HAEMOPTYSIs management , definition, clinical features

hemoptysis

1. HAEMOPTYSIS Diagnostic approach and management Dr Dimple Makhija

2. Definition Expectoration of blood that originates from the lower respiratory tract Ranges in severity from blood-streaked sputum to gross hemoptysis (expectoration of blood without any accompanying sputum) T he cause and location of bleeding should be identified in order to guide treatment.

3. Massive/ Life threatening haemoptysis Expectoration of a large amount of blood and/ or to a rapid rate of bleeding Blood volume expectorated over 24 hours is generally used for distinguishing massive and non massive hemoptysis Volumes of 100 to 1000 mL of blood (no specific volume has been universally accepted) Amount of blood sufficient to cause haemodynamic instability, abnormal gas exchange, airway obstruction can be a more correct and functional definition of severe hemoptysis Cardiovasc Intervent Radiol 2010; 33:240– 25 Eur Respir J 2008; 32:1131

4. The morbidity and mortality of this disease is due to asphyxiation in 80% of cases, and exsanguination in the remaining Pseudohemoptysis  – Blood from the upper respiratory tract and the upper gastrointestinal tract can also be expectorated and, thus, mimic blood coming from the lower respiratory tract

5. Sources of Haemoptysis Bronchial circulation ‐ 90% Pulmonary circulation – 5% Non‐bronchial systemic collaterals –5% Bronchial arteries are the main vascular supply to the airways (from the mainstem bronchi to terminal bronchioles), and the supporting framework of the lung Pulmonary arteries supply the pulmonary parenchymal tissue including the respiratory bronchioles

6. Orthotopic origin- The bronchial arteries commonly originate from the upper portion of the descending thoracic aorta at the level of T5–T6 Ectopic origin -Bronchial arteries originating at other levels, including aortic branches

7. Diagnosis

8. Initial evaluation Goals 1)Confirmation of hemoptysis : Should be distinguished from pseudohemoptysis that may arise from epistaxis or hematemesis. 2) Evaluation of severity: bleeding must be quantified 3) Location of origin and etiology: for appropriate definitive treatment

9. Etiology Pulmonary- Airway Neoplasm∗ Bronchitis∗ Bronchiectasis∗ Airway trauma Foreign body Bronchovascular fistula Pulmonary Parenchyma Pneumonia∗ Tuberculosis∗ Mycetomas ∗(aspergillosis)/fungal infections Lung abcess Parasitic diseases Leptospirosis Cocaine inhalation Lung contusion Pulmonary- Vascular Pulmonary embolism∗ Vasculitis (Wegener, etc.) SLE Behcet’s disease Goodpasture syndrome AV malformation Pulmonary artery pseudoaneurysm Dieulafoy’s disease PVOD Cardiac Heart failure∗ Mitral stenosis Congenital heart disease Iatrogenic Anticoagulant and antiplatelet medications Pulmonary artery catheter Biopsy Bronchoscopy Airway stent Endotracheal tube erosion Others Idiopathic∗ Disorders of coagulation Thoracic endometriosis (catamenial hemoptysis )

10. Diagnostic modalities Chest x ray Quick, noninvasive, and widely available first step that can localize the site of abnormality in 19 to 83% of cases Sensitivity varies from 35 – 50% A negative CXR warrants other diagnostic studies, including bronchoscopy or MDCT Chest 1997; 112:440–444 AJR Am J Roentgenol 2002; 179:1217–1224 Chest 2001; 120:1592–1594

11. CT thorax CT is superior to CXR for detecting the site of bleeding in life-threatening hemoptysis, with correct localization in 70–88.5% of cases Diagn Interv Imaging. 2015; 96(7-8):775–88. Angio-MDCT accurately identifies the presence, origin, number and trajectory of the thoracic, bronchial and non-bronchial arteries and pulmonary arteries which may be the source of bleeding. Detects 100% of pathological bronchial arteries Eur J Radiol . 2013;82:e742–7 Bronchial arteries are considered pathological if they are ≥2 mm in diameter, tortuous, and if their trajectory can be identified from their origin to the pulmonary hilum

12. Non-bronchial systemic arteries are considered pathological if ≥2 mm in diameter and tortuous visualization in extrapleural fat associated with pleural thickening ≥3 mm Associated with changes in underlying pulmonary parenchyma Angio-MDCT detects 62%–97% of the non-bronchial arteries seen on standard angiography Eur J Radiol . 2013;82:e742–7

13. Limitations- requires temporary movement of an unstable patient out of ICU In Unstable patients with active bleeding who require endobronchial treatment and P atients with bilateral radiological abnormalities in whom radiological localization of the bleeding is a challenge

14. Digital subtraction angiography Marginal role as a diagnostic tool in detecting the origin of hemoptysis Inferior to contrast-enhanced MDCT in the detection of both bronchial and non-bronchial arteries It is now performed only as a procedure previous to the embolization of pathological arteries detected on angio-MDCT and if bleeding persists after bronchoscopy Cardiovasc Interv Radiol . 2010;33:240–50 Radiology 2004; 233: 741–9.

15. Diagnostic bronchoscopy Fulfills the following objectives- 1)Confirmation of hemoptysis 2)Localization of bleeding- locates the origin of bleeding in 73%–93% of cases Source of active bleeding is more likely to be located when bronchoscopy is performed during active hemoptysis or within 24–48 h after cessation (strong recommendation - Separ’s guidelines 2016) In life-threatening hemoptysis, bronchoscopy must be performed as soon as possible if the patient is unstable and after intubation

16. 3) Diagnosis of cause of bleeding- Endobronchial inspection and to determine the appearance of the mucosa: capillary vascular hypertrophy or malformation, areas of inflammation or thickening of the mucosa, bronchial stenosis, endobronchial tumors Samples for cytology and microbiological studies, BAL- if alveolar bleeding is suspected, and biopsies or bronchial brushing, if malignancy is suspected can be collected

17. CT vs Bronchoscopy A study comparing CT imaging to bronchoscopy to determine the site and cause of life threatening hemoptysis found that CT is much more efficient than bronchoscopy for determining the cause of bleeding (60–77 vs. 2.5–8%) American Journal of Roentgenology. 2002;179: Another study published in 2015 comapring diagnostic Accuracy of MDCT and Bronchoscopy (N=40) sensitivity of MDCT (60%) for detecting cause of the bleeding was higher than that of radiography (25%) and bronchoscopy (32.5%) whwereas efficacy of MDCT and bronchoscopy in identifying bleeding site weren’t significantly different Global Journal of Health Science; Vol. 7, No. 3; 2015

18. J Thorac Dis 2017;9(Suppl 10) J Thorac Dis 2017

19. CT vs Bronchoscopy Complementary to each other Combined yield better than individual yield FOB –exact localization of bleeding segment, therapeutic application, initial choice in patients with high suspicion of lung cancer/clinically unstable

20. Management

21. Initial stabilisation and airway management Severity of hemoptysis determined in the initial evaluation Patients with gross hemoptysis require hospitalization Treatment is directed at ensuring airway patency and oxygenation, locating and stopping bleeding, achieving hemodynamic stability and identifying and treating the cause of the hemoptysis

22. General measures Lateral decubitus bed rest on the affected side- to protect the airway and avoid aspiration of blood into the unaffected lung Monitoring of vital signs , oxygen supplementation Administration of antitussives (chest physio to be avoided) Total fasting to avoid aspiration and to facilitate urgent tests- bronchoscopy, CT or angiogram. Availability of a blood reserve and placement of large caliber venous access for fluid management

23. Antifibrinolytics- Tranexamic acid (IV/oral) 0.5- 1 g three times a day Investigate effectiveness of tranexamic acid in reducing hemoptysis volume and duration Four RCTs met eligibility criteria- 183 patients were recruited from different countries. In these RCTs, TXA was typically administered intravenously; only one RCT administered TXA through inhalation The pooled results demonstrated no significant differences in bleeding duration or hemoptysis resolution between the TXA and control groups. TXA use reduced bleeding volume, further intervention risk and length of hospital stay

24. double-blind, randomized controlled trial of treatment with nebulized TA (500 mg tid ) vs placebo (normal saline) in patients admitted with hemoptysis of various etiologies. Patients with massive hemoptysis and hemodynamic or respiratory instability were excluded 47 patients were randomized to receive TA inhalations (n = 25) or normal saline (n = 22). Resolution of hemoptysis within 5 days of admission was observed in more TA-treated patients than in those receiving placebo Mean hospital length of stay was shorter for the TA group with fewer patients requiring invasive procedures a reduced recurrence rate was noted at the 1-year follow-up

25. Airway protection For massive hemoptysis, intubation with larger diameter ETTs of 8.5 mm inner diameter is recommended To enable passage of therapeutic flexible bronchoscopes with large working channels Allow extraction of obstructing blood clots and placement of bronchial blockers Placement of inflatable bronchial blockers or Fogarty balloons either coaxially through an ETT or in parallel to the tube can be done

26. Large lumen ET Double Lumen ETT (not preferred) Rigid bronchoscopy Time to establish the airway Fastest Requires experience and FOB confirmation of placement Requires experience, equipment Time consuming to set up Advantages Availability of operator, can be performed at the bedside, large lumen allows use of large FOB for suction and placement of bronchial blocker Single lung ventilation can be accomplished if the lumen is not occluded with clots, can be performed at the bedside Ability to ventilate while operating the rigid scope, FOB can be used concomitantly, ability to alternate between bleeding and non-bleeding lungs, large lumen allows for passage of multiple instruments Disadvantages Single lung intubation will not allow intervention on the bleeding lung Multiple attempts may be needed Small lumen can only accommodate pediatric FOB which is inefficient for airway clearance Can be easily occluded with clots Requires expertise for safe practice, equipment, and personnel

27. A double lumen tube (DLT) is the least optimal choice for massive hemoptysis. The small lumens of the tube afford only passage of a smaller pediatric bronchoscope that is inefficient in clot extraction. As a result, in this image of right-sided hemorrhage with spillage of blood to the contralateral lung, the lumens of the DLT are occluded with clot and clot evacuation from either side is suboptimal

28. Left-sided mainstem is intubated with rigid bronchoscope in the case of left-sided hemorrhage. The bevel of the rigid bronchoscope safeguards the right-sided airways, whereas blood can be suctioned efficiently with the use of a rigid suction catheter and therapeutic flexible bronchoscope simultaneously. This technique is superior in control of hemorrhage in the bleeding side, while securing the unaffected lung. Ventilation of the right side of the lung is maintained through the rigid tube’s side ports, The lumen of the rigid bronchoscope accommodates tools for therapeutic interventions such as tumor debulking, thermal ablation, and flexible bronchoscopy.

29. Role of Bronchoscopy Initial procedure of choice in patients with life-threatening hemoptysis and hemodynamic instability in which control of bleeding is essential Primary therapeutic goal is to ensure sufficient exchange of gases by freeing the airways of blood For iatrogenic bleed (after biopsy)the bronchoscope should be kept in a wedged position, to ensure effective tamponade of the bleeding mucosa Suctioning and frequent scope repositioning should be kept to a minimum

30. Endobronchial Medical Therapy Cold saline Lavage First case of endobronchial irrigation with cold saline for the early management of hemoptysis was reported in 1980 in which lavage with normal saline at 4 ° C in 50-ml aliquots (average volume of 500 ml, range 300–750 ml) stopped the bleeding in 23 patients with massive hemoptysis obviating the need for emergency thoracotomy Conlan AA et al; Thorax 1980; 35: 901–904 Transient sinus bradycardia was observed in a single patient, there was control of hemorrhage in all patients undergoing treatment Large-volume cold saline lavages have not been studied again in more recent trials

31. Topical Vasoconstrictive agents Effective in mild to moderate hemoptysis following bronchial brushing and biopsy procedures Not useful for massive bleeding, however, because the drug is diluted and washed away Agent – topical use of lower concentration of epinephrine 1:100,000 instilled in small (2-ml) aliquots up to a maximum dose of 0.6 mg Am J Respir Crit Care Med. 2013 High plasma levels following endobronchial application Significant CVS effects – hypertension and tachyarrthythmias

32. Alternative agents – terlipressin and ornipressin (ADH derivatives) Topical ornipressin proved as effective as adrenaline at promoting hemostasis but with significantly fewer hemodynamic adverse events Acta Anaesthesiol Scand 1982

33. Fibrinogen/Thrombin Injection of the prothrombotic fibrinogen-thrombin (FT) combination via flexible bronchoscopy was first reported by Tsukamoto et al in 14 patients with massive hemoptysis, which demonstrated a very good response in 11 cases and a partial response in 3 cases Chest 1989; 96: 473–476 Promising as an initial strategy for the early management of massive hemoptysis when other modalities are not available

34. Topical hemostatic tamponade therapy (THT) Valipour et al. described a method of bronchoscopy guided topical hemostatic tamponade therapy (THT) in patients with life-threatening hemoptysis Chest. 2005 Jun;127(6):2113-8 Hemostatic agent used was oxidized regenerated cellulose (ORC), a sterile, knitted fabric, which swells into a gelatinous mass and helps in the formation of clot Control of hemoptysis ‐ achieved in 56 of 57 patients who remained free of hemoptysis for the first 48 h

35. Mild to moderate bleeding (30–100 ml) recurred in 6 subjects (10.5%) 3–6 days after the procedure Not suitable for proximal sites of bleeding such as the trachea Temporary measure

36. Endobronchial Sealing with Biocompatible Glue Used in mild hemoptysis N‐butyl cyanoacrylate ‐ biocompatible adhesive that solidifies on contact with humidity Injected into the bleeding airway through catheter via FOB Was used in 6 patients with mild hemoptysis leading to immediate arrest of bleeding without any recurrence for a mean follow-up period of 127 days Chest. 2002;121(6)

37. Bronchial blocking techniques Bronchial blockade prevents the aspiration and contamination of blood in the contralateral lung Allows for continued ventilation to the unaffected side I deally used on subsegmental, segmental or lobar bleeding sites Balloon tamponade is achieved under direct visualization by placement of a 4 Fr 100 cm Fogarty balloon catheter (which is inserted through the working channel of a flexible bronchoscope)

38. In contrast, endobronchial blockers are inserted via the endotracheal tube (ETT) under bronchoscopic guidance  A benefit of a dedicated bronchial blocker is that the bronchoscope can be removed and the blocker left in place Once a bronchial blocker is placed and the cuff inflated, the bronchoscope is removed and the patient is observed for 24-48 hrs Daily flexible bronchoscopy should be performed to monitor for bleeding as well as the position of the blocker

39. After 24 to 48 hours the balloon can be deflated and the patient is observed to ensure that no recurrent bleeding occurs If there is no evidence of rebleeding, the balloon catheter is removed Leaving the blocker in place for longer durations increases the risk of post-obstructive atelectasis, pneumonia, compression trauma and necrosis of the bronchial wall mucosa

40. BB port bronchoscope port, ventilator port, Three-way connector adaptor for endotracheal tube, and Connector to the endotracheal tube.

41. Endobronchial blockade using silicon spigot Spigots are prosthetic pluglike devices that can be delivered to subsegmental airways using flexible bronchoscopy A retrospective study on t emporary endobronchial embolization with silicone spigots (EESS)for moderate hemoptysis on 9 patients demonstrated success rate of 78% Spigot ensures airway protection while waiting for definitive management.

42. Ablative therapies Laser photocoagulation (Nd: YAG, Nd: YAP, diode laser) First introduced by Dumon et al in 1982 Effective option endoluminal tumors with symptomatic airway obstruction or bleeding Effective in causing photocoagulation in depth Efficacy in stopping bleeding ranges from 60 to 74%, although a reduction is achieved in up to 94% of cases J Thorac Oncol. 2007

43. Argon Plasma Coagulation (APC) Non contact elctro coagulation tool Argon plasma medium is employed to conduct high‐frequency electrical current through a flexible probe Blood is a good conductor for the highfrequency current Effective dessication of a bleeding bronchus After dessication of target surface achieved- it becomes less electrically conductive, thus preventing deeper penetration of the current

44. Allows homogeneous tissue dessication because APC seeks areas with higher water content Less effective than laser in coagulating in depth, and mechanical debridement is more difficult (depth-2-3 mm vs 5-10 mmm in YAG) In a retrosepective study by Morice et al ‐ 31 patients with hemoptysis and 25 patients with both airway obstruction and hemoptysis treated by endobronchial APC therapy No recurrence of bleeding was observed on a mean follow-up period of 97 days Chest 2001; 119: 781–787

45. Electrocautery This technique uses direct electrical energy applied to tissue by contact. The tissue converts the electrical energy to heat, resulting in coagulation and necrosis Once the site of bleeding is identified and accessible to a contact probe, this technique may be used in the management of both massive and non-massive hemoptysis

46. Cryotherapy and Brachytherapy Cryotherapy has been proven effective in managing hemoptysis in patients with inoperable endoluminal malignancies Because of its delayed effect, cryotherapy has no role in the management of massive hemoptysis Brachytherapy has been described in patients with hemoptysis due to endobronchial malignancy with no benefit over external beam radiation, chemotherapy, or Nd:YAG in hemoptysis control Cochrane Database Syst Rev 2008; 16: CD004284

47. Bronchial Artery Embolization (BAE) First performed by Remy et al. in 1973 Indications- Massive hemoptysis in whom pathological arteries observed in CT angio Lesser degrees of hemoptysis may also require treatment, depending on the patient’s underlying pulmonary reserve and ability to maintain a patent airway Preparing the patient for elective surgery • Unfit for surgery

48. Technique - Preliminary descending thoracic aortogram – anatomy of arteries supplying lung Bronchial angiography is performed with manual injection of contrast medium The catheter is guided selectively to the pathological artery via the femoral artery, using the Seldinger technique.

49. Materials used for the occlusion of small distal arteries -most typical are calibrated non-resorbable polyvinyl alcohol particles or gelatin-coated acrylic polymer microspheres Size of particles ‐ 350–500 µm in diameter For good hemoptysis management, all pathological arteries must be embolized ( Separ 2016 guidelines -strong recommendation, 1B)

50. Angiographic criteria to determine that the systemic arteries, whether bronchial or non-bronchial, are the source of bleeding and require embolization are: Tortuous, dilated arteries Peribronchial hypervascularity or neovascularity Shunts from systemic arteries to pulmonary arteries or veins Extravasation of contrast medium Bronchial artery aneurysm

51. Causes of Recurrent Bleeding Recanalization of embolized vessels Incomplete embolization Revascularization by the collateral circulation Inadequate treatment of the underlying disease Progression of basic lung disease Non‐bronchial systemic arterial supply Recurrence is particularly noted in TB, bronchiectasis, aspergilloma and bronchogenic carcinoma

52. Complications- Chest pain – most common • Dysphagia due to embolization of esophageal branches • Subintimal dissection of the aorta or the bronchial artery Most serious complication of bronchial artery embolization is medullary ischemia due to inadvertent occlusion of a spinal artery, particularly the artery of Adamkiewicz , when it arises from the thoracic artery between levels T5 and T8. Risk of this complication is reduced when embolization of the bronchial artery is performed superselectively with microcatheter

53. Bronchial artery embolization for hemoptysis: A systematic review and meta-analysis (2021) Objective-To assess the safety and efficacy of BAE for hemoptysis N=2511 The technical success and immediate control rates were 99.9% and 99.5% respectively Hemoptysis recurrence =23.7% Mortality rate of 2% Complication rate of 13.4%  Bronchial artery embolization in hemoptysis: a systematic review (2017) N=50 Success rate of BAE, (defined as complete cessation of hemoptysis) varied from 70%–99%. Recurrence rate remains high, ranging from 10%–57% Complication- 0.1%

54. Surgical Treatment Surgery (typically a lobectomy) is reserved for patients who fail bronchoscopic or arteriographic interventions Early surgery indicated in circumstances, such as pulmonary artery rupture, complex AVMs that fail embolization, refractory bleeding from an aspergilloma, and chest trauma Effective modality to control hemoptysis in patients with localized disease but mortality rates between 2% and 18% Can Respir J. 2017;2017:1565030

55. Prognosis M ortality rates ranging from 7 to 30 percent Respiration. 2012;83(2):106. Predictors of poor outcome- Poor performance status Advanced stage of malignancy Mechanical ventilation (particularly the need for single lung ventilation) Hypotension

56. Presence of cavitation or necrosis or lung densities involving two or more quadrants on chest radiograph Bleeding from the pulmonary artery, cancer, aspergillosis Alcoholism Aspiration of blood into the contralateral lung

57. Bronchoscopy algorithm in non-life-threatening hemoptysis

58. Multidisciplinary approach of managing Massive hemoptysis

59. Thank You…