Hemoptysis

This lecture
include all the
slide :D

Introduction:
To have hemoptysis is the most frightened experience, even worse than hematemesis or
bleeding 1 litter or more from other part of the body. It is a frightening event to both:
Health- care Providers and Patients & families.

Definition:
As doctors, we should differentiate hemoptysis from other type of bleeding. Heamoptysis is
the expectoration (or coughing up) of blood from the lung and the airways. Patients always
describe it in different ways. Some patients will describe it as mucus with blood streaks, or
mucus with dots, Pink sputum, Frank blood (with or without clots), Others will describe it as
fresh blood, or black blood.

Site of bleeding:
If we go back to the physiology of blood circulation in the lung, we will find that we have 2
circulations:
1- The bronchial circulation: this is high pressure (Bronchial arteries & collaterals originate
from the aorta ) ,also known as systemic circulation.
2- The pulmonary circulation: this is low pressure :
systolic BP= 15-20mmHg.
diastolic BP= 5-10mmHg .
Most of the time, Hemoptysis comes from the low pressure circulation which is close to the
venous system- & thats why it is always watery and low amount. In contrast, if the bleeding is
from high pressure circulation -the arterial system - , there will be massive hemoptysis.
*In the slides : bronchial circulation is The source of bleeding in most cases.

 Mechanism of bleeding:
Hemoptysis occurs as a result of:
1- Inflammation with erosion of blood vessels.
2- Increase pressure in the vessels, which lead to dilatation & aneurysm formation ,and finally
it will rupture

Severity of hemoptysis:
Depends on 3 factors:
1- Amount & rapidity of bleeding:
Its very important point to understand that, severity of hemoptysis is not only related to the
amount of blood expectorated in 24h. In the past, they thought that the severity is
proportional to the amount of blood. But nowadays, they find that the severity of the case is
much more related to the rapidity of bleeding. E.g. patient with rapid but small amount
bleeding is more critical than patient with slow but huge amount bleeding.
2- Cardio-respiratory reserve:
So patients with low cardio-respiratory reserve as in COPD, lung fibrosis or
Bronchiectasis - will have much more severe hemoptysis than one with healthy high
reserve.
3- The effect on gas exchange:
We must conceder the effect of bleeding on gas exchange. In other word, we should ask: does
the bleeding affect the gas exchange? & what does it cause in the respiratory tract?!!
Sometimes, small amount of blood can cause a major obstruction that will lead to
Asphyxiation or flooding of tracheo-bronchial tree and finally respiratory arrest (Medical
Emergency: Occur in 1-5% of patients).
*In medical emergency the amount reported to range from
[ > 100 250 500 600 1000 ] cc / 24 hrs.

So , we should look for all these 3 factors to assess the severity.

Note: First make sure it is hemoptysis. Because there are lots of

patients have nesopharengeal bleeding and cough which looks like
hemoptysis & will give wrong diagnosis. So, you should ask about
history of Hematemesis, Epistaxis, or other nasopharyngeal bleeding.
Look at the table

Etiology:
Its important to define the etiology & the cause of hemoptysis to be able to deal with it and
treat the patient. We can classify the etiology according to:

1- the site of bleeding:

It might be from tracheobronchial
tree, lung parenchyma, lung
vasculature, or related to systemic
problem read the table- slide#6-.
- Bronchogenic carcinoma,
Bronchitis, & Bronchiectasis are
common cause for tracheobronchial
bleeding.
- TB is most common cause for lung parenchymal bleeding
- Other causes are rare cases.
2- The cause of bleeding:
It might be infection, foreign body, trauma,
malignancy, cardio-pulmonary causes, connective
tissue disorders, factitious, or cryptogenic.

Factitious disorders: are conditions in which

a person acts as if he or she has an illness by
deliberately producing, feigning, or
exaggerating symptoms.

3- Incidence & frequency:

It varies in different study populations. The
most common cause worldwide is Bronchitis.
Pneumonia is 2nd most common cause, then
TB , Bronchiectasis, & lung CA.

 Approach to Patient with Hemoptysis:

When a patient comes to the ER with hemoptysis, we need to:
- Take good history.
- Assess the severity, Urgency, amount, duration & extent of bleeding.
- Assess the Cardio-Respiratory reserve whither he/she has HF, IHD, or previous lung
problem.
- Ask about Prior Episodes of bleeding.

Clues from the history:

These clues can help us to define the cause of hemoptysis. Its not 100% true, but it can
help.
- If the patient has blood streaking of mucopurulent or purulent sputum, then think of
Bronchitis.
- If he has Blood streaking of purulent sputum + fever & chills, think of Pneumonia.
If he has chronic cough & sputum production + Recent change in quantity or
appearance, think of Acute Exacerbation of COPD.
- If he comes with foul smell of purulent sputum, check for Lung abscess.
- If the chief complaint is sudden chest pain with SOB, think of pulmonary embolism.
In patient with Bronchiectasis, we expect to have Copious secretions & recurrent
respiratory infections.- Its very important to recognize the color of the sputum for
Bronchiectasis, & thats why the DR. put it in separated slide#14
- In a patient with positive Hx of asbestosis or smoking, we should think of Bronchogenic
CA.
Alcoholic patient, or patient with recurrent coma or with poor dental hygiene are at
high risk for lung abscess.
- +ve Hx of drug abuse, or blood transfusion, or sexual practice may indicate HIV
infection.
If hemoptysis is combined with renal disease or hematuria- , think of Goodpasture
syndrome or Wegener disease.
- SLE patients may come with Lupus Pneumonitis
- Hx of other cancers as renal cell carcinoma- with hemoptysis may indicate metastasis.
- AIDS patients usually have endobronchial Kaposi sarcoma that may cause hemoptysis.
If patient has +ve Hx of previous bleeding, think of thrombocytopenia or anti-coagulant
overdose.

 Diagnostic:
For any patient coming with hemoptysis we do: labs, radiologic studies and
endoscopic studies.

1.

Labs:

Hemoglobin (the most important one)

PT, PTT & INR to know if the patient has bleeding diathesis.
Sputum studies when suspect infectious or neoplastic etiologies.
Cultures.
KFT (Kidney Function Test) because, as we said, there are some illnesses which are
associated with renal problems.
UA (Urine Analysis)
ABG's (Arterial Blood Gas) to know how much the patient is affected.
CVD (Collagen Vascular Diseases) like: diabetes, rheumatoid arthritis etc
Differential diagnosis of hemoptysis + hematuria:
GPS, Goodpasture syndrome
WG, Wegener disease
SLE.
Lung cancer. What is the cause of hematuria in lung cancer patients? Membranous GN.
Renal cell carcinoma from lung metastasis.
Bleeding diathesis which may cause bleeding from any site.
Student: what is the meaning of bleeding diathesis?
Doctor: patients who have bleeding tendency.
2. Radiologic studies:
CXR (Chest X-Ray): When a patient comes to with any respiratory illness, you should do x-ray
to him. In hemoptysis, it may be normal in up to one third of cases and in the other two thirds
you may see the etiology. If you see an abnormality in one side of the x-ray, it may not reflect
the exact site of the bleeding. Why? Because the bleeding accumulates in gravity-depending
areas (the patient may be ambulating or bedridden).So, the infiltrate in the x-ray indicates the
blood but does not indicate where the blood is coming from.

 CT scan:It has higher yield and the highest yield is in bronchiactasis.

Here the x-ray is normal (look at the CT for
the same patient)

There is a cavity behind the heart ,

diagnosed after tha as adenocarcinoma

Diagnostic clues for chest radiograph: Here, the doctor just talked about some examples:
Cardiomegaly: the patient may have heart failure or mitral stenosis.
Hyperinflation: the patient may have COPD.
Mass lesions, nodules, granulomas: may suggest carcinomas, metastatic diseases,
Wegener's granulomatosis, septic embolism (multiple nodules) or vasculitis (nodular lesions).
Bilateral hilar adenopathy: may suggest TB.

3 . Bronchoscopy: there are two types:

FPB (FiberOptic Bronchoscopy): can be inserted into any segment of the lung. The
disadvantage is that the blood can obliterate the field quickly because is very small.
So, you may be obligated to take it out, clean it and insert it again.
Rigid bronchoscopy: the advantage is that you can do better blood suctioning and you can
do more therapeutic interventions.
We, as pulmonologists, do not do rigid bronchoscopy because rigid bronchoscopy needs to be
done in the operation room. As you can do therapeutic interventions, you may harm the
patient in rigid bronchoscopy and proceed more. So, you have to have more control to the
environment and nowadays rigid bronchoscopy is done by surgeons and
pulmonologists do the FPB.

You can see a bronchus and there is a white mass. The

first thing you should think about is mucous plug and we see
this a lot in ICU patients. If it is a tissue rather than
mucous plug, this tends to be a bronchogenic carcinoma

4. Bronchial angiography:
After doing bronchoscopy, you may have to do something we call "bronchial angiography".
This angiography has two benefits: 1diagnostic to determine the exact site of the bleeding
and if the bleeding is uncontrolled, you may do 2intervention by occlusion of the artery
where the bleeding is come from. But we do not do this angiography unless we have
refractory bleeding

 Management:
Management of hemoptysis depends on: 1the severity of bleeding, 2the cause of bleeding
and 3the general condition of the patient.
Management of non-massive hemoptysis: we have time to take history, do all
investigations (CBC, IV fluidsetc) and monitor the patient. When we find the cause, we
treat him according to the cause. If it is infection, we give antibiotics. If the cause is
vasculitis, we start to give steroids or other immunosuppressive drugs. If it is cancer, we give
chemotherapy. If there is foreign body, we remove it.
Management of massive hemoptysis(indictated by:
Priorities
Rapidity of bleeding and Respiratory function)
Airway protection
it is a medical emergency. We must put the patient in the
ETT / MVS
ICU. The priority is always for the airways because, as we
said, the most common cause of death in hemoptysis is
Patient Stabilization
asphyxiation rather than exsanguinations. So, we need to
Find the site /cause of bleeding
make sure that the airways are protected. If there is drop
in oxygenation, we do intubation. As any bleeding, we put
Attempt to stop bleeding
large needles and prepare blood. We do
Prevent recurrence of bleeding
bronchoscope and during the bronchoscope, we attempt
to stop the hemoptysis. We may give cough suppressant
Specific therapy
but you need to correct any coagulopathy and give fluids.
We have some interventions that we may do when the patient is is intubated in severe
massive hemoptysis:
Iced saline lavage on the segment that the blood is come from because it causes
vasospasm.
Topical vasopressors like: adrenaline.
Selective intubation. It has specific types of endotracheal tubes that have two lumens: one
goes to the right lung and the other goes to the left lung. If the bleeding is coming from the
left lung, we blow a balloon and close the left lung. So, the left lung will collapse. Blood supply
will be diverted to the other lung and the bleeding will decrease.
Endobronchial tamponade. There is a special catheter called "Fogarty catheter". You insert
this catheter by bronchoscope. When you reach to the segment that causes the bleeding, you
blow the balloon of Fogarty catheter. So, it will cause tamponade for
the eondobronchial segment. Then, you leave it for about an hour until the bleeding stops.

Laser photocoagulation. It needs special training and here we do cautery

Bronchial artery embolization. We do not do it during bronchoscopy. We do it during
bronchial angiography.
Surgery (lobectomy / pneumonectomy) if the previous interventions are not effective
considering the cardio-pulmonary reserve because not all patients can tolerate. For example:
COPD patients cannot tolerate lobectomy. So, mortality rate is high in these patients.

Good Luck