HEMOPTYSIS
by 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
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Neoplasms- Bronchogenic CA
Bronchitis – Acute/ Chronic
Bronchiectesis
Airways trauma
Foreign Body
B. Pulmonary Parenchymal Diseases
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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.
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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 bloodDiagnosis 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 ventilation
to 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
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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.
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(b) For the elective but definitive
management of localised disease subject to
recurrent bleeding.
MCQs
1)Hemoptysis in mitral stenosis occurs due toa)Left atrial enlargement
b)Right ventricular hypertrophy
c)Bronchial arterial bleed
d)Pulmonary venous congestion
2)A chronic smoker patient presenting with
superior vena caval syndrome with hemoptysis.
Most likely cause isa)Intrathoracic tubercular lymphadenitis
b)Bronchogenic CA
c)Lymphoma
d)Aortic arch syndrome
3)A patient presenting with high fever ,chest
pain and hemoptysis. CXR –Air bronchogram
sign presenta)Lobar pneumonia
b)Lung abscess
c)Bronchiectasis
d)Bronchogenic CA
4)A patient of hemoptysis presents with normal
CXR. Suggest the next best investigation to help
Dxa)Sputum cytology
b)Bronchoscopy
c)Thoracoscopy
d)HRCT Thorax