can make an appearance

• Rectal examination – possibly melaena

• Gastric endoscopy – useful for diagnosing oesophagus-gastro-duodenal bleeding

• Bleeding from upper airways: • epistaxis (nosebleed)• bleeding gums• polyp, otorhinolaryngological cancer• pharynx-laryngeal varicose veins • otorhinolaryngological examination

sets the diagnosis

Medical attitude to hemoptysis

Massive hemoptysis – immediate therapy:• Place the patient in the Trendelenburg position• Remove the blood from bronchi by intubation and

suction• Oxygen therapy• Make up for blood loss• Administrate vasoconstricting substances• Admit to intensive care unit

• Having taken these measures, one should resort to:

• Bronchoscopy – to locate the origin of bleeding• Bronchial arteriography – ahead of embolisation

Medium and mild hemoptysis

• The most frequent clinical cases – originally they require an overall examination

• Anamnesis – to detect a possible cardiovascular or respiratory disorder, or certain treatments (anticoagulants)

• Full physical examination – hemoptysis may be a complication of an already known respiratory disease or it could be an isolated hemoptysis

• Chest X-ray – front & side profile photos. This can be normal or can reveal certain features typical of hemoptysis (tumours, TB)

• Bronchoscopy – indispensable for the diagnosis. It reveals the origin of bleeding or a certain disorder (tumour)

Medium and mild hemoptysis• Chest CT scan – may reveal lesions that are not visible on

the chest X-ray and may locate precisely vascular relationships with a certain wound. It may settle the diagnosis in pulmonary embolism.

• Complementary examination:• Blood count• ESR• Coagulation test• Sputum examination for BK

• ECG• Lung scintigraphy – in case of a suspected pulmonary

embolus• Bronchial arteriography – in case of repeated hemoptyses

before therapeutic embolisation

Medium and mild hemoptysis

• Sometimes, the cause of hemoptysis is not obvious, as it can occur during:• a thoracic trauma, even a small one: broken rib,

pulmonary hematoma• a barometric trauma• after inhaling toxic gas (caustic vapors)• after bronchoscopy• in other cases, hemoptysis can be a syndrome

revealing a certain disorder or a complication of an already known pathology

Hemoptysis – causes1. Infectious TB, bronchiectasis, pneumonia, bronchitis,

chronic obstructive lung disease, lung abscess, viruses (pneumonia, cryoglobulinaemia, HIV-related pneumocystis), fungi (aspergillosis), helminti

2. Neoplasia Primary or secondary pulmonary disorders

3. Vascular Pulmonary infarction, vasculitis (Wegener, rheumatoid polyarthritis, systemic lupus erythematosus, Rendu-Osler-Weber syndrome), arterial-venous malformations, capillaritis

4. Parenchymatous Diffuse interstitial pulmonary fibrosis, sarcoidosis, haemosiderosis, Goodpasture syndrome, cystic fibrosis

5. HTP Acute pulmonary oedema, mitral stenosis, coarctation of the aorta, idiopathic HTP, Eisenmenger syndrome

6. Coagulopathies whichever

7. Trauma/foreign object Post tracheal intubation

Medium and mild hemoptysis – possible etiologies –

Bronchial and pulmonary disorders• Tuberculosis

• hemoptysis can be a sign of M. tuberculosis infection, indicating the presence of ulcer-related or nodular forms

• the diagnosis is based on clinical signs: malaise, fever, cough and a chest X-ray showing: nodular, infiltrative or cavity-like images. The diagnosis is confirmed by identifying BK in sputum either in direct examination or in cultures

• hemoptysis may occur in the context of an already known and under-treatment TB. This is an alarm signal, pointing to either failure of the treatment or inadequately applied treatment. If the patient treated adequately, hemoptysis is a sign of aggravation.


• hemoptysis in a patient who has been treated for tuberculosis may mean:

• reactivated TB (chest X-rays alter and BK is identifyied in sputum)

• bronchiectasis – due to fiber-like structural changes (CT examination suggests the diagnosis)

• aspergillum grafting in a remaining cavity (immuno-electrophoresis suggests the diagnosis)

• lung cancer


• Lung cancer • hemoptysis can be revealing is mild, it recurrent itself and is

whimsical. • occurs in smokers, with the accompanying clinical signs: rebel

cough, chest pains, malaise. • chest X-ray and thoracic CT scans show hilar or para-hilar tumor-like

images. Thus, bronchoscopy is compulsory even when the chest X-ray is normal.

• hemoptysis may appear in a patient with lung cancer. It can:• be foudroyant by eroding the wall of a vessel close to the tumour• become manifest long after the surgery, meaning a possible local

recurrence, which requires a new bronchoscopy • occur during radiotherapy and then require the treatment be

discontinued


• Bronchiectasis• revealing hemoptysis: occurs most frequently in a

patient suffering from purulent bronchorrhea. The diagnosis is established by chest X-ray and High-resolution thoracic CT scans

• hemoptysis can complicate the evolution of a patient with known bronchiectasis. An overview of the patient is necessary as regards the development of lesions and different medical treatment (antibiotics fit for the treatment of superinfection)


• Chronic bronchitis• hemoptysis can occur only in relation to the

superinfection episodes. It must also be investigated wheather lung cancer is associated.

• Pneumonia• every type can trigger hemoptysis. The most frequent

infections that may trigger hemoptysis are influenzae pneumonia, Klebsiella pneumoniae and staphylococcus. In these cases bronchoscopy is compulsory for excluding lung cancer and the routine examination of sputum for BK

• Lung abscess • can be associated with hemoptysis, particularly that

caused by Klebsiella pneumoniae and staphylococcus


Cardiovascular disorders

• Mitral insufficiency or stenosis

• occurs after undertaking efforts or over the last three months of pregnancy in an patient not previously diagnosed with valvulopathy

• Pulmonary embolism• hemoptysis can be the only sign of disease• the other suggestive signs that could favour

pulmonary embolism (deep vein thrombosis) or associated illnesses (chronic obstructive lung disease, malignity) should also be looked for

Medium and mild hemoptysis - possible etiologies -

• Hemoptysis can also occur in the case of:

• Pulmonary oedema • Heart failure• Acute myocardial infarction• Congenital cardiopathy• Cor pulmonale• Ruptured aortic aneurysm

Medium and mild hemoptysis - possible etiologies -

• Parasitizes and pulmonary mycoses

• Hydatid cyst (Echinococcosis) – fissure or rupture, can be accompanied by hemoptysis. Chest X-ray and prick-skin testing may settle the diagnosis

• Aspergillosis – either aspergilloma grafting in general on an old TB-related cavity or allergic bronchial aspergillosis, with fugacious pulmonary infiltrates, chronic bronchorrhea and asthma

• Amibiasis or other mycoses as histoplasmosis

• Goodpasture syndrome• can seldom be held responsible for hemoptysis• can have symptoms such as diffuse alveolar

hemorrhages and rapidly progressive glomerulonephritis• the disease occurs due to some basement anti-

membrane cytotoxic antibodies and linear deposits along the alveolar and glomerular basement membrane

• Clinical – the triad: • pulmonary hemorrhage (hemoptyses, pulmonary

infiltrate)• Glomerulonephritis• Anti-glomerular basement membrane antibodies

Medium and mild hemoptysis – Goodpasture syndrome –

• Patients manifest the following symptoms: • Cough, mild and reccurent, rarely important

hemoptysis with related anaemia• Kidney – proteinuria or micro hematuria. Within a few

days/weeks, it occurs the rapidly progressive glomerulonephritis (RPGN) with rapidly progressive kidney failure

• General symptoms: fever, joint pain, weight loss• Chest X-ray:

• pulmonary infiltrate of variable bilateral diffuse size, mostly symmetrical, that are not seen at the lung apices costodiaphragmatic recesses. The lesions disappear within two to three days, but might last for two weeks



• DLCO – if performed repeatedly, it shows a steady increase (due to diffuse alveolar hemorrhage)

• Lung perfusion scan – pulmonary iron sequestration

• In the kidney• nephritic syndrome• renal biopsy – proliferating GN forming crescents

and IgG linear deposits along the glomerular basement membrane

• The evolution of the disease depends upon how severe lung hemorrhages are, how strong the hypoxemia is and, subsequently, how badly the kidney is affected

• Treatment:• Plasmapheresis to remove circulating anti-GMB Ab• Immunosuppression to suppress the antibodies

production• Originally: pulse-therapy with Methylprednisolone

1g/day for 3 days, then p.o. Prednisone 1 mg/kgc/day and Cyclophosphamide 2 mg/kgc/day

• Favourable effects from treatment occur after 8 weeks• In case of aggravating kidney failure, physicians

recommend renal dialyse, nephrectomy and kidney transplantation


Medium and mild hemoptysis– systemic necrotising vasculitis –

Hemoptysis occurs as a complication in:• Wegener’s granulomatosis • periarthritis nodosa • more rarely in Behçet syndrome and mixed

cryoglobulinaemia

• They occur due to a pulmonary capillaritis• Treatment: pulse therapy with

Methylprednisolone 1g/day for 3 days, followed by prolonged oral therapy with Cyclophosphamide and Corticosteroids

Medium and mild hemoptysis– Collagen vascular diseases –

• Especially systemic lupus erythematosus (SLE) – may get complicated by an alveolar hemorrhage in 10-30% of total cases. It is usually active SLE – with fever, polyserositis and arthritis

• Hemoptysis may also occur in rheumatoid polyarthritis, polymyositis and dermatomyositis

• Treatment: pulse-therapy with Methylprednisolone for

more severe forms or high-dose oral corticotherapy for milder forms. If they do not respond to treatment, plasmapheresis or immunosuppressant medication (more frequent in SLE) is indicated.

Medium and mild hemoptysis– Idiopathic pulmonary hemosiderosis –

• a disorder due to an unspecified cause featuring repeated hemoptysis, iron deficiency anaemia and transitory infiltrative changes

• reccurent lung bleeding causes alveolar macrophages to be filled with hemosiderin, leading to diffuse pulmonary fibrosis

• more frequent in children• starts in the infancy and includes among its

symptoms cough, repeated hemoptysis, dyspnea

Medium and mild hemoptysis– Idiopathic pulmonary hemosiderosis –• Chest X-ray:

• bilateral infiltrates, poorly shaped, located particularly in the lower lobes of lungs

• these changes fade out 2-3 weeks after hemoptysis cease or translate into pulmonary fibrosis with micronodules, mainly in lower lobes, and +/- hilar adenopathy

• Diagnosis based on clinical examination, X-ray and through the macrophages filled with hemosiderin in sputum/bronchoalveolar lavage fluid

• Treatment is non-specific and symptomatic

Medium and mild hemoptysis– Bone marrow transplantation –

• For malign hemopathies or solid tumors may induce hemoptysis in 20% of patients. It is a very severe complication with 50-80% mortality

• The complication occurs two weeks after the transplantation, with patients showing hemoptysis (rarely), fever, dyspnea, dry, non-productive cough, hypoxemia and focal/diffuse alveolar infiltrate

• Recommendation: high-dose corticotherapy

Medium and mild hemoptysis– possible etiologies –

• Vascular congenital anomalies • Rendu-Osler-Weber syndrome – which may feature

diffuse manifestations, accompanied by hemoptysis

• Rare bronchial causes • Bronchial angioma – diagnosis is set by bronchoscopy

and arteriography. Usually, it is an exclusion diagnosis.• Bronchial carcinoid tumor – is rare, affecting

generally young subjects. Chest X-ray may reveal atelectasis and bronchoscopy confirms the diagnosis

• Foreign objects – in this case bronchoscopy plays a therapeutic role – can be taken out

Even if there are many etiological ways to explain hemoptysis, roughly 10% of the cases remain without an obvious cause. This is why patients must be placed under careful surveillance.

Abnormal

Chest X-ray

–Cancer–Tuberculosis–Artery/vein aneurysm–Hydatid cyst–Pulmonary sequester: CT, angiography, surgery–Goodpasture syndrome: renal biopsy

CTAngiography

surveillance

Seemingly insulated hemoptysis

Evocative context•Cardiovascular – etiologic treatment

Pneumopathyo Antibioticso Bronchoscopy

COPD – CT Allergic bronchopulmonary aspergillosiso Serodiagnosiso IgEo CTo Corticoids

Normal

bronchoscopy

Normal Abnormal

surveillance

CTSecondary bronchoscopyBronchographyAngiography

hemoptysis

Documents

blood originating

blood pressure

blood clots

case of hemoptysis

expectorated blood volume

expectorated blood ranging

left bronchial arteries

anatomy bronchial arteries