HEMOPTYSISby Prof. Arvind Mishra M.D.

Department of medicine

What is Hemoptysis

• Expectoration of blood from respiratory tract (from streaking to massive amount)

Massive Hemoptysis

• Expectoration of >100-600ml over a 24hr period

• Acute life threatening condition.• Blood can fill the airways and the alveolar

spaces.• Seriously disturbing gas exchange and may

lead to asphyxia.

Establish Hemoptysis

• Should be differentiated from hemetemesis.• Fresh blood and froth on coughing.• Altered blood ( brown) with food particles in

vomit.• Associated features.• Dilemma

Once established, evaluate etiology

A. Bleeding from tracheobronchial tree• Neoplasms- Bronchogenic CA• Bronchitis – Acute/ Chronic• Bronchiectesis• Airways trauma• Foreign Body

B. Pulmonary Parenchymal Diseases• Tuberculosis• Lung Abscess• Pneumonia• Wegner’s Granulomatosis• Good Pasture’s Syndrome

C. Primary Vascular Diseases• Mitral Stenosis• Pulmonary Embolism• A V Malformations

D. Miscellaneous• Systemic Coagulopathy• Pt. on Anticoagulants / Thrombolytic agents

Approach

HISTORY• Blood streaking with mucopurelent sputum -- Bronchitis • Fever with chills+ Blood with rusty sputum – Pneumonia• Blood + putrid sputum - Lung abscess• Blood + copious sputum - Bronchiectesis• Hemoptysis following acute onset of pleuritic Chest pain with dyspnoea – Pulm.Embolism

H/O coexisting Disorders

• Renal disease-Good Pasture’s Syndrome Wegner’s Granulomatosis• Lupus Eyrthematosus-Lupus Pneumonia• Non pulmonary malignancy-Endobronchial metastasis• AIDS-Kaposi’s Sarcoma• Risk factors for Bronchogenic CA-Smoking Asbestosis

Also ask for• previous bleeding disorders• treatment with anticoagulants• use of drugs leading to thrombocytopenia

PHYSICAL EXAM.

• Pleural friction rub-Pulmonary Embolism• Localised/Diffuse crepts-Parenchymal dis.• Evidence of airflow obstr.-Chr.Bronchitis• Ronchi +Crackles-Bronchiectesis• CVS-Pulm.Hpt., Mitral stenosis, LVF

Diagnostic Evaluation

• Chest radiograph/CT Scan-- mass lesion, bronchiectatic Changes, focal areas of pneumonitis.

• CBC• Coagulation profile• Assessment of renal profile– urine

analysis,Blood urea,S.Creatinine• Sputum– Gm. Staining, C/S

• Fibreoptic bronchoscopy– useful for localising the siteof bleeding and for visualisation of endobronchial lesions.

• Rigid bronchoscopy– preferred when bleeding is massive because this procedure has better airways control and greater suction capability.

Treatment

What determines the urgency of management -Rapidity of bleeding -Effect on gas exchange(A) If streaking or small amount of blood-Diagnosis is priority.(B) If massive—Mx. Is top priority

• Maintaining adequate gas exchange.• Preventing blood spilling into unaffected areas

of the lung. Keep the affected lung in the dependent position to avoid aspiration of blood into the unaffected lung.

• Avoid asphyxiation• Keep patient at rest/provide codeine containing

cough suppressants- may help to stop bleeding.

Management of massive bleeding

• May necessitate - Endobronchial intubation - Mechanical ventilationto control airways and maintain adequate gas exchange.• To avoid blood spilling into contralateral lung (1)Selective intubation of non bleeding lung (2)Use of specially designed double lumen endotracheal tubes.

• Another option- Inserting a ballon catheter through a bronchoscope under direct vision and inflating the ballon to occlude the branches leading to bleeding site.

Other techniques

• Laser Phototherapy• Electrocautery• Bronchial artery embolism• Surgical resection

• Bronchial artery embolisation-it involves an arteriographic procedure in which a vessel proximal to bleeding site is cannulated and a material such as Gelfoam is injected to occlude the bleeding vessel.

• Surgical resection of involved area of the lung—(a) Emergency therapy of life threatening hemoptysis that fails to respond to other measures.

• (b) For the elective but definitive management of localised disease subject to recurrent bleeding.

MCQs

1)Hemoptysis in mitral stenosis occurs due to-a)Left atrial enlargementb)Right ventricular hypertrophyc)Bronchial arterial bleedd)Pulmonary venous congestion

2)A chronic smoker patient presenting with superior vena caval syndrome with hemoptysis.Most likely cause is-a)Intrathoracic tubercular lymphadenitisb)Bronchogenic CAc)Lymphomad)Aortic arch syndrome

3)A patient presenting with high fever ,chest pain and hemoptysis. CXR –Air bronchogram sign present-a)Lobar pneumoniab)Lung abscessc)Bronchiectasisd)Bronchogenic CA

4)A patient of hemoptysis presents with normal CXR. Suggest the next best investigation to help Dx-a)Sputum cytologyb)Bronchoscopyc)Thoracoscopyd)HRCT Thorax