Hemoptysis

Hemoptysis

 Hemoptysis = expectoration of blood, alone or mixed with mucus,

from the lower respiratory tract
 Annual incidence: 1% ambulatory patients, 0.2% inpatients
 Male: female = 2:1
 Potentially life-threatening medical emergency
 90% are self-limiting
 Require rapid diagnosis and treatment
True Hemoptysis vs Pseudohemoptysis

True Hemoptysis Pseudohemoptysis

 Source of bleeding: airways or lungs  Source of bleeding:upper
gastrointestinal tract or upper
 Alkaline
respiratory tract (mouth, nose, throat)
 Bright red
 Hematinized blood
 Foamy blood
 Acid pH
 Breathing difficulty
 Food particles
 Sensation of warmth in thorax
 Abdominal pain
 Nausea
Causes of Hemoptysis

Cryptogenic

Pulmonary Disease
• Airway infections
• Malignancy
• Bronchiectasis/ cystic fibrosis
• Tuberculosis, etc
Cardiovascular Causes
• Pulmonary artery embolism
• Vascular malformations
• Idiopathic pulmonary hemosiderosis, etc

Others
• Iatrogenic: lung biopsy, right heart catheterization
• Trauma/llung contusion
• Foreign body, etc
Pathophysiology
Hypoxic Pulmonary AV
Vasculitis
vasoconstriction malformation

Pulmonary arterial Impairment of Chronic inflammatory

thromboembolism pulmonary arterial or neoplastic lung
or thrombosis circulation disease

Secretion of
neoangiogenetic
growth factor

Thinner and more fragile

walls of bronchial
arteries

Ruptures and
haemorrhages
Initial Assessment and Management

 Goal of initial assessment: detect any danger to life by quantifying the

bleeding and evaluating the patient’s oxygenation
 Clinical signs of impaired gas exchange:
 Cyanosis
 Dyspnea
 Tachypnea
 Decrease consciousness
 Increased work of breathing
 Goal of initial management: maintenance of gas exchange
 Initial Assessment and Management
Action
Monitor vital parameters
Give oxygen
Place the patient with the bleeding side down
Sedation/anxiolysis
In massive hemoptysis: endotracheal or, if
required, unilateral endobronchial intubation
Purpose
Registration of pulse-oximetric oxygen
saturation (SpO2), respiratory and circulatory
function (non-invasive blood pressure
measurement [NIBP]); assessment of risk
involved in interventional procedures and
medicinal treatment
Improvement of oxygenation
Prevention of the flow of endobronchial blood
into unaffected lung segments
Calming of the patient, facilitation of diagnostic
and therapeutic measures (NB: re- striction of
breathing activity, ability to expectorate, ability
to cooperate/communicate)
Maintenance of gas exchange
Diagnosis

 Goal: identify site and cause of bleeding

 Standardized procedure:
 Case history and clinical examination
 Determine severity of bleeding: mild or massive?, 1st or recurrent event?
 Explore signs and risk factors of underlying disease
 Laboratory test
 Chest radiographs at 2 levels or contrast-enhanced multislice computed
tomography with CT angiography of the chest
 Bronchoscopy if chest radiography or multislice CT failed
 Diagnostic Methods
Method Result of Analysis
Clinical chemistry Primary: Inflammation parameters, blood count,
coagulation status Secondary: Autoimmune
diagnosis
Vital parameters Gas exchange and hemodynamics
Chest X-ray Localization of bleeding Cause of bleeding
(pneumonia, lung abscess, bronchial carcinoma,
acute or chronic pulmonary tuberculosis)
Contrast-enhanced multislice computed Localization of bleeding Cause of bleeding
tomography with CT angiography Anatomy
Bronchoscopy Localization of bleeding (right or left lung, lobe,
segment, etc.), cause of bleeding, harvesting of
material (microbiology, cytology, histology)
Treatment as required: keep airways free of blood,
administer vasoconstrictors, tamponade, balloon
catheter, laser, argon plasma coagulation
Overview of Treatment

 Goal: control and stop bleeding

 Treatment options:
 Conservative Treatment
 Bronchial Artery Embolization
 Endoscopic Treatment
 Pulmonary Isolation
 Surgery
Treatment: Conservative

 For mild or moderate hemoptysis

 Can be managed by:
 Treatment of underlying pathology
 Ex: treat infection or inflammation
 Optimization of coagulation status
 Stabilizing coagulation  stop bleeding
 Antifibrinolytic treatment with tranexamic acid
Treatment: Bronchial Artery Embolization

 Minimally invasive endovascular technique

 Method of choice in massive and recurrent hemoptysis
 Goal: reduction of the systemic arterial perfusion pressure in the bronchial arteries
of the affected area in order to stop the bleeding
 Findings showing bronchial artery pathology as source of bleeding:
 Bronchial artery diameter >2 mm
 Tortuosity of the bronchial arteries
 Shunts
 Aneurysms
 Extravasation of contrast medium
 Hypervascularized zones of lung parenchyma
Treatment: Bronchial Artery Embolization

 Most frequent embolizing agents: polyvinyl alcohol (usually 300–600 μm)

 Advantage: nonabsorbable, available in different sizes
 Effective in wide array of pathologies:
 Tuberculosis
 Bronchiectasis
 Aspergilloma
 Malignancy
 Major complication: embolization of anterior spinal arteries  spinal cord
ischemia (uncommon)
Treatment: Endoscopic Treatment

 Noniatrogenic hemoptysis: flexible bronchoscopy is used to identify source of

bleeding, perform endoscopic treatment, and perform pulmonary isolation to
protect unaffected lung
 Many bronchoscopic techniques have been reported to manage signi cant
hemorrhages with an interesting success rate
 For severe hemoptysis, experienced bronchoscopic team and adequate
equipment are needed
 Endotracheal intubation prior to procedure is used in some situations
 If endotracheal intubation is performed  use large endotracheal tube  allow
passage of therapeutic flexible bronchoscope (larger working channel which provides
better suction)
Treatment: Endoscopic Treatment

 Rigid bronchoscopy:
 allows bronchoscopists to perform local tamponade of the bleeding if the
source is central
 Allows usage of a wide variety of endoscopic techniques
 allows selective intubation for pulmonary isolation in case of catastrophic
bleeding
Treatment: Endoscopic Treatment

 Different techniques:
 Cold saline
 Vasoconstrictive Agents
 Bronchoscopy-Guided Topical Hemostatic
 Endobronchial Biocompatible Glue
 Endobronchial stents
 Endobronchial Embolization Using Silicone Spigots
 Fibrinogen-Thrombin
 Laser Photocoagulation
 Argon Plasma Coagulation
 Endobronchial Valves
Endobronchial Blockers
 Treatment: Pulmonary Isolation

 Aim: prevent blood from the bleeding lung to enter the

normal lung  maintain ventilation and oxygenation
 First simple maneuver: place the bleeding source in a
dependent position by turning the patient on the side of the
bleeding
 Trendelenburg and reverse Trendelenburg positions may also
be useful depending on the position of the source of
bleeding
 Other techniques:
 Selective endobronchial intubation
 Placement of a bronchial blocker (BB) after endotracheal
intubation
 Intubation with a double-lumen endotracheal tube (DLT)
Treatment: Surgery

 Effective modality to control hemoptysis in patients with localized disease

 Also useful for conditions with a high risk of recurrence after bronchial
artery embolization
 Mortality rates of 2% -18%
 due to compromised hemodynamic and respiratory function

 Mortality rate increases when the surgery is extensive or performed in an

emergency setting, reaching up to 50%
 In survivors, recurrence rates are relatively low
Thank You