Approach to a patient with Haemoptysis

Prof. Dr. Md. Khairul Hassan Jessy
Professor Of Respiratory Medicine
NIDCH, Bangladesh

1. Approach to a Patient with
Haemoptysis
Prof. Dr. Md. KhairulHassan Jessy
Professor Of Respiratory Medicine
NIDCH

2. Definition
•Haemoptysis is the expectoration of blood or
blood stained sputum that originates below the
vocal cords from tracheobronchial tree or
pulmonary parenchyma.
•A spectrum that varies from blood streaking of sputum to
coughing up of large amounts of pure blood.

3. General Considerations
•Coughing up of blood, irrespective of the amount, is an
alarming symptom.
•Haemoptysis must always be assumed to have a serious
cause until appropriate investigations have excluded the
causes.
•May be a marker for potentially serious disease, such as
Bronchial carcinoma.

4. General Considerations (contd…)
•Mild haemoptysisis < 20 ml of blood in 24 hrs
•Moderate haemoptysisis 20-200 ml in 24 hrs
•Severe haemoptysisis 200-600 ml in 24 hrs
•Massive haemoptysisis any amount of blood loss
more than 600 ml in 24 hrs

5. General Considerations (contd…)
•Massive haemoptysishas been variably defined as 100
ml to more than 1000 ml of blood expectorated from
lungs over 24 to 48 hours.
(More than 600 mLin 24 hours [Baum])
•May be usefully defined as any amount of blood that is
hemodynamicallysignificant or threatens ventilation.
•In this case, the initial management goal is not
diagnostic but therapeutic.

6. General Considerations (contd…)
•Massive haemoptysis is a life-threatening problem.
•Tuberculosis is the most common cause worldwide.
•The etiologies of massive hemoptysis are:
Tuberculosis
Bronchiectasis
Bronchial Carcinoma
Others: e.g. Mycetoma (fungus ball) etc.
Male: Female ratio is 76.6 : 23.4
Only 5% of hemoptysis is massive but mortality is 80%.

7. General Considerations (contd…)
•Haemoptysis is rarely a solitary event, almost always
being followed by the production of further blood
stained sputum.
•Haemoptysis must be differentiated from bleeding in the
mouth or pharynx, nosebleed and haematemesis.
•Usually, but not always, this can be ascertained from the
history.

8. Hemoptysis Versus Hematemesis
Hemoptysis Hematemesis
History
Absence of nausea, vomitingPresence of nausea, vomiting
Lung disease Gastric or hepatic disease
Sputum examination
Frothy Rarely frothy
Bright red; Liquid or clotted
appearance
Coffee ground appearance
Laboratory
Alkaline pH Acidic pH
Mixed with macrophages
and neutrophils
Mixed with food particles

9. General Considerations (contd…)
•Approximately 1/3 of cases (up to 30% in some series)
remain unexplained, despite use of all of the available
diagnostic techniques for the evaluation of hemoptysis.
•These patients are classified as having idiopathic or
cryptogenic hemoptysis and subtle airway or
parenchymal disease is presumably responsible for the
bleeding.

10. Anatomy and Physiology
•The lungs are supplied with a dual circulation.
•The pulmonary arteries arise from the right ventricle to
supply the pulmonary parenchyma in a low-pressure
circuit.
•The bronchial arteries arise from the aorta or intercostal
arteries and carry blood under high systemic pressureto
the airways, blood vessels and visceral pleura.

11. Anatomy and Physiology (contd…)
Although the bronchial circulation represents
only 1–2% of total pulmonary blood flow, it can
increase dramatically under conditions of chronic
inflammation, e.g., chronic bronchiectasisand is
frequently the source of haemoptysis.

12. Anatomy and Physiology (contd...)
Blood can fill the airways and the alveolar
spaces causing not only serious
disturbance in gas exchange but also
asphyxiation.

16. Aetiology
•Most cases of haemoptysis presenting in the
outpatient setting are due to infection (eg,
acute or chronic bronchitis, pneumonia,
tuberculosis).
•Haemoptysis due to lung cancer increases with
age, accounting for up to 20% of cases among
the elderly.

17. Causes of Haemoptysis
Bronchial Diseases/ Tracheobronchial source(Commonest)
•Neoplasm(Bronchial carcinoma, Endobronchial metastatic
tumor, Kaposi's sarcoma, Bronchial carcinoid, Bronchial
adenoma, haemangioma)
•Bronchiectasis
•Bronchitis(acuteor chronic)
•Foreign body
•Broncholithiasis
•Airway trauma
High pressure
systemic bronchial
arteries are the
source of bleeding

18. Causes of Haemoptysis (contd…)
Parenchymal Diseases
•Tuberculosis
•Lung abscess
•Pneumonia (esp. Suppurative pneumonia)
•Mycetoma (fungus ball)
•Trauma
•Lung contusion
•Parasites (e.g. Hydatid disease, flukes)
•Actinomycosis
•Lupus pneumonitis
•Pneumoconiosis

19. Causes of Haemoptysis (contd...)
Pulmonary Vascular Causes
•Wegener's granulomatosis
•Goodpasture's syndrome
•Pulmonary infarction
•Pulmonary embolism
•Polyarteritis nodosa
•Idiopathic pulmonary
haemosiderosis
•Arteriovenous
Malformation (AVM)
•Pulmonary artery
catheterization
•Fistula between a vessel
and tracheobronchial tree

20. Causes of Haemoptysis (contd...)
Cardiovascular Diseases
•Acute left ventricular failure
•Elevated pulmonary venous pressure (esp. Mitral stenosis)
•Aortic aneurysm
Blood disorders
•Leukaemia
•Haemophilia
•Anticoagulants/ Systemic coagulopathy
•DIC

21. Causes of Haemoptysis (contd…)
Miscellaneous
•Pulmonary endometriosis (catamenial hemoptysis)
•Myxoma
•Cocaine
Idiopathic
•Many episodes of haemoptysis are unexplained, even
after full investigation and are likely to be caused by
simple bronchial infection

22. Aetiology
•Less commonly (<10% of cases), pulmonary venous
hypertension (eg, mitral stenosis, pulmonary embolism)
causes haemoptysis.
•Iatrogenic hemorrhage may follow transbronchial lung
biopsies, anticoagulation or pulmonary artery rupture
due to distal placement of a balloon-tipped catheter.

23. Mechanism of Haemorrhage
Pulmonary Tuberculosis
•Inflammation of airway
•Parenchymaldestruction
•Rupture of pulmonary capillary
•Rupture of Rasmussen aneurysms

24. Mechanism of Hemorrhage
Mycetoma (Fungal ball)
•Friction of fungal ball against hypervascularized
walls of the cavity
•Toxins or fibrinotytic enzymes elaborated by
fungus
•Antigen-antibody reactions in the cavity wall

25. Mechanism of Hemorrhage
Bronchiectasis
•Proliferation and enlargement of bronchial
arteries and precapillary bronchopulmonary
anastomoses
•Erosion of these vessels
Chronic necrotizing pneumonitis
•Can bleed massively
•Alcoholism often a predisposing factor

26. Mechanism of Hemorrhage
Bronchial Carcinoma
•Proliferation of bronchial arteries
•May cause massive bleeding by direct invasion of central
pulmonary arteries
Lung Abscess
•Destruction of lung tissue due to suppuration and
necrosis
•When necrosis involves vascular granulation tissue, the
capillaries bleed into the cavity of the abscess

30. Evaluation of Haemoptysis
Non-pulmonary sources of haemorrhage:
oral, nasopharyngeal or gastrointestinal bleeding
should be excluded.

31. Evaluation of Haemoptysis contd…
•Blood-tinged sputum in the setting of an upper
respiratory tract infection in an otherwise healthy,
young (age < 40 years) nonsmoker does not warrant an
extensive diagnostic evaluationif the hemoptysis
subsides with resolution of the infection.

32. Evaluation of Haemoptysis contd…
•Haemoptysis that is described as blood-streaking of
mucopurulent or purulent sputum often suggests
bronchitis.

33. Evaluation of Haemoptysis contd…
•A history of repeated small haemoptyses or blood
streaking of sputum, is highly suggestive of bronchial
carcinoma.
•Fever, night sweats and weight loss suggest Tuberculosis.

34. Evaluation of Haemoptysis contd…
•Pneumococcal pneumoniaoften causes rusty coloured
sputum.
•Putrid sputum with haemoptysis raises the possibility of
lung abscess.

35. Evaluation of Haemoptysis contd…
•When sputum production has been chronic and copious,
the diagnosis of Bronchiectasisshould be considered.
•In Bronchiectasis and intracavitary mycetoma, there may
be a history of previous tuberculosis or pneumonia.

36. Evaluation of Haemoptysis contd…
•Hemoptysis following the acute onset of pleuritic chest
pain and dyspnea is suggestive of pulmonary embolism.

37. Evaluation of Haemoptysis contd…
Inquiries should include-
•Smoking history, Asbestos exposure
•Symptoms of upper and lower respiratory tract infection
•Previous diagnosis of bronchial carcinoma
•Features of vasculitis
•Bleeding disorders
•Treatment with anticoagulants

38. Physical Examination
•Finger clubbingin bronchial carcinoma or bronchiectasis
•Other signs of malignancy: cachexia, hepatomegaly,
lymphadenopathy etc
•Unilateral leg swelling and pain of deep venous
thrombosis in a minority of patients with pulmonary
infarction
•Systemic diseases: rash, purpura, splinter haemorrhage,
lymphadenopathy or splenomegaly

39. Physical Examination
•Elevated pulse, hypotension and decreased oxygen
saturation suggest large volume hemorrhage that
warrants emergent evaluation and stabilization.
•The nares and oropharynx should be carefully inspected
to identify a potential upper airway source of bleeding.

40. Systemic Examination
Respiratory
•Features of bronchial carcinoma
•Crackles (bronchiectasis)
•Signs of consolidation and pleurisy in pneumonia or
pulmonary infarction
•Evidence of airflow obstruction
Cardiac
•Findings of heart failure, pulmonary arterial hypertension,
mitral stenosis

41. Diagnostic Clues in Hemoptysis
Clinical clues Suggested diagnosis
Anticoagulant use Medication effect, coagulation
disorder
Association with menses Catamenialhemoptysis
Dyspneaon exertion, fatigue,
orthopnea, paroxysmal nocturnal
dyspnea, frothy pink sputum
Congestive heart failure, left
ventricular dysfunction, mitral
valve stenosis
Fever, productive cough Upper respiratory infection,
acute sinusitis, acute bronchitis,
pneumonia, lung abscess

42. Diagnostic Clues in Hemoptysis
Clinical clues Suggested diagnosis
History of breast, colon or renal
cancers
Endobronchialmetastatic disease
of lungs
History of chronic lung disease,
recurrent lower respiratory track
infection, cough with copious
purulent sputum
Bronchiectasis, lung abscess
HIV, immunosuppression Neoplasia, tuberculosis, Kaposi’s
sarcoma
Nausea, vomiting, melaena,
alcoholism, chronic use of non -
steroidal anti-inflammatory drugs
Gastritis, gastric or peptic ulcer,
esophageal varices

43. Diagnostic Clues in Hemoptysis
Clinical clues Suggested diagnosis
Pleuriticchest pain, calf
tenderness
Pulmonary embolism or infarction
Tobacco use Acute bronchitis, chronic bronchitis, lung
cancer, pneumonia
Travel history Tuberculosis, parasites (e.g.,
paragonimiasis, schistosomiasis, amebiasis,
leptospirosis), biologic agents (e.g., plague,
tularemia, T2 mycotoxin)
Weight loss Emphysema, lung cancer, tuberculosis,
bronchiectasis, lung abscess, HIV

44. Diagnostic Clues in Hemoptysis
Clinical clues Suggested diagnosis
Cachexia, clubbing, voice
hoarseness, Cushing’s syndrome,
hyperpigmentation, Horner’s
syndrome
Bronchogeniccarcinoma, small cell
lung cancer, other primary lung
cancers
Clubbing Primary lung cancer, bronchiectasis,
lung abscess, severe chronic lung
disease, secondary lung metastases
Dullness to percussion, fever,
unilateral rales
Pneumonia
Facial tenderness, fever,
mucopurulentnasal discharge,
postnasal drainage
Acute upper respiratory infection,
acute sinusitis

45. Diagnostic Clues in Hemoptysis
Clinical clues Suggested diagnosis
Fever, tachypnea, hypoxia,
hypertrophied accessory respiratory
muscles, barrel chest, intercostal
retractions, pursed lip breathing,
rhonchi, wheezing, tympani to
percussion, distant heart sounds
Acute exacerbation of
chronic bronchitis, primary
lung cancer, pneumonia
Gingival thickening, mulberry
gingivitis, saddle nose, nasal
septum perforation
Wegener’s granulomatosis
Heart murmur, pectusexcavatum Mitral valve stenosis

46. Diagnostic Clues in Hemoptysis
Clinical clues Suggested diagnosis
Lymphnodeenlargement,
cachexia, violaceoustumorson
skin
Kaposi’s sarcoma secondary to
human immunodeficiency
virus infection
Orofacialand mucous membrane
telangiectasia, epistaxis
Osler-Weber-Rendudisease
Tachycardia, tachypnea, hypoxia,
jugulovenousdistention,S3 gallop,
decreased lung sounds, bilateral
rales, dullness to percussion in
lower lung fields
Congestive heart failure caused
by left ventricular dysfunction or
severe mitral valve stenosis

47. Diagnostic Clues in Hemoptysis
Clinical clues Suggested diagnosis
Tachypnea, tachycardia,
dyspnea, fixed split S2,
pleural friction rub, unilateral
leg pain and edema
Pulmonary thromboembolic
disease
Tympani to percussion over
lung apices, cachexia
Tuberculosis

48. Investigations
In the vast majority of cases, the haemoptysis itself
is not life-threatening and it is possible to follow
a logical sequence of investigations.

49. Investigations
•Chest X Ray: Mandatory
•CT scan of Chest
•Sputum for-
–AFB stain and Culture
–Gram stain and Culture
–Malignant cell
–Iron containing macrophages: Haemosiderosis, Goodpasture’s syndrome
•Full blood count
•Other haematological tests including coagulation profile

50. Investigations
Bronchoscopy: Flexible and Rigid
•Particularly useful for localizing the site of bleeding and
for visualization of endobronchial lesions.
•Flexible bronchoscopy reveals endobronchial cancer in
3–6%of patients with hemoptysis who have a normal
(non-lateralizing) chest radiograph.

51. Investigations
Bronchoscopy: Flexible and Rigid
•When bleeding is massive, rigid bronchoscopy is often
preferable to fiberoptic bronchoscopy because of
better airway control and greater suction capability.
•Flexible bronchoscopy is preferred in all other situations.

52. Investigations
Bronchoscopy: Flexible and Rigid
•Appropriate timing of bronchoscopy for hemoptysis can
be very difficult to determine.
•Factors that need to be considered in the decision
making process include hemodynamics, volume of
bleeding, rapidity of bleeding and comorbiditiesof the
patient.

53. Investigations
Bronchoscopy: Flexible and Rigid
Usually Bronchoscopy should be carried out
after acute bleeding has settled.

54. Investigations
Bronchoscopy: Flexible and Rigid
•If the site of bleeding is not readily apparent, serial
washings of the suspected bronchial segments with 15
to 20 mL of 0.9% normal saline may help to identify the
location of the bleed.

55. Investigations
•CT scan of chestis particularly useful in investigating
peripheral lesion and facilitates accurate percutaneous
needle biopsy where indicated.
•High-resolution chest CTscanning is the test of choice
for suspected small peripheral malignancies and
bronchiectasis.

56. Investigations
Most cases of haemoptysis that have no visible cause on
CT scan or bronchoscopy will resolve within 6 months
without treatment, with the notable exception of
patients at high risk for lung cancer (smokers, older
than 40 years).

57. Investigations
•Bronchial arteriography
•Pulmonary angiography
•Additional screening evaluation often includes
assessment for renal disease with a urinalysis, blood
urea nitrogen and creatininelevel. Hematuria that
accompanies hemoptysis may be a clue to Goodpasture
syndrome or vasculitis.

58. Investigations
•Ventilation-perfusion (V/Q) lung scanis helpful in
establishing a diagnosis of suspected pulmonary
thromboembolic disease.
•CT pulmonary angiography may be necessary in patients
with pre-existing lung disease where interpretation of
the V/Q scan can be difficult.

59. An algorithm for
the evaluation of
non-massive
hemoptysis.

64. Management
•The management of haemoptysis depends on the
primary condition.
•Keeping the patient at rest and partially suppressing
cough may help the bleeding to subside.
•In general, haemoptysis settles if the patient is rested
and sedated.
•In mild haemoptysis with preserved gas exchange,
establishing a diagnosis is the first priority followed by
treatment of the cause.

65. Management of massive
Haemoptysis

66. Management
•Massive hemoptysis is life-threatening.
•Investigations will follow treatment, which may
be difficult and is often unsuccessful.
•In some cases, active treatment may be
inappropriate and palliative treatment with O2
and diamorphine may be warranted.

67. Management
•Airway protection and ventilation:
Protection of the non-bleeding lung is vital to maintain
adequate gas exchange.
This may involve either sitting the patient up or lying on
the bleeding side (to prevent blood from flowing into the
unaffected lung and causing asphyxiation), or intubation
with a double-lumen tube.
If intubation is not needed or not appropriate, give high-
flow Oxygen

68. Management
•Cardiovascular support:
Fluid resuscitation ±Transfusion
Correct clotting, e.g. vitamin K 10mg od; platelets
Inotropes may be required
•Nebulized adrenaline (1ml of 1:1000 made 5ml with NS)
•Oral or IV tranexamic acid (1g tds, not if severe renal
failure)
•IV terlipressin, 2mg IV, then 1-2mg every 4–6h if
continued bleeding

69. Management
•CXR ±Chest CT (depending on stability of patient)
•Early bronchoscopy: diagnostic and therapeutic
•Rigid bronchoscopy is preferable. May allow
localization of the site of bleeding; balloon tamponade
with a Fogarty catheter
•Bronchial artery embolization: usually with coils or glue
•Treatment of primary condition
•Surgery: resection of bleeding lobe (if all other
measures have failed)

70. Management
•Bronchoscopyin the acute phase is difficult and often
merely shows blood throughout the bronchial tree.
•If radiology shows an obvious central cause then rigid
bronchoscopy under general anaesthesia may allow
intervention to stop bleeding.

71. Management
•Bronchoscopic modalities include airway
tamponade, electrotherapy, cryotherapy and
instillation of vasoconstrictive medications at the
site of bleeding.

72. Management
•Radiotherapyis often successful in stopping
bleeding from bronchial tumours, while other
local causes of persistent haemorrhage may
sometimes be controlled by bronchial artery
embolization.

73. Management
Bleeding from aspergilloma may be controlled
by radiotherapy or intracavitary instillation of
antifungal drugs.

74. Management
Some techniques for control of significant bleeding:
•Laser phototherapy
•Electrocautery
•Bronchial arteriography and embolisation
•Emergency surgical resection of the involved area of
lung

75. Management
•With bleeding from an endobronchialtumor, argon
plasma coagulation or the neodymium:yttrium-
aluminum-garnet (Nd:YAG) lasercan often achieve at
least temporary hemostasisby coagulating the bleeding
site.
•Electrocautery, which uses an electric current for thermal
destruction of tissue, can be used similarly for
management of bleeding from an endobronchialtumor.

76. Management
Bronchial artery embolizationinvolves an
arteriographic procedure in which a vessel proximal to
the bleeding site is cannulated and a material such as
Gelfoam is injected to occlude the bleeding vessel.
Embolization is effective initially in 85% of cases,
although rebleeding may occur in up to 20% of
patients over the following year.

77. Management
•The anterior spinal artery arises from the bronchial artery
in up to 5% of people and paraplegia may result if it is
inadvertently cannulated.

78. Management
•Surgical resectionis a therapeutic option either
for the emergent therapy of life-threatening
hemoptysis that fails to respond to other
measures or for the elective but definitive
management of localized disease subject to
recurrent bleeding.

79. Management
•Selective coagulative treatment: Topical thrombin
and fibrinogen-thrombin solutions have been used
with reported success in the treatment of patients
with massive hemoptysis.

80. Management
•When to Admit
•To stabilize bleeding process in patients at risk
for massive haemoptysis.
•To correct disordered coagulation (clotting
factors or platelets, or both).
•To stabilize gas exchange.

81. Management
The criteria for selecting surgical cases include:
•Localized site of bleeding
•Adequate pulmonary function
•Resectable carcinomas without distant
metastasis
•No mitral diseases

82. Management
Surgical procedures are classified into 4 groups:
•Pulmonary resections (pneumonectomy,
lobectomy, wedge resections, segmentectomy)
•Collapse therapy (thoracoplasty)
•Cavernostomies
•Intrathoracic vascular ligatures

83. Management
•With the introduction of ice-cold saline lavage and
arterial embolizationit is possible to control majority
of cases of massive hemoptysis.
•Urgent surgery (i,e. within 24 to 48 hours after initial
control) is required only in cases of fungal ball, lung
abscess, failure of any control method, presence of
cavity, obstruction of the main or lobar bronchus with a
clot that can not be suctioned during a rigid
bronchoscope.

84. Medically treated patients probably have a
higher risk of re-bleeding within the first
six months.

85. THANK
YOU