HEMOPTYSIS

PULMONARY BLEEDING (HEMOPTYSIS)

1. PULMONARY BLEEDING (HEMOPTYSIS)

2. Definition of hemoptysis Definition of hemoptysis Causes of of hemoptysis hemoptysis Causes Differential diagnosis of hemoptysis of hemoptysis Differential diagnosis Diagnosis of hemoptysis of hemoptysis Diagnosis Treatment of hemoptysis of hemoptysis Treatment Contents Contents

3. Pulmonary Bleeding Pulmonary Bleeding  (or  pulmonary haemorrhage ) is an  acute   bleeding  from the  lung , from the upper  respiratory tract  and the  trachea , and the alveoli. When evident clinically, the condition is usually massive. [1]  The onset of pulmonary hemorrhage is characterized by cough productive of blood ( hemoptysis ) and worsening of oxygenation leading to  cyanosis . [1]  Treatment should be immediate and should include tracheal suction, oxygen, positive pressure ventilation, and correction of underlying abnormalities (e.g. disorders of  coagulation ). A  blood transfusion  may be necessary.

4. Hemoptysis Hemoptysis 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 word "hemoptysis" The "hemoptysis" comes from from the the Greek Greek comes "haima" meaning "blood“ & "ptysis" which means "a "haima" meaning "blood“ & "ptysis" which means "a spitting". spitting". Hemoptysis can range from Hemoptysis can range from blood-streaking blood-streaking of of sputum to the presence of gross blood in the absence sputum to the presence of gross blood in the absence of any accompanying sputum. of any accompanying sputum. Definition Definition

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

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

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

8. Cause of Hemoptysis Hemoptysis Cause of

9. 1. 2. 1. Pulmonary tuberculosis. Pulmonary tuberculosis. 2. Pulmonary infarction. Pulmonary infarction. 3. 3. Bronchiectasis. Bronchiectasis. 4. 4. Cystic fibrosis Cystic fibrosis 5. 5. Lung abscess. Necrotizing pneumonia. Lung abscess. Necrotizing pneumonia. 6. 6. 7. 8. 7. Mitral stenosis. Pulmonary arteriovenous stenosis. Pulmonary arteriovenous Mitral 8. malformation. malformation. Causes of Massive Hemoptysis Causes of Massive Hemoptysis

10. Sources: Sources: 1. 1. Bronchial circulation. circulation. Bronchial 2. 2. Pulmonary circulation. Pulmonary circulation. 3. 3. Anatomizes between pulmonary & bronchial between pulmonary & bronchial circulation. circulation. Anatomizes Mechanisms: Mechanisms: 1. 1. Vessel engorgement. engorgement. Vessel 2. 2. Erosion (or) rupture of vessels. Erosion (or) rupture of vessels. 3. 3. Mucosal ulceration. ulceration. Mucosal 4. 4. Vascular granulation tissue. granulation tissue. Vascular Mechanism & Sources of Hemoptysis Hemoptysis Mechanism & Sources of

11. Make sure that this this is is True Hemoptysis. Make sure that True Hemoptysis. Identify the Severity Identify the Severity of hemoptysis. of hemoptysis. Clinical clues clues in in History Clinical History & Examination. & Examination. Diagnostic Investigations. Diagnostic Investigations. Appropriate Treatment. Appropriate Treatment. Clinical Approach for Management of Clinical Approach for Management of Hemoptysis Hemoptysis

12. Important points to address in History Important points to address in History Clinical Clues Clues Clinical Suggested Diagnosis Suggested Diagnosis Anticoagulant use use Anticoagulant Medication effect, coagulation disorder coagulation disorder Medication effect, Association with menses Association with menses Catamenial hemoptysis hemoptysis Catamenial Dyspnea on exertion, fatigue, fatigue, orthopnea, PND, frothy pink sputum orthopnea, Dyspnea on exertion, PND, frothy pink sputum Congestive heart failure, failure, Lt Lt V. V. dysfunction, dysfunction, MS MS Congestive heart Fever, productive cough productive cough Fever, URTI, acute bronchitis, acute bronchitis, pneumonia, pneumonia, lung abscess lung abscess URTI, History of breast, breast, colon, colon, or or renal renal cancers cancers History of Endobronchial metastatic lung disease metastatic lung disease Endobronchial History of chronic lung disease, chronic lung disease, recurrent recurrent History of LRTI, cough with copious purulent sputum sputum LRTI, cough with copious purulent Bronchiectasis, lung abscess lung abscess Bronchiectasis, Melena, alcoholism, alcoholism, chronic use of chronic use of NSAIDs NSAIDs Melena, Gastritis, gastric or gastric or peptic ulcer, peptic ulcer, esophageal esophageal varices varices Gastritis, Pleuritic chest pain, pain, calf tenderness calf tenderness Pleuritic chest Pulmonary embolism or infarction infarction Pulmonary embolism or Tobacco use Tobacco use Acute bronchitis, chronic bronchitis, chronic bronchitis, lung Ca, lung Ca, pneumonia pneumonia Acute bronchitis, Toxic symptoms Toxic symptoms Tuberculosis Tuberculosis Weight loss loss Weight Emphysema, lung cancer, lung cancer, TB, TB, bronchiectasis, bronchiectasis, lung abscess lung abscess Emphysema,

13. True Hemoptysis Versus Spurious (False) Hemoptysis True Hemoptysis Versus Spurious (False) Hemoptysis True hemoptysis True hemoptysis False hemoptysis False hemoptysis Below vocal cords cords Below vocal Above vocal cords cords Above vocal Persists as blood tinged sputum blood tinged sputum Persists as Does not persist not persist Does May be mixed with sputum May be mixed with sputum Not mixed with sputum Not mixed with sputum History of cardiopulmonary disease History of cardiopulmonary disease Obvious by ENT examination Obvious by ENT examination CXR may be abnormal CXR may be abnormal Normal CXR CXR Normal

14. Hemoptysis Versus Hematemsis Hemoptysis Versus Hematemsis Hemoptysis Hemoptysis Hematemsis Hematemsis Coughing of blood Coughing of blood Vomiting of blood Vomiting of blood History of cardiopulmonary disease History of cardiopulmonary disease History of GIT disease History of GIT disease Bright red in color red in color Bright Dark brown in color Dark brown in color Sputum remains blood stained blood stained after the attack for few days Sputum remains after the attack for few days Usually followed by melena Usually followed by melena Mixed with sputum Mixed with sputum Mixed with gastric contents contents Mixed with gastric Blood is frothy frothy Blood is Airless Airless Alkaline Alkaline Acidic Acidic Sputum contains hemosedrin laden macrophages Sputum contains hemosedrin laden macrophages No No

15. Examination Examination Clinical Clues Clues Clinical Suggested Diagnosis Suggested Diagnosis Cachexia, clubbing, hoarseness, Cushing's syndrome syndrome, Cachexia, clubbing, hoarseness, Cushing's syndrome, hyperpigmentation, Horner's hyperpigmentation, Horner's syndrome Bronchogenic carcinoma, carcinoma, SCLC SCLC Bronchogenic Clubbing Clubbing Lung cancer, bronchiectasis, bronchiectasis, lung abscess lung abscess Lung cancer, Dullness to percussion, to percussion, fever, fever, crepitations crepitations Dullness Pneumonia Pneumonia Fever, tachypnea, tachypnea, hypoxia, hypoxia, working accessory respiratory working accessory respiratory Fever, muscles, barrel chest, intercostal retractions, retractions, pursed lip rhonchi, distant heart sounds pursed lip muscles, barrel chest, intercostal breathing, breathing, rhonchi, distant heart sounds COPD, Lung cancer, Lung cancer, pneumonia pneumonia COPD, Gingival thickening, thickening, saddle nose, saddle nose, nasal nasal septum perforation septum perforation Gingival Wegener's granulomatosis granulomatosis Wegener's Mid diastolic rumbling murmur Mid diastolic rumbling murmur MS MS LN enlargement, cachexia, cachexia, violaceous violaceous skin lesions skin lesions LN enlargement, Kaposi's sarcoma 2ry to HIV sarcoma 2ry to HIV Kaposi's Tachypnea, tachycardia, tachycardia, dyspnea, dyspnea, S1Q3T3, rub, unilateral leg pain & edema S1Q3T3, pleural pleural friction friction Tachypnea, rub, unilateral leg pain & edema Pulmonary thromboembolism Pulmonary thromboembolism Orofacial & mucous & mucous membrane telangiectasia, membrane telangiectasia, epistaxis epistaxis Orofacial Osler-Weber-Rendu disease Osler-Weber-Rendu disease Tachycardia, tachypnea, tachypnea, hypoxia, hypoxia, congested neck veins, congested neck veins, S3 gallop, bilateral fine basal crepitations S3 Tachycardia, gallop, bilateral fine basal crepitations CHF caused by Lt V. V. dysfunction or dysfunction or MS MS CHF caused by Lt

16. Diagnosis Diagnosis Laboratory Investigations Laboratory Investigations Test Test Diagnostic Findings Diagnostic Findings WBCs with differential WBCs with differential ↑  WBCs count ↑  WBCs & shift to the left in URTI & LRTI to the left in URTI & LRTI count & shift Hemoglobin & hematocrit Hemoglobin & hematocrit ↓  in anemia ↓  in anemia Platelet count count Platelet ↓  in thrombocytopenia ↓  in thrombocytopenia PT, INR & PTT INR & PTT PT, ↑  in anticoagulant ↑  use, disorders disorders of of coagulation coagulation in anticoagulant use, ABGs ABGs Hypoxia, hypercarbia hypercarbia Hypoxia, d-dimer d-dimer ↑  in pulmonary embolism ↑  in pulmonary embolism Sputum Gram stain, culture, culture, AFB smear & culture Sputum Gram stain, AFB smear & culture Sputum Gram stain, culture, culture, AFB & culture AFB & culture Sputum Gram stain, Sputum cytology Sputum cytology Neoplasm Neoplasm Tuberculin Test Tuberculin Test Positive in TB Positive in TB ESR ESR ↑  in ↑  in infection, autoimmune autoimmune disorders disorders (e.g., (e.g., Wegener's Wegener's infection, syndrome, SLE, Goodpasture's syndrome) & malignancy syndrome, SLE, Goodpasture's syndrome) & malignancy

17. Diagnosis Diagnosis Chest X Ray (CXR) X Ray (CXR) Chest Chest Radiograph Radiograph Chest Suggestive Diagnosis Suggestive Diagnosis Cardiomegaly, increased increased Cardiomegaly, pulmonary vascular distribution distribution pulmonary vascular Chronic heart heart failure, failure, mitral mitral valve stenosis valve stenosis Chronic Cavitary lesions Cavitary lesions Lung abscess, TB, TB, necrotizing carcinoma necrotizing carcinoma Lung abscess, Diffuse alveolar infiltrates infiltrates Diffuse alveolar Chronic heart heart failure, failure, pulmonary edema, pulmonary edema, aspiration aspiration Chronic Hilar adenopathy or adenopathy or mass mass Hilar Carcinoma, metastatic metastatic disease, disease, infection infection Carcinoma, Hyperinflation Hyperinflation COPD COPD Lobar or or segmental segmental infiltrates infiltrates Lobar Pneumonia, thromboembolism, obstructing carcinoma thromboembolism, obstructing carcinoma Pneumonia, Mass lesion, lesion, nodules, nodules, granulomas granulomas Mass Carcinoma, granulomatosis, metastatic disease, Wegener's vasculitides Carcinoma, metastatic disease, Wegener's septic embolism, granulomatosis, septic embolism, vasculitides Patchy alveolar infiltrates infiltrates Patchy alveolar Bleeding disorders, idiopathic pulmonary Bleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture's syndrome syndrome hemosiderosis, Goodpasture's

18. Diagnosis Diagnosis CXR CXR

19. Diagnosis Diagnosis CXR CXR

20. Diagnosis Diagnosis CXR CXR

21. Diagnosis Diagnosis CXR CXR

22. Diagnosis Diagnosis CXR CXR

23. Diagnosis Diagnosis CXR CXR

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

25. Diagnosis Diagnosis CT Scan CT Scan

26. Diagnosis Diagnosis CT Scan CT Scan

27. Diagnosis Diagnosis CT Scan CT Scan

28. Advantages: Advantages: 1. 1. It is diagnostic diagnostic for central for central endobronchial endobronchial lesions. lesions. It is 2. 2. Allows direct visualization of the bleeding site. direct visualization of the bleeding site. Allows 3. 3. Permits tissue biopsy, tissue biopsy, bronchial bronchial lavage, lavage, or brushings for pathologic or brushings for pathologic Permits diagnosis. diagnosis. 4. 4. FOB also can provide direct therapy in cases therapy in cases of non massive of non massive FOB also can provide direct hemoptysis: hemoptysis: Instillation of diluted adrenaline. Instillation of diluted adrenaline. Iced cooled saline. Iced cooled saline. Wedging & temponade → Fogarty catheter Wedging & temponade → balloon Fogarty catheter balloon Diagnosis Diagnosis Fiberoptic Bronchoscopy (FOB) Fiberoptic Bronchoscopy (FOB)

29. Diagnosis Diagnosis (FOB) (FOB)

30. Advantages Advantages : : 1. 2. 1. Wide suction channel. Wide suction channel. 2. Ensures ventilation. Ensures ventilation. 3. Allows 3. Allows Interventional Interventional procedure application in cases procedure application in cases of of Electrocautery, massive hemoptysis Cryotherapy. e.g., Laser, massive hemoptysis e.g., Laser, Electrocautery, Cryotherapy. Disadvantages: Disadvantages: 1. 2. 1. Requires general anesthesia. general anesthesia. Requires 2. Needs special skills. Needs special skills. Diagnosis Diagnosis Rigid Bronchoscopy Rigid Bronchoscopy

31. Diagnosis Diagnosis Rigid Bronchoscopy Rigid Bronchoscopy

32. Angiography Angiography Advantages Advantages : : 1. 1. Gold standard diagnostic tool tool for for suspected PE. suspected PE. Gold standard diagnostic 2. Diagnosis 2. Diagnosis of of arteriovenous malformation. arteriovenous malformation. 3. Allows management 3. Allows management of of some cases some cases of of hemoptysis hemoptysis using using endovascular embolization. endovascular embolization. Disadvantages: Disadvantages: 1. 1. Embolization of Spinal arteries → Embolization of Spinal arteries → paraplegia. paraplegia. 2. Needs special skills. 2. Needs special skills.

33. Angiography Angiography

34. Angiography Angiography

35. Ventilation/Perfusion Lung Scan Ventilation/Perfusion Lung Scan (V/Q scan) (V/Q scan)

36. Management of of Hemoptysis Hemoptysis Management Goal Goal : : 1. 1. Evaluate the severity of hemoptysis. hemoptysis. Evaluate the severity of 2. Airway protection & patency. 2. Airway protection & patency. 3. Identify the site of 3. Identify the site of bleeding. bleeding. 4. Protect the contralateral un involved lung. 4. Protect the contralateral un involved lung. 5. Stop the bleeding. 5. Stop the bleeding. 6. Treatment 6. Treatment of of the cause of the cause of bleeding. bleeding.

37. Management of of Hemoptysis Hemoptysis Management Non-Massive Non-Massive Massive Massive Treatment of the Treatment of the underlying cause underlying cause Medical Medical Surgical Surgical Endobronchial Endobronchial Endovascular Endovascular

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

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

40. Management of Massive Massive Management of Hemoptysis Hemoptysis III. Endobronchial III. Endobronchial : : Identify: S Identify: S ource, R ource, R ate & to S ate & to S low (or) A low (or) A rrest bleeding. rrest bleeding.

41. Management of Massive Massive Management of Hemoptysis Hemoptysis

42. Management of Massive Massive Management of Hemoptysis Hemoptysis

43. IV.Endovascular: IV. Endovascular: First results of embolization were published in 1973 embolization were published in 1973 . First results of . In most patients bronchial arteries the bleeding originates from In most patients the bleeding originates from bronchial arteries rather than pulmonary arteries . rather than pulmonary arteries . Transcatheter embolization is effective in immediate Transcatheter embolization is effective in immediate control of of massive hemoptysis massive hemoptysis (73% - (73% - 98%). 98%). control 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. circulation. Revascularization through collateral Progression of basic lung disease. lung disease. Progression of basic Management of Massive Massive Management of Hemoptysis Hemoptysis

44. Management of Massive Massive Management of Hemoptysis Hemoptysis ICU Admission ICU Admission Conservative Medical Care Conservative Medical Care Rigid Bronchoscope Rigid Bronchoscope Hemoptysis stop Hemoptysis stop Investigate the cause Investigate the cause Hemoptysis did not stop Hemoptysis did not stop Surgical/Embolization Surgical/Embolization