Respiratory EmergenciesRespiratory EmergenciesStepwise management of Stepwise management of

HemoptysisHemoptysis

Tarek Mohsen MD, FRCSTarek Mohsen MD, FRCS

Cardiothoracic SurgeonCardiothoracic Surgeon

Cairo UniversityCairo University

DefinitionsDefinitions Hemoptysis is the expectoration of blood or of blood-

stained sputum.

Massive hemoptysis, the amount varies from 200 – 1L / 24 hrs, but is usually defined as 600 / 24 hrs.

Any amount that causes respiratory compromise and/or hemodynamic instability is life threatening and constitutes a medical emergency.

The mortality ranges 7–30% for non-massive, and up to 80% for massive hemoptysis.

Questions and AnswersQuestions and Answers

Is it Hemoptysis?Is it Hemoptysis?What is the Cause?What is the Cause?What is the source?What is the source?

When massive hemoptysis is the caseWhen massive hemoptysis is the case

Resuscitation + search for the cause + Resuscitation + search for the cause + active treatment are held hand in hand active treatment are held hand in hand

Is it Hemoptysis?Is it Hemoptysis?

HemoptysisHemoptysis

HistoryHistoryLung diseaseLung diseaseAsphyxia is possibleAsphyxia is possible

Sputum examinationSputum examinationFrothy, bright red.Frothy, bright red.

LabLabAlkaline pHAlkaline pHMixed with macrophages and Mixed with macrophages and

neutrophilsneutrophils

HematemesisHematemesis

HistoryHistoryNausea and vomitingNausea and vomitingGastric or hepatic diseaseGastric or hepatic disease

Sputum examinationSputum examinationCoffee ground, black or brownCoffee ground, black or brown

LabLabAcidic pHAcidic pHMixed with food particlesMixed with food particles

What is the cause?What is the cause? NeoplasticBronchogenic carcinomaBronchial adenomaPulmonary metastasis

InfectiousTuberculosis #Fungal infectionsNecrotising pneumoniaLung abscessHydatid cyst

PulmonaryBronchiectasis #Cystic fibrosisLAM

VascularPulmonary thrombo-embolismAV malformation Mitral stenosisThoracic aorta aneurysm

Systemic diseasesBehcet’s diseaseWegener’s granulomatosisGoodpasture’s syndromeSLE

CoagulopathiesDIC, Thrombocytopenia, HaemophiliaAnticoagulant therapy

Misc.Catamenial and brocholith

Source of bloodSource of blood

In 90% of cases, hemoptysis originates from the bronchial arteries, in 5% from the pulmonary arteries, and in the remainder from non bronchial collaterals.

Bronchial hemoptysis is usually profuse while pulmonary hemoptysis is not.

Most common cause in EgyptMost common cause in Egypt

In adults exclude TB, bronchiactesis and In adults exclude TB, bronchiactesis and bronchogenic and DON’T forget RTI.bronchogenic and DON’T forget RTI.

In children exclude FB and RTI.In children exclude FB and RTI.

Put in mind AV malformation and Put in mind AV malformation and vasculitisvasculitis

Steps towards diagnosisSteps towards diagnosis

History and clinical examinationsHistory and clinical examinations

LabsLabs

Radiography (HRCT) + contrast.Radiography (HRCT) + contrast.

BronchoscopyBronchoscopy

Bronchial angioBronchial angio

CT pulmonary angioCT pulmonary angio

Echo heart.Echo heart.

Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Physical HistoryPhysical History

Clinical cluesClinical clues

Association with mensesAssociation with menses

Anticoagulant useAnticoagulant use

Dyspnea on exertion, fatigue, Dyspnea on exertion, fatigue, orthopnea, PND, frothy pink sputumorthopnea, PND, frothy pink sputum

Fever, productive coughFever, productive cough

History of chronic lung disease, History of chronic lung disease, recurrent lower RTI, cough with recurrent lower RTI, cough with copious purulent sputumcopious purulent sputum

Pleuritic chest pain, calf tendernessPleuritic chest pain, calf tenderness

Suggested diagnosisSuggested diagnosis

Catamenial hemoptysisCatamenial hemoptysis

Medication effect, coagulation disorderMedication effect, coagulation disorder

Congestive heart failure, left ventricular Congestive heart failure, left ventricular dysfunction, mitral valve stenosisdysfunction, mitral valve stenosis

Upper RTI, acute sinusitis, acute Upper RTI, acute sinusitis, acute bronchitis, pneumonia, lung abscessbronchitis, pneumonia, lung abscess

Bronchiectasis, lung abscessBronchiectasis, lung abscess

Pulmonary embolism or infarctionPulmonary embolism or infarction

Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Physical History IIPhysical History II

Clinical cluesClinical clues

Tobacco useTobacco use

Weight lossWeight loss

History of breast, colon, or renal History of breast, colon, or renal cancerscancers

ImmunosuppressionImmunosuppression

Suggested diagnosisSuggested diagnosis

Acute bronchitis, chronic bronchitis, Acute bronchitis, chronic bronchitis, lung cancer, pneumonialung cancer, pneumonia

Emphysema, lung cancer, tuberculosis, Emphysema, lung cancer, tuberculosis, bronchiectasis, lung abscess, HIVbronchiectasis, lung abscess, HIV

Endobronchial metastatic disease of Endobronchial metastatic disease of lungslungs

Neoplasia, tuberculosis, Kaposi's Neoplasia, tuberculosis, Kaposi's sarcomasarcoma

Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Laboratory TestsLaboratory Tests

TestTest

CBCCBC

INR and PTTINR and PTT

ESR and Tuberculin testESR and Tuberculin test

ABGABG

Sputum for Gram stain, culture Sputum for Gram stain, culture and sensitivity and cytology.and sensitivity and cytology.

D- dimerD- dimer

Diagnostic findingDiagnostic finding

Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Chest RadiographChest Radiograph

Radiological findingsRadiological findings

Normal or no change from base lineNormal or no change from base line

Cavitary lesionCavitary lesion

Hilar adenopathy or mass lesionHilar adenopathy or mass lesion

Nodules or granulomasNodules or granulomas

Diffuse alveolar infiltrateDiffuse alveolar infiltrate

Patchy alveolar infiltratePatchy alveolar infiltrate

Lobar or segmental infiltrateLobar or segmental infiltrate

HyperinflationHyperinflation

Suggested diagnosisSuggested diagnosis

Sinusitis, bronchitis, PESinusitis, bronchitis, PE

TB, lung abscess, necrotizing ca. TB, lung abscess, necrotizing ca.

Sarcoid, lung ca., infectious processSarcoid, lung ca., infectious process

Carcinoma, mets, Wegener's granulomatosis, septic Carcinoma, mets, Wegener's granulomatosis, septic embolism, vasculitidesembolism, vasculitides

Chronic heart failure, pul. edema, aspiration, toxic Chronic heart failure, pul. edema, aspiration, toxic injury.injury.

Bleeding disorders, idiopathic pulmonary Bleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture's syndromehemosiderosis, Goodpasture's syndrome

Pneumonia, thromboembolism, obstructing carcinomaPneumonia, thromboembolism, obstructing carcinoma

Cavitary lesionsCavitary lesions

Hilar adenopathy and massHilar adenopathy and mass

Nodule or granulomaNodule or granuloma

Lobar or segmental infiltratesLobar or segmental infiltrates

Alveolar infiltrateAlveolar infiltrate

BronchiactesisBronchiactesis

Hydatid cystHydatid cyst

Role of bronchoscopyRole of bronchoscopy Bronchoscopy is useful in both the diagnostic work-up as

well as a therapeutic modality. The timing of performing bronchoscopy is controversial.

One suggestion is to perform urgent bronchoscopy when there is rapid deterioration and elective bronchoscopy within 24–48 h in stable patients.

In patients with massive hemoptysis, rigid bronchoscopy is the method of choice due to its better suction ability. The major limitation of rigid bronchoscopy is that it is difficult or even impossible to visualize the upper lobes or peripheral lesions

Initial management stepsInitial management steps

1) Resuscitation and airway protection are the first priority.

2) Localization of the site and establishing the cause of bleeding is the next step.

3) The final step is directed at specific and definitive treatments to stop the haemoptysis and to prevent rebleeding

Resuscitation

Admit to ICU with full monitoring.Admit to ICU with full monitoring.

Position the patient with the bleeding site down.Position the patient with the bleeding site down.

Estimate of blood Loss (Hb, Hct and CVP).Estimate of blood Loss (Hb, Hct and CVP).

Stable patient are investigated.Stable patient are investigated.

Unstable patients are intubated and ventilated.Unstable patients are intubated and ventilated.

Airway protection Selective intubation of one

lung can be performed by a rotational technique. After intubating the trachea, the tube is rotated through 90 in the direction of the desired placement until resistance is felt. The tube placement should be confirmed both clinically and radiologically.

Alternatively, a double-lumen endotracheal tube can be passed to protect the unaffected lung.

Localization of the site

Localization of the bleeding site directs

definitive treatment. This can be achieved by combining the various imaging techniques with bronchoscopy.

Definitive and specific treatments.

Bronchoscopic treatment.Bronchoscopic treatment.

Bronchial Embolization.Bronchial Embolization.

Surgery.Surgery.

Disease specific approach. Disease specific approach.

Bronchoscopic managementBronchoscopic management

When bleeding is mild to moderate instillation of cold When bleeding is mild to moderate instillation of cold saline, adrenaline (1: 20.000). I.V or local ornipressin 5 saline, adrenaline (1: 20.000). I.V or local ornipressin 5 IU in 20 ml normal saline.IU in 20 ml normal saline.

If massive bleeding, rigid bronchoscopy or combined If massive bleeding, rigid bronchoscopy or combined bronchoscopy is needed.bronchoscopy is needed.

Bronchial tamponade may be needed in some cases, Bronchial tamponade may be needed in some cases, Fogarty size 4 – 6, 170 cm can be placed via Fogarty size 4 – 6, 170 cm can be placed via bronchoscopy. Up to 7 days until definitive treatment is bronchoscopy. Up to 7 days until definitive treatment is establishedestablished

Bronchoscopic interventionBronchoscopic intervention

The use of laser, The use of laser, electrocauteryelectrocautery

Coagulation– laser– electrocautery– cryotherapy

Mechanical debulking

twist&

push

Bronchoscopic interventionBronchoscopic intervention

Bronchoscopic interventionBronchoscopic intervention

Bronchial artery embolisation.

BAE is a technically demanding procedure and should always be performed by skilled

interventional radiologists. Multi-detector row helical CT angiography could be used as a

road map guiding the interventional radiologist.

The most commonly used agent is polyvinyl alcohol (PVA) with particles sized 350–500 mm in diameter.

Immediate response rates after BAE range 73–98%.

Complications are chest pain and is transient, Spinal cord injury in 1 %.

SurgerySurgery Currently, surgery represents one of a few

treatment options, but still represents the only definitive one.

Surgical mortality ranges 1–50%.

Surgery remains the procedure of choice in patients with localised bronchiectasis, trauma, hydatid cyst, arteriovenous malformations, thoracic aneurysm and aspergilloma, because it is curative for these underlying diseases.

Disease-specific approaches.

Aspergilloma.A patient with an aspergilloma should undergo surgical resection.

Unfortunately, such patients often have significant concomitant bronchiectasis that may preclude them from surgery due to insufficient pulmonary reserves. In these patients intracavitary Na of K iodide is curative. In some series external beam irradiation was used.

Immunological diseases. Some of the immunological diseases, such as Goodpasture’s disease, can present with massive haemoptysis. These diseases do

not need invasive procedures and are usually treated with high-dose corticosteroids, cytotoxic agents or plasmapheresis.

In practice tailored management for In practice tailored management for hemoptysis is neededhemoptysis is needed

Case ICase I

58 yrs old male presented with frank 58 yrs old male presented with frank hemoptysis and heart failure.hemoptysis and heart failure.

History of old TB, asthmatic bronchitis, History of old TB, asthmatic bronchitis, previous cardiac catheterization and previous cardiac catheterization and MarevanMarevan

Examination revealed features of heart Examination revealed features of heart failure, and murmur of AS. failure, and murmur of AS.

InvestigationInvestigation

Hb 7gm%, CT scan, Echocardiography, Hb 7gm%, CT scan, Echocardiography, PFTs.PFTs.

CT scan revealed bilateral epical fibrotic CT scan revealed bilateral epical fibrotic lesions, pulm edema and bilateral pl lesions, pulm edema and bilateral pl effusion. Calcified Ao. Valveeffusion. Calcified Ao. Valve

Echo revealed AS with a gradient of 60 Echo revealed AS with a gradient of 60 mmHg and ejection fraction of 38 % mmHg and ejection fraction of 38 %

ManagementManagement

Resuscitation with Blood to restore HbResuscitation with Blood to restore HbUpright positionUpright positionCoagulantsCoagulantsAnti failure measuresAnti failure measuresNo bronchodilators or cough sedativesNo bronchodilators or cough sedatives

Hemoptysis decreased in amount but did not stop on the 3Hemoptysis decreased in amount but did not stop on the 3rdrd day of admission.day of admission.

Bronchoscopy was done revealing right upper lobe a Bronchoscopy was done revealing right upper lobe a source of bleeding. source of bleeding.

What NextWhat Next

a)a) Consider RUL followed by AVRConsider RUL followed by AVR

b)b) Consider AVR followed by RULConsider AVR followed by RUL

c)c) Combined procedureCombined procedure

d)d) Embolization followed by AVREmbolization followed by AVR

What Valve is suitable for this patient?What Valve is suitable for this patient?

Final managementFinal management

Because we considered the patient for valve Because we considered the patient for valve replacement his marginal pulmonary functions replacement his marginal pulmonary functions and bilateral lesion we decided to do bronchial and bilateral lesion we decided to do bronchial angiography and possible embolization. angiography and possible embolization.

Four weeks later the patient had dobutamine Four weeks later the patient had dobutamine stress echo and cardiac catheterization.stress echo and cardiac catheterization.

Ao. Valve replacement with a tissue valve was Ao. Valve replacement with a tissue valve was

then done.then done.

Bronchial embolizationBronchial embolization

Case IICase II

72 yrs old female presented with repeated 72 yrs old female presented with repeated attacks of hemoptysisattacks of hemoptysis

History of CAD, hypertension, DM, left History of CAD, hypertension, DM, left mastectomy for Ca breast 10 yrs ago with mastectomy for Ca breast 10 yrs ago with post resection chemo and radiotherapy.post resection chemo and radiotherapy.

Angina class IIIAngina class III

InvestigationInvestigation

Routine investigations were normalRoutine investigations were normal

CT scan showed a Rt lower lobe mass, CT scan showed a Rt lower lobe mass, adenoca. was confirmed by TBLB. Patient adenoca. was confirmed by TBLB. Patient was staged as stage IIBwas staged as stage IIB

Coronary angio revealing 3 Vs disease with Coronary angio revealing 3 Vs disease with critical proximal LAD.critical proximal LAD.

Problem ListProblem List

CAD + other co-morbidity.CAD + other co-morbidity.

Hemoptysis due to operable malignant Hemoptysis due to operable malignant mass.mass.

High mortality if resection is done in CAD.High mortality if resection is done in CAD.

So what next?So what next?

ManagementManagement

In our patient hemoptysis didn’t respond to In our patient hemoptysis didn’t respond to conservative therapy.conservative therapy.

Options left wereOptions left were

a)a) Lobectomy followed by CABGLobectomy followed by CABG

b)b) CABG followed by lobectomyCABG followed by lobectomy

c)c) Combined procedureCombined procedure

d)d) Stenting followed by RLLStenting followed by RLL

Definitive managementDefinitive management

A drug eluding stent to LAD and mid RCA A drug eluding stent to LAD and mid RCA were done.were done.

Patient developed left hemiparesis few Patient developed left hemiparesis few hours after the procedure.hours after the procedure.

On the 3On the 3rdrd day significant attack of day significant attack of hemoptysis. hemoptysis.

OptionsOptions

Urgent RLL.Urgent RLL.

Urgent wedge resection of the mass (not Urgent wedge resection of the mass (not oncologically radical).oncologically radical).

Rigid bronchoscopy and packing.Rigid bronchoscopy and packing.

Rigid bronchoscopy and Rigid bronchoscopy and tamponadetamponade

Urgent rigid Urgent rigid bronchoscopy bronchoscopy with packing of with packing of the Rt the Rt intermediate intermediate bronchus, using bronchus, using Fogarty size 6 Fogarty size 6 hemoptysis was hemoptysis was then controlled.then controlled.

Two weeks later uneventful RLL was done.Two weeks later uneventful RLL was done.

Case IIICase III

Male 48 yrs old chronic heavy cigarette Male 48 yrs old chronic heavy cigarette smokersmoker

Hemoptysis responded to conservative Hemoptysis responded to conservative managementmanagement

All investigations were normalAll investigations were normal

Multi slice Pulmonary angioMulti slice Pulmonary angio

BronchoscopyBronchoscopy

White light bronchoscopy revealed bleeding White light bronchoscopy revealed bleeding middle lobe but no lesion.middle lobe but no lesion.

EBUS revealed distraction of cartilage and EBUS revealed distraction of cartilage and biopsy revealed grade II dysplasiabiopsy revealed grade II dysplasia

Patient was diagnosed as stage 0 caPatient was diagnosed as stage 0 ca

He underwent middle lobectomyHe underwent middle lobectomy

EBUSEBUS

Thank YouThank You