Hemoptysis

1. HEMOPTYSISHEMOPTYSIS
ByBy
Iman Galal, MDIman Galal, MD
Assistant Professor Pulmonary MedicineAssistant Professor Pulmonary Medicine
Ain Shams UniversityAin Shams University
E-mail: [email protected]: [email protected]

2. Definition of hemoptysisDefinition of hemoptysis
Causes of hemoptysisCauses of hemoptysis
Differential diagnosis of hemoptysisDifferential diagnosis of hemoptysis
Diagnosis of hemoptysisDiagnosis of hemoptysis
Treatment of hemoptysisTreatment of hemoptysis
ContentsContents

3. HemoptysisHemoptysis is defined as coughing of blood is defined as coughing of blood
originating from below the vocal cords.originating from below the vocal cords.
The word The word "hemoptysis""hemoptysis" comes from the Greek comes from the Greek
"haima""haima" meaning "blood“ & meaning "blood“ & "ptysis""ptysis" which means "a which means "a
spitting".spitting".
HemoptysisHemoptysis can range from can range from blood-streakingblood-streaking of of
sputum to the presence of sputum to the presence of gross bloodgross blood in the absence in the absence
of any accompanying sputum.of any accompanying sputum.
DefinitionDefinition

4. Life threatening (or) Massive hemoptysisLife threatening (or) Massive hemoptysis is is
defined as coughing of blood > 150 ml/time (or) > 600 defined as coughing of blood > 150 ml/time (or) > 600
ml/24 hours.ml/24 hours.
Only 5% of hemoptysis is Only 5% of hemoptysis is massivemassive but mortality is 80%. but mortality is 80%.
DefinitionDefinition

5. Tracheobronchial causes:Tracheobronchial causes:
1. Bronchitis (acute & chronic).1. Bronchitis (acute & chronic).
2. Bronchiectasis.2. Bronchiectasis.
3. Foreign body.3. Foreign body.
4. Tumor (e.g., bronchial carcinoma, tracheal & laryngeal tumors).4. Tumor (e.g., bronchial carcinoma, tracheal & laryngeal tumors).
5. Bronchial telangectasia. 5. Bronchial telangectasia.
Cardiovascular causes:Cardiovascular causes:
1. 1. Left Ventricular Failure.Left Ventricular Failure.
2. Mitral stenosis.2. Mitral stenosis.
3. Aortic aneurism.3. Aortic aneurism.

Cause of HemoptysisCause of Hemoptysis

6. Pulmonary:Pulmonary:
1. Tuberculosis.1. Tuberculosis.
2. Tumor.2. Tumor.
3. Pneumonia.3. Pneumonia.
4. Abscess.4. Abscess.
5. Infarction.5. Infarction.
6. Trauma.6. Trauma.
7. Vasculitis & collagen disorders.7. Vasculitis & collagen disorders.
8. Cystic fibrosis.8. Cystic fibrosis.
9. Alveolar hemorrhage.9. Alveolar hemorrhage.
10.Arteriovenous malformation10.Arteriovenous malformation
Other causes:Other causes:
1. Blood diseases.1. Blood diseases.
2. Anticoagulant therapy.2. Anticoagulant therapy.
Cause of HemoptysisCause of Hemoptysis Cont.Cont.

7. Cause of HemoptysisCause of Hemoptysis

8. 1.1.Pulmonary tuberculosis.Pulmonary tuberculosis.
2.2.Pulmonary infarction.Pulmonary infarction.
3.3.Bronchiectasis.Bronchiectasis.
4.4.Cystic fibrosisCystic fibrosis
5.5.Lung abscess.Lung abscess.
6.6.Necrotizing pneumonia.Necrotizing pneumonia.
7.7.Mitral stenosis.Mitral stenosis.
8.8.Pulmonary arteriovenous malformation.Pulmonary arteriovenous malformation.
Causes of Massive HemoptysisCauses of Massive Hemoptysis

9. Sources:Sources:
1.1.Bronchial circulation.Bronchial circulation.
2.2.Pulmonary circulation.Pulmonary circulation.
3.3.Anatomizes between pulmonary & bronchial circulation.Anatomizes between pulmonary & bronchial circulation.
Mechanisms:Mechanisms:
1.1.Vessel engorgement.Vessel engorgement.
2.2.Erosion (or) rupture of vessels.Erosion (or) rupture of vessels.
3.3.Mucosal ulceration.Mucosal ulceration.
4.4.Vascular granulation tissue.Vascular granulation tissue.
Mechanism & Sources of HemoptysisMechanism & Sources of Hemoptysis

10. Make sure that this is Make sure that this is True Hemoptysis.True Hemoptysis.
Identify the Identify the SeveritySeverity of hemoptysis. of hemoptysis.
Clinical clues in Clinical clues in HistoryHistory & & Examination.Examination.
Diagnostic Diagnostic Investigations.Investigations.
Appropriate Appropriate Treatment.Treatment.
Clinical Approach for Management of Clinical Approach for Management of
HemoptysisHemoptysis

11. Important points to address in HistoryImportant points to address in History
Clinical CluesClinical Clues Suggested DiagnosisSuggested Diagnosis
Anticoagulant useAnticoagulant use Medication effect, coagulation disorderMedication effect, coagulation disorder
Association with mensesAssociation with menses Catamenial hemoptysisCatamenial hemoptysis
Dyspnea on exertion, fatigue, orthopnea, Dyspnea on exertion, fatigue, orthopnea,
PND, frothy pink sputumPND, frothy pink sputum
Congestive heart failure, Lt V. dysfunction, MSCongestive heart failure, Lt V. dysfunction, MS
Fever, productive coughFever, productive cough URTI, acute bronchitis, pneumonia, lung abscessURTI, acute bronchitis, pneumonia, lung abscess
History of breast, colon, or renal cancersHistory of breast, colon, or renal cancersEndobronchial metastatic lung diseaseEndobronchial metastatic lung disease
History of chronic lung disease, recurrent History of chronic lung disease, recurrent
LRTI, cough with copious purulent sputumLRTI, cough with copious purulent sputum
Bronchiectasis, lung abscessBronchiectasis, lung abscess
Melena, alcoholism, chronic use of NSAIDsMelena, alcoholism, chronic use of NSAIDsGastritis, gastric or peptic ulcer, esophageal varicesGastritis, gastric or peptic ulcer, esophageal varices
Pleuritic chest pain, calf tendernessPleuritic chest pain, calf tenderness Pulmonary embolism or infarctionPulmonary embolism or infarction
Tobacco useTobacco use Acute bronchitis, chronic bronchitis, lung Ca, pneumoniaAcute bronchitis, chronic bronchitis, lung Ca, pneumonia
Toxic symptomsToxic symptoms TuberculosisTuberculosis
Weight lossWeight loss Emphysema, lung cancer, TB, bronchiectasis, lung abscessEmphysema, lung cancer, TB, bronchiectasis, lung abscess

12. True Hemoptysis VersusTrue Hemoptysis Versus
Spurious (False) HemoptysisSpurious (False) Hemoptysis
True hemoptysisTrue hemoptysis False hemoptysisFalse hemoptysis
Below vocal cordsBelow vocal cords Above vocal cordsAbove vocal cords
Persists as blood tinged sputumPersists as blood tinged sputumDoes not persistDoes not persist
May be mixed with sputumMay be mixed with sputum Not mixed with sputumNot mixed with sputum
History of cardiopulmonary diseaseHistory of cardiopulmonary diseaseObvious by ENT examinationObvious by ENT examination
CXR may be abnormalCXR may be abnormal Normal CXRNormal CXR

13. Hemoptysis Versus HematemsisHemoptysis Versus Hematemsis
HemoptysisHemoptysis HematemsisHematemsis
Coughing of bloodCoughing of blood Vomiting of bloodVomiting of blood
History of cardiopulmonary diseaseHistory of cardiopulmonary diseaseHistory of GIT diseaseHistory of GIT disease
Bright red in colorBright red in color Dark brown in colorDark brown in color
Sputum remains blood stained Sputum remains blood stained
after the attack for few daysafter the attack for few days
Usually followed by melenaUsually followed by melena
Mixed with sputumMixed with sputum Mixed with gastric contentsMixed with gastric contents
Blood is frothyBlood is frothy AirlessAirless
AlkalineAlkaline AcidicAcidic
Sputum contains hemosedrin Sputum contains hemosedrin
laden macrophagesladen macrophages
NoNo

14. ExaminationExamination
Clinical CluesClinical Clues Suggested DiagnosisSuggested Diagnosis
Cachexia, clubbing, hoarseness, Cushing's syndrome, Cachexia, clubbing, hoarseness, Cushing's syndrome,
hyperpigmentation, Horner's syndromehyperpigmentation, Horner's syndrome
Bronchogenic carcinoma, SCLCBronchogenic carcinoma, SCLC
ClubbingClubbing Lung cancer, bronchiectasis, lung abscessLung cancer, bronchiectasis, lung abscess
Dullness to percussion, fever, crepitationsDullness to percussion, fever, crepitations PneumoniaPneumonia
Fever, tachypnea, hypoxia, working accessory respiratory Fever, tachypnea, hypoxia, working accessory respiratory
muscles, barrel chest, intercostal retractions, pursed lip muscles, barrel chest, intercostal retractions, pursed lip
breathing, rhonchi, distant heart soundsbreathing, rhonchi, distant heart sounds
COPD, Lung cancer, pneumoniaCOPD, Lung cancer, pneumonia
Gingival thickening, saddle nose, nasal septum perforationGingival thickening, saddle nose, nasal septum perforationWegener's granulomatosisWegener's granulomatosis
Mid diastolic rumbling murmurMid diastolic rumbling murmur MSMS
LN enlargement, cachexia, violaceous skin lesionsLN enlargement, cachexia, violaceous skin lesions Kaposi's sarcoma 2ry to HIV Kaposi's sarcoma 2ry to HIV
Tachypnea, tachycardia, dyspnea, S1Q3T3, pleural friction Tachypnea, tachycardia, dyspnea, S1Q3T3, pleural friction
rub, unilateral leg pain & edemarub, unilateral leg pain & edema
Pulmonary thromboembolismPulmonary thromboembolism
Orofacial & mucous membrane telangiectasia, epistaxisOrofacial & mucous membrane telangiectasia, epistaxisOsler-Weber-Rendu diseaseOsler-Weber-Rendu disease
Tachycardia, tachypnea, hypoxia, congested neck veins, S3 Tachycardia, tachypnea, hypoxia, congested neck veins, S3
gallop, bilateral fine basal crepitationsgallop, bilateral fine basal crepitations
CHF caused by Lt V. dysfunction or MSCHF caused by Lt V. dysfunction or MS

15. DiagnosisDiagnosis
Laboratory InvestigationsLaboratory Investigations
TestTest Diagnostic FindingsDiagnostic Findings
WBCs with differentialWBCs with differential ↑↑WBCs count & shift to the left in URTI & LRTIWBCs count & shift to the left in URTI & LRTI
Hemoglobin & hematocritHemoglobin & hematocrit ↓↓ in anemiain anemia
Platelet countPlatelet count ↓↓ in thrombocytopeniain thrombocytopenia
PT, INR & PTTPT, INR & PTT ↑↑ in anticoagulant use, disorders of coagulationin anticoagulant use, disorders of coagulation
ABGsABGs Hypoxia, hypercarbiaHypoxia, hypercarbia
d-dimerd-dimer ↑↑ in pulmonary embolismin pulmonary embolism
Sputum Gram stain, culture, Sputum Gram stain, culture,
AFB smear & cultureAFB smear & culture
Sputum Gram stain, culture, AFB & cultureSputum Gram stain, culture, AFB & culture
Sputum cytologySputum cytology NeoplasmNeoplasm
Tuberculin TestTuberculin Test PositivePositive in TB in TB
ESR ESR
↑↑in infection, autoimmune disorders (e.g., Wegener's in infection, autoimmune disorders (e.g., Wegener's
syndrome, SLE, Goodpasture's syndrome) & malignancysyndrome, SLE, Goodpasture's syndrome) & malignancy

16. DiagnosisDiagnosis
Chest X Ray (CXR)Chest X Ray (CXR)
Chest RadiographChest Radiograph Suggestive DiagnosisSuggestive Diagnosis
Cardiomegaly, increasedCardiomegaly, increased
pulmonary vascular distributionpulmonary vascular distribution
Chronic heart failure, mitral valve stenosisChronic heart failure, mitral valve stenosis
Cavitary lesionsCavitary lesions Lung abscess, TB, necrotizing carcinomaLung abscess, TB, necrotizing carcinoma
Diffuse alveolar infiltratesDiffuse alveolar infiltratesChronic heart failure, pulmonary edema, aspirationChronic heart failure, pulmonary edema, aspiration
Hilar adenopathy or massHilar adenopathy or mass Carcinoma, metastatic disease, infectionCarcinoma, metastatic disease, infection
HyperinflationHyperinflation COPDCOPD
Lobar or segmental infiltratesLobar or segmental infiltratesPneumonia, thromboembolism, obstructing carcinomaPneumonia, thromboembolism, obstructing carcinoma
Mass lesion, nodules, granulomas Mass lesion, nodules, granulomas
Carcinoma, metastatic disease, Wegener's Carcinoma, metastatic disease, Wegener's
granulomatosis, septic embolism, vasculitidesgranulomatosis, septic embolism, vasculitides
Patchy alveolar infiltratesPatchy alveolar infiltrates
Bleeding disorders, idiopathic pulmonary Bleeding disorders, idiopathic pulmonary
hemosiderosis, Goodpasture's syndromehemosiderosis, Goodpasture's syndrome

17. DiagnosisDiagnosis
CXRCXR

18. DiagnosisDiagnosis
CXRCXR

19. DiagnosisDiagnosis
CXRCXR

20. DiagnosisDiagnosis
CXRCXR

21. DiagnosisDiagnosis
CXRCXR

22. DiagnosisDiagnosis
CXRCXR

23. Advantages:Advantages:
1)1)Tomography is valuable in selected cases to better show the Tomography is valuable in selected cases to better show the
presence presence
of lung cavities, solid masses, and mediastinal & hilar LDN.of lung cavities, solid masses, and mediastinal & hilar LDN.
2)2)Its complementary use with FOB gives a greater positive yield of Its complementary use with FOB gives a greater positive yield of
pathology & is useful for excluding malignancy in high-risk patients.pathology & is useful for excluding malignancy in high-risk patients.
3)3)Allows application of special imaging techniques: e.g.,Allows application of special imaging techniques: e.g.,
HRCT (1-3mm thickness section) HRCT (1-3mm thickness section) ®®Bronchiectasis Bronchiectasis
Spiral CT with pulmonary angiography Spiral CT with pulmonary angiography ®®PEPE
DiagnosisDiagnosis
Computed Tomographic Scan (CT)Computed Tomographic Scan (CT)

24. DiagnosisDiagnosis
CT ScanCT Scan

25. DiagnosisDiagnosis
CT ScanCT Scan

26. DiagnosisDiagnosis
CT ScanCT Scan

27. Advantages:Advantages:
1.1.It is diagnostic for central endobronchial lesions.It is diagnostic for central endobronchial lesions.
2.2.Allows direct visualization of the bleeding site. Allows direct visualization of the bleeding site.
3.3.Permits tissue biopsy, bronchial lavage, or brushings for pathologic Permits tissue biopsy, bronchial lavage, or brushings for pathologic
diagnosis. diagnosis.
4.4.FOB also can provide direct therapy in cases of non massive FOB also can provide direct therapy in cases of non massive
hemoptysis:hemoptysis:
Instillation of diluted adrenaline.Instillation of diluted adrenaline.
Iced cooled saline. Iced cooled saline.
Wedging & temponade Wedging & temponade ®®Fogarty catheter balloonFogarty catheter balloon
DiagnosisDiagnosis
Fiberoptic Bronchoscopy (FOB)Fiberoptic Bronchoscopy (FOB)

28. DiagnosisDiagnosis
(FOB)(FOB)

29. AdvantagesAdvantages::
1.1.Wide suction channel.Wide suction channel.
2.2.Ensures ventilation.Ensures ventilation.
3.3.Allows Interventional procedure application in cases of Allows Interventional procedure application in cases of
massive hemoptysis e.g., Laser, Electrocautery, massive hemoptysis e.g., Laser, Electrocautery,
Cryotherapy.Cryotherapy.
Disadvantages:Disadvantages:
1.1.Requires general anesthesia.Requires general anesthesia.
2.2.Needs special skills.Needs special skills.
DiagnosisDiagnosis
Rigid BronchoscopyRigid Bronchoscopy

30. DiagnosisDiagnosis
Rigid BronchoscopyRigid Bronchoscopy

31. AngiographyAngiography
AdvantagesAdvantages::
1.1.Gold standard diagnostic tool for suspected PE.Gold standard diagnostic tool for suspected PE.
2.2.Diagnosis of arteriovenous malformation.Diagnosis of arteriovenous malformation.
3.3.Allows management of some cases of hemoptysis using Allows management of some cases of hemoptysis using
endovascular embolization.endovascular embolization.
Disadvantages:Disadvantages:
1.1.Embolization of Spinal arteries Embolization of Spinal arteries ®® paraplegia. paraplegia.
2.2.Needs special skills.Needs special skills.

32. AngiographyAngiography

33. AngiographyAngiography

34. Ventilation/Perfusion Lung ScanVentilation/Perfusion Lung Scan
(V/Q scan)(V/Q scan)

35. Algorithm for Diagnosing Non-massive Algorithm for Diagnosing Non-massive
HemoptysisHemoptysis

36. Management of HemoptysisManagement of Hemoptysis
GoalGoal::
1.1.Evaluate the severity of hemoptysis.Evaluate the severity of hemoptysis.
2.2.Airway protection & patency.Airway protection & patency.
3.3.Identify the site of bleeding.Identify the site of bleeding.
4.4.Protect the contralateral un involved lung.Protect the contralateral un involved lung.
5.5.Stop the bleeding.Stop the bleeding.
6.6.Treatment of the cause of bleeding.Treatment of the cause of bleeding.

37. Management of HemoptysisManagement of Hemoptysis
Non-MassiveNon-Massive MassiveMassive
Treatment of the Treatment of the
underlying causeunderlying cause
MedicalMedical
SurgicalSurgical
EndobronchialEndobronchial
EndovascularEndovascular

38. Management of Massive Management of Massive
HemoptysisHemoptysis
I.I.MedicalMedical::
Endotacheal tube (single wide bore (or) double lumen).Endotacheal tube (single wide bore (or) double lumen).
Position of the patient sitting (or) bleeding side downPosition of the patient sitting (or) bleeding side down
Large bore IV line fluids, blood transfusion Large bore IV line fluids, blood transfusion (EXCEPT??)(EXCEPT??)
Supplemental Oxygen/ Mechanical ventilation.Supplemental Oxygen/ Mechanical ventilation.
Avoid cough suppressants (if necessary Benzodiazepine).Avoid cough suppressants (if necessary Benzodiazepine).
Pitressin (Vasopressin) 0.2-0.4 units/min. IV.Pitressin (Vasopressin) 0.2-0.4 units/min. IV.

39. Management of Massive Management of Massive
HemoptysisHemoptysis
II.II.SurgicalSurgical::
Emergency resection for Emergency resection for
bronchogenic mass.bronchogenic mass.
Resection of bronchogenic Resection of bronchogenic
mass after patient mass after patient
stabilization.stabilization.
Surgical resection for Surgical resection for
aspergilloma.aspergilloma.

40. Management of Massive Management of Massive
HemoptysisHemoptysis
III.III.EndobronchialEndobronchial::
Identify: Identify: SSource, ource, RRate & to ate & to SSlow (or) low (or) AArrest bleeding.rrest bleeding.

41. Management of Massive Management of Massive
HemoptysisHemoptysis

42. Management of Massive Management of Massive
HemoptysisHemoptysis

43. IV.IV.Endovascular:Endovascular:
First results of embolization were published in 1973First results of embolization were published in 1973..
In most patients the bleeding originates from In most patients the bleeding originates from
bronchial arteriesbronchial arteries rather than pulmonary arteries rather than pulmonary arteries..
Transcatheter embolization is effective in immediate Transcatheter embolization is effective in immediate
control of massive hemoptysis (73% - 98%). control of massive hemoptysis (73% - 98%).
Recurrence may be caused by:Recurrence may be caused by:
Incomplete embolization of artery.Incomplete embolization of artery.
Recanalization of previously embolized artery.Recanalization of previously embolized artery.
Revascularization through collateral circulation.Revascularization through collateral circulation.
Progression of basic lung disease.Progression of basic lung disease.
Management of Massive Management of Massive
HemoptysisHemoptysis

44. Management of Massive Management of Massive
HemoptysisHemoptysis
ICU AdmissionICU Admission
Conservative Medical CareConservative Medical Care
Rigid BronchoscopeRigid Bronchoscope
Hemoptysis stopHemoptysis stop
Investigate the causeInvestigate the cause
Hemoptysis did not stopHemoptysis did not stop
Surgical/EmbolizationSurgical/Embolization