hemoptysis edited

8/18/2019 Hemoptysis Edited

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Hemoptysis

Introduction:

To have hemoptysis is the most frightened experience, even worse than hematemesis or

bleeding 1 litter or more from other part of the body. It is a frightening event to both:

Health- care Providers and Patients & families.

Definition:

As doctors, we should differentiate hemoptysis from other type of bleeding. Heamoptysis is

the expectoration (or coughing up) of blood from the lung and the airways. Patients always

describe it in different ways. Some patients will describe it as mucus with blood streaks, or

mucus with dots, Pink sputum, Frank blood (with or without clots), Others will describe it as

fresh blood, or black blood.

Site of bleeding:

If we go back to the physiology of blood circulation in the lung, we will find that we have 2

circulations:

1- The bronchial circulation: this is high pressure (Bronchial arteries & collaterals originate

from the aorta ) ,also known as systemic circulation.

2- The pulmonary circulation: this is low pressure :

systolic BP= 15-20mmHg.

diastolic BP= 5-10mmHg .

Most of the time, Hemoptysis comes from the low pressure circulation – which is close to the

venous system- & that’s why it is always watery and low amount. In contrast, if the bleeding i

from high pressure circulation -the arterial system - , there will be massive hemoptysis.

*In the slides : bronchial circulation is The source of bleeding in most cases.

This lecture

include all the

slide :D


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Mechanism of bleeding:

Hemoptysis occurs as a result of:

1- Inflammation with erosion of blood vessels.

2- Increase pressure in the vessels, which lead to dilatation & aneurysm formation ,and finally

it will rupture

Severity of hemoptysis:

Depends on 3 factors:

1- Amount & rapidity of bleeding:

It’s very important point to understand that, severity of hemoptysis is not only related to the

amount of blood expectorated in 24h. In the past, they thought that the severity is

proportional to the amount of blood. But nowadays, they find that the severity of the case ismuch more related to the rapidity of bleeding. E.g. patient with rapid but small amount

bleeding is more critical than patient with slow but huge amount bleeding.

2- Cardio-respiratory reserve:

So patients with low cardio-respiratory reserve –as in COPD, lung fibrosis or

Bronchiectasis - will have much more severe hemoptysis than one with healthy high

reserve.

3- The effect on gas exchange:

We must conceder the effect of bleeding on gas exchange. In other word, we should ask: does

the bleeding affect the gas exchange? & what does it cause in the respiratory tract?!!

Sometimes, small amount of blood can cause a major obstruction that will lead to

Asphyxiation or flooding of tracheo-bronchial tree and finally respiratory arrest (Medical

Emergency: Occur in 1-5% of patients).

*In medical emergency the amount reported to range from

[ > 100 – 250 – 500 – 600 – 1000 ] cc / 24 hrs.

So , we should look for all these 3 factors to assess the severity.


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Etiology:

It’s important to define the etiology & the cause of hemoptysis to be able to deal with it and

treat the patient. We can classify the etiology according to:

1- the site of bleeding:

It might be from tracheobronchial

tree, lung parenchyma, lung

vasculature, or related to systemic

problem – read the table- slide#6-.

- Bronchogenic carcinoma,Bronchitis, & Bronchiectasis are

common cause for tracheobronchial

bleeding.

- TB is most common cause for lung parenchymal bleeding

- Other causes are rare cases.

2- The cause of bleeding:

It might be infection, foreign body, trauma,

malignancy, cardio-pulmonary causes, connective

tissue disorders, factitious, or cryptogenic.

Note: First make sure it is hemoptysis. Because there are lots of

patients have nesopharengeal bleeding and cough which looks like

hemoptysis & will give wrong diagnosis. So, you should ask about

history of Hematemesis, Epistaxis, or other nasopharyngeal bleeding.

Look at the table

Factitious disorders: are conditions in which

a person acts as if he or she has an illness by

deliberately producing, feigning, or

exaggerating symptoms.


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3- Incidence & frequency:

It varies in different study populations. The

most common cause worldwide is Bronchitis.

Pneumonia is 2nd

most common cause, thenTB , Bronchiectasis, & lung CA.


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Approach to Patient with Hemoptysis:

When a patient comes to the ER with hemoptysis, we needto:

- Take good history.

- Assess the severity, Urgency, amount, duration & extent of bleeding.

- Assess the Cardio-Respiratory reserve whither he/she has HF, IHD, or previous lung

problem.

- Ask about Prior Episodes of bleeding.

Clues from the history:

These clues can help us to define the cause of hemoptysis. It’s not 100% true, but it can

help.

- If the patient has blood streaking of mucopurulent or purulent sputum, then think of

Bronchitis.

- If he has Blood streaking of purulent sputum + fever & chills, think of Pneumonia.

- If he has chronic cough & sputum production + Recent change in quantity or

appearance, think of Acute Exacerbation of COPD.

- If he comes with foul smell of purulent sputum, check for Lung abscess.

- If the chief complaint is sudden chest pain with SOB, think of pulmonary embolism.

- In patient with Bronchiectasis, we expect to have Copious secretions & recurrent

respiratory infections.- It’s very important to recognize the color of the sputum for

Bronchiectasis, & that’s why the DR. put it in separated slide#14 – - In a patient with positive Hx of asbestosis or smoking, we should think of Bronchogenic

CA.

- Alcoholic patient, or patient with recurrent coma or with poor dental hygiene are at

high risk for lung abscess.

- +ve Hx of drug abuse, or blood transfusion, or sexual practice may indicate HIV

infection.

- If hemoptysis is combined with renal disease – or hematuria- , think of Goodpasture

syndrome or Wegener disease.- SLE patients may come with Lupus Pneumonitis

- Hx of other cancers – as renal cell carcinoma- with hemoptysis may indicate metastasis.

- AIDS patients usually have endobronchial Kaposi sarcoma that may cause hemoptysis.

- If patient has +ve Hx of previous bleeding, think of thrombocytopenia or anti-coagulant

overdose.


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Diagnostic:

For any patient coming with hemoptysis we do: labs, radiologic studies and

endoscopic studies.

1. Labs:

Hemoglobin (the most important one) PT, PTT & INR to know if the patient has bleeding diathesis.

Sputum studies when suspect infectious or neoplastic etiologies.

Cultures.

KFT (Kidney Function Test) because, as we said, there are some illnesses which are

associated with renal problems.

UA (Urine Analysis)

ABG's (Arterial Blood Gas) to know how much the patient is affected.

CVD (Collagen Vascular Diseases) like: diabetes, rheumatoid arthritis… etc

Differential diagnosis of hemoptysis + hematuria:

GPS, Goodpasture syndrome

WG, Wegener disease

SLE.

Lung cancer. What is the cause of hematuria in lung cancer patients? Membranous GN.

Renal cell carcinoma from lung metastasis. Bleeding diathesis which may cause bleeding from any site.

Student: what is the meaning of bleeding diathesis?

Doctor: patients who have bleeding tendency.

2. Radiologic studies:

CXR (Chest X-Ray): When a patient comes to with any respiratory illness, you should do x-ray

to him. In hemoptysis, it may be normal in up to one third of cases and in the other two thirds

you may see the etiology. If you see an abnormality in one side of the x-ray, it may not reflect

the exact site of the bleeding. Why? Because the bleeding accumulates in gravity-depending

areas (the patient may be ambulating or bedridden).So, the infiltrate in the x-ray indicates the

blood but does not indicate where the blood is coming from.


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CT scan:It has higher yield and the highest yield is in bronchiactasis.

Diagnostic clues for chest radiograph: Here, the doctor just talked about some examples:

Cardiomegaly: the patient may have heart failure or mitral stenosis.

Hyperinflation: the patient may have COPD.

Mass lesions, nodules, granulomas: may suggest carcinomas, metastatic diseases,

Wegener's granulomatosis, septic embolism (multiple nodules) or vasculitis (nodular lesions).

Bilateral hilar adenopathy: may suggest TB.

Here the x-ray is normal (look at the CT for

the same patient)

There is a cavity behind the heart ,

diagnosed after tha as adenocarcinoma


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3 . Bronchoscopy: there are two types:

FPB (FiberOptic Bronchoscopy): can be inserted into any segment of the lung. The

disadvantage is that the blood can obliterate the field quickly becauseلضو يخية

is very small.

So, you may be obligated to take it out, clean it and insert it again.

Rigid bronchoscopy: the advantage is that you can do better blood suctioning and you can

do more therapeutic interventions.

We, as pulmonologists, do not do rigid bronchoscopy because rigid bronchoscopy needs to be

done in the operation room. As you can do therapeutic interventions, you may harm the

patient in rigid bronchoscopy and proceed more. So, you have to have more control to the

environment and nowadays rigid bronchoscopy is done by surgeons and

pulmonologists do the FPB.

4. Bronchial angiography:

After doing bronchoscopy, you may have to do something we call "bronchial angiography".

This angiography has two benefits:1diagnostic to determine the exact site of the bleeding

and if the bleeding is uncontrolled, you may do2intervention by occlusion of the artery

where the bleeding is come from. But we do not do this angiography unless we haverefractory bleeding

You can see a bronchus and there is a white mass. The

first thing you should think about is mucous plug and we see

this a lot in ICU patients. If it is a tissue rather than

mucous plug, this tends to be a bronchogenic carcinoma


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Management:

Management of hemoptysis depends on:1the severity of bleeding,

2the cause of bleeding

and3the general condition of the patient.

Management of non-massive hemoptysis: we have time to take history, do all

investigations (CBC, IV fluids…etc) and monitor the patient. When we find the cause, we

treat him according to the cause. If it is infection, we give antibiotics. If the cause is

vasculitis, we start to give steroids or other immunosuppressive drugs. If it is cancer, we give

chemotherapy. If there is foreign body, we remove it.

Management of massive hemoptysis(indictated by:

Rapidity of bleeding and Respiratory function)

it is a medical emergency. We must put the patient in the

ICU. The priority is always for the airways because, as we

said, the most common cause of death in hemoptysis is

asphyxiation rather than exsanguinations. So, we need to

make sure that the airways are protected. If there is drop

in oxygenation, we do intubation. As any bleeding, we put

large needles and prepare blood. We do

bronchoscope and during the bronchoscope, we attempt

to stop the hemoptysis. We may give cough suppressant

but you need to correct any coagulopathy and give fluids.

We have some interventions that we may do when the patient is is intubated in severe

massive hemoptysis:

Iced saline lavage on the segment that the blood is come from because it causes

vasospasm.

Topical vasopressors like: adrenaline.

Selective intubation. It has specific types of endotracheal tubes that have two lumens: one

goes to the right lung and the other goes to the left lung. If the bleeding is coming from the

left lung, we blow a balloon and close the left lung. So, the left lung will collapse. Blood supply

will be diverted to the other lung and the bleedingwill decrease.

Endobronchial tamponade. There is a special catheter called "Fogarty catheter". You insert

this catheter by bronchoscope. When you reach to the segment that causes the bleeding, you

blow the balloon of Fogarty catheter. So, it will cause tamponade for

the eondobronchial segment. Then, you leave it for about an hour until the bleeding stops.

Priorities

Airway protection

ETT / MVS

Patient Stabilization

Find the site /cause of bleeding

Attempt to stop bleeding

Prevent recurrence of bleeding

Specific therapy


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Laser photocoagulation. It needs special training and here we do cautery

Bronchial artery embolization. We do not do it during bronchoscopy. We do it during

bronchial angiography.

Surgery (lobectomy / pneumonectomy) if the previous interventions are not effective

considering the cardio-pulmonary reserve because not all patients can tolerate. For example:

COPD patients cannot tolerate lobectomy. So, mortality rate is high in these patients.

Good Luck…

hemoptysis edited

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