HEMOPTYSIS

Dr. Daniela Barto, Ph. D.

Definition
Hemoptysis means coughing-up blood originating from the subglottic airways. In large amounts, hemoptysis can have an unfavourable vital prognostic and requires emergency treatment. In small amounts, the disease should not be overlooked, since it can relapse to a serious form or can conceal a pulmonary disease.

Anatomy
Bronchial arteries derive from the descending thoracic aorta at level T4-T8. Their number varies, but most frequently there are the right bronchial artery and two left bronchial arteries, and possibly many anatomic variants. There may also be an ectopic bronchial artery, originating in other ramifications of the aorta, most frequently in the internal mammary, subclavian, inferior thyroid artery. Bronchial arteries are between 0.5 and 2 mm wide. Bronchial arteries can create an anastomosis between them.

Physiopathology
Hemoptysis can occur via several mechanisms: Blood vessel breakage is a seldom occurrence, being the origin of massive hemoptysis
detectable in arterial and venous pulmonary aneurysms if the carcinoma eroded the walls of arteries seldom in case of tuberculosis (Rasmunsens pseudo-aneurysm close to a cavern)

Sanguine leak from pulmonary capillaries into alveoli

this mechanism explains the hemoptysis in the acute pulmonary oedema and partly that in acute infectious diseases alteration of the alveolar basement membrane via immunologic disorders (Goodpasture syndrome) increases permeability and enables sanguine leak

Physiopathology
Change in capillary circulation with systemic hyper-vascularisation. This mechanism is manifest in: inflammatory or acute infectious (pneumonia, abscess, tuberculosis) disabling processes (dilated Bronchiectasis) or aspergillomas diseases

bronchi

diffuse angiomatosis

Diagnosis
Clinical signs of hemoptysis: expectoration of red blood with air bubbles while coughing There can be prodromes:
retro-sternal heat anxiety a sensation of tickling in the throat syncope

Diagnosis
Judging by the amount, hemoptysis can be:
foudroyant: leading to death within minutes by losing blood and asphyxiation by flooding the airways massive, abundant: more than 500 ml of blood. It is accompanied by signs of acute anaemia (pallor, tachycardia, falling blood pressure or hemorrhagic shock, consciousness disorders), thus requiring urgent therapeutic steps. NB: The same clinical significance have the repeated hemoptyses in which the expectorated blood volume is equal to or higher than 500 ml per day or higher than 150 ml per hour.

Diagnosis
Medium: expectorated blood ranging from 300 to 400 ml. It can be a therapeutic emergency owing to the risk of repeating itself with unpredictable severity Mild: most often it consists only in some blood clots or coughing up of blood-stained sputum. It is most of all a diagnosis-related emergency. Respiratory clinical examination in case of hemoptysis can only detect less worthy elements:
subcrepitant and bronchial rales crepitant rales in case of pneumonia

Differentiated diagnosis
Hemoptysis should be distinguished primarily from:
Hematemesis
Ejection after emesis effort Dark-coloured blood mixed with food particles In this context, stomach ache or gastric ulcer pain can make an appearance Rectal examination possibly melaena Gastric endoscopy useful for diagnosing oesophagus-gastro-duodenal bleeding

 Bleeding from upper airways: epistaxis (nosebleed) bleeding gums polyp, otorhinolaryngological cancer pharynx-laryngeal varicose veins otorhinolaryngological examination sets the diagnosis

Medical attitude to hemoptysis

Massive hemoptysis immediate therapy:
Place the patient in the Trendelenburg position Remove the blood from bronchi by intubation and suction Oxygen therapy Make up for blood loss Administrate vasoconstricting substances Admit to intensive care unit

Having taken these measures, one should resort to:

Bronchoscopy to locate the origin of bleeding Bronchial arteriography ahead of embolisation

Medium and mild hemoptysis

The most frequent clinical cases originally they require an overall examination
Anamnesis to detect a possible cardiovascular or respiratory disorder, or certain treatments (anticoagulants) Full physical examination hemoptysis may be a complication of an already known respiratory disease or it could be an isolated hemoptysis Chest X-ray front & side profile photos. This can be normal or can reveal certain features typical of hemoptysis (tumours, TB) Bronchoscopy indispensable for the diagnosis. It reveals the origin of bleeding or a certain disorder (tumour)

Medium and mild hemoptysis

Chest CT scan may reveal lesions that are not visible on the chest X-ray and may locate precisely vascular relationships with a certain wound. It may settle the diagnosis in pulmonary embolism. Complementary examination: Blood count ESR Coagulation test Sputum examination for BK ECG Lung scintigraphy in case of a suspected pulmonary embolus Bronchial arteriography in case of repeated hemoptyses before therapeutic embolisation

Medium and mild hemoptysis

Sometimes, the cause of hemoptysis is not obvious, as it can occur during:
a thoracic trauma, even a small one: broken rib, pulmonary hematoma a barometric trauma after inhaling toxic gas (caustic vapors) after bronchoscopy in other cases, hemoptysis can be a syndrome revealing a certain disorder or a complication of an already known pathology

Hemoptysis causes
1. Infectious TB, bronchiectasis, pneumonia, bronchitis, chronic obstructive lung disease, lung abscess, viruses (pneumonia, cryoglobulinaemia, HIV-related pneumocystis), fungi (aspergillosis), helminti Primary or secondary pulmonary disorders Pulmonary infarction, vasculitis (Wegener, rheumatoid polyarthritis, systemic lupus erythematosus, Rendu-Osler-Weber syndrome), arterial-venous malformations, capillaritis Diffuse interstitial pulmonary fibrosis, sarcoidosis, haemosiderosis, Goodpasture syndrome, cystic fibrosis Acute pulmonary oedema, coarctation of the aorta, Eisenmenger syndrome whichever Post tracheal intubation mitral stenosis, idiopathic HTP,

2. Neoplasia 3. Vascular

4. Parenchymatous

5. HTP

6. Coagulopathies 7. Trauma/foreign object

Medium and mild hemoptysis possible etiologies

Bronchial and pulmonary disorders Tuberculosis
hemoptysis can be a sign of M. tuberculosis infection, indicating the presence of ulcer-related or nodular forms the diagnosis is based on clinical signs: malaise, fever, cough and a chest X-ray showing: nodular, infiltrative or cavity-like images. The diagnosis is confirmed by identifying BK in sputum either in direct examination or in cultures hemoptysis may occur in the context of an already known and under-treatment TB. This is an alarm signal, pointing to either failure of the treatment or inadequately applied treatment. If the patient treated adequately, hemoptysis is a sign of aggravation.

Medium and mild hemoptysis possible etiologies

hemoptysis in a patient who has been treated for tuberculosis may mean: reactivated TB (chest X-rays alter and BK is identifyied in sputum) bronchiectasis due to fiber-like structural changes (CT examination suggests the diagnosis) aspergillum grafting in a remaining cavity (immuno-electrophoresis suggests the diagnosis) lung cancer

Medium and mild hemoptysis possible etiologies

Lung cancer
hemoptysis can be revealing is mild, it recurrent itself and is whimsical. occurs in smokers, with the accompanying clinical signs: rebel cough, chest pains, malaise. chest X-ray and thoracic CT scans show hilar or para-hilar tumor-like images. Thus, bronchoscopy is compulsory even when the chest Xray is normal. hemoptysis may appear in a patient with lung cancer. It can: be foudroyant by eroding the wall of a vessel close to the tumour become manifest long after the surgery, meaning a possible local recurrence, which requires a new bronchoscopy occur during radiotherapy and then require the treatment be discontinued

Medium and mild hemoptysis possible etiologies

Bronchiectasis
revealing hemoptysis: occurs most frequently in a patient suffering from purulent bronchorrhea. The diagnosis is established by chest X-ray and Highresolution thoracic CT scans hemoptysis can complicate the evolution of a patient with known bronchiectasis. An overview of the patient is necessary as regards the development of lesions and different medical treatment (antibiotics fit for the treatment of superinfection)

Medium and mild hemoptysis possible etiologies

Chronic bronchitis
hemoptysis can occur only in relation to the superinfection episodes. It must also be investigated wheather lung cancer is associated.

Pneumonia
every type can trigger hemoptysis. The most frequent infections that may trigger hemoptysis are influenzae pneumonia, Klebsiella pneumoniae and staphylococcus. In these cases bronchoscopy is compulsory for excluding lung cancer and the routine examination of sputum for BK

Lung abscess
can be associated with hemoptysis, particularly that caused by Klebsiella pneumoniae and staphylococcus

Medium and mild hemoptysis possible etiologies

Cardiovascular disorders Mitral insufficiency or stenosis
occurs after undertaking efforts or over the last three months of pregnancy in an patient not previously diagnosed with valvulopathy

Pulmonary embolism
hemoptysis can be the only sign of disease the other suggestive signs that could favour pulmonary embolism (deep vein thrombosis) or associated illnesses (chronic obstructive lung disease, malignity) should also be looked for

Medium and mild hemoptysis - possible etiologies Hemoptysis can also occur in the case of:
Pulmonary oedema Heart failure Acute myocardial infarction Congenital cardiopathy Cor pulmonale Ruptured aortic aneurysm

Medium and mild hemoptysis - possible etiologies

Parasitizes and pulmonary mycoses

Hydatid cyst (Echinococcosis) fissure or rupture, can be accompanied by hemoptysis. Chest X-ray and prick-skin testing may settle the diagnosis Aspergillosis either aspergilloma grafting in general on an old TB-related cavity or allergic bronchial aspergillosis, with fugacious pulmonary infiltrates, chronic bronchorrhea and asthma Amibiasis or other mycoses as histoplasmosis

Medium and mild hemoptysis Goodpasture syndrome

Goodpasture syndrome
can seldom be held responsible for hemoptysis can have symptoms such as diffuse alveolar hemorrhages and rapidly progressive glomerulonephritis the disease occurs due to some basement antimembrane cytotoxic antibodies and linear deposits along the alveolar and glomerular basement membrane Clinical the triad: pulmonary hemorrhage (hemoptyses, pulmonary infiltrate) Glomerulonephritis Anti-glomerular basement membrane antibodies

Medium and mild hemoptysis Goodpasture syndrome

Patients manifest the following symptoms: Cough, mild and reccurent, rarely important hemoptysis with related anaemia Kidney proteinuria or micro hematuria. Within a few days/weeks, it occurs the rapidly progressive glomerulonephritis (RPGN) with rapidly progressive kidney failure General symptoms: fever, joint pain, weight loss Chest X-ray:
pulmonary infiltrate of variable bilateral diffuse size, mostly symmetrical, that are not seen at the lung apices costodiaphragmatic recesses. The lesions disappear within two to three days, but might last for two weeks

Medium and mild hemoptysis Goodpasture syndrome

DLCO if performed repeatedly, it shows a steady increase (due to diffuse alveolar hemorrhage) Lung perfusion scan pulmonary iron sequestration In the kidney nephritic syndrome renal biopsy proliferating GN forming crescents and IgG linear deposits along the glomerular basement membrane The evolution of the disease depends upon how severe lung hemorrhages are, how strong the hypoxemia is and, subsequently, how badly the kidney is affected

Medium and mild hemoptysis Goodpasture syndrome

Treatment:
Plasmapheresis to remove circulating anti-GMB Ab Immunosuppression to suppress the antibodies production Originally: pulse-therapy with Methylprednisolone 1g/day for 3 days, then p.o. Prednisone 1 mg/kgc/day and Cyclophosphamide 2 mg/kgc/day Favourable effects from treatment occur after 8 weeks In case of aggravating kidney failure, physicians recommend renal dialyse, nephrectomy and kidney transplantation

Medium and mild hemoptysis systemic necrotising vasculitis

Hemoptysis occurs as a complication in:
Wegeners granulomatosis periarthritis nodosa more rarely in Behet syndrome and mixed cryoglobulinaemia

They occur due to a pulmonary capillaritis Treatment: pulse therapy with Methylprednisolone 1g/day for 3 days, followed by prolonged oral therapy with Cyclophosphamide and Corticosteroids

Medium and mild hemoptysis Collagen vascular diseases

Especially systemic lupus erythematosus (SLE) may get complicated by an alveolar hemorrhage in 10-30% of total cases. It is usually active SLE with fever, polyserositis and arthritis Hemoptysis may also occur in rheumatoid polyarthritis, polymyositis and dermatomyositis Treatment: pulse-therapy with Methylprednisolone for more severe forms or high-dose oral corticotherapy for milder forms. If they do not respond to treatment, plasmapheresis or immunosuppressant medication (more frequent in SLE) is indicated.

Medium and mild hemoptysis Idiopathic pulmonary hemosiderosis

a disorder due to an unspecified cause featuring repeated hemoptysis, iron deficiency anaemia and transitory infiltrative changes reccurent lung bleeding causes alveolar macrophages to be filled with hemosiderin, leading to diffuse pulmonary fibrosis more frequent in children starts in the infancy and includes among its symptoms cough, repeated hemoptysis, dyspnea

Medium and mild hemoptysis Idiopathic pulmonary hemosiderosis

Chest X-ray:
bilateral infiltrates, poorly shaped, located particularly in the lower lobes of lungs these changes fade out 2-3 weeks after hemoptysis cease or translate into pulmonary fibrosis with micronodules, mainly in lower lobes, and +/- hilar adenopathy

Diagnosis based on clinical examination, X-ray and through the macrophages filled with hemosiderin in sputum/bronchoalveolar lavage fluid Treatment is non-specific and symptomatic

Medium and mild hemoptysis Bone marrow transplantation

For malign hemopathies or solid tumors may induce hemoptysis in 20% of patients. It is a very severe complication with 50-80% mortality The complication occurs two weeks after the transplantation, with patients showing hemoptysis (rarely), fever, dyspnea, dry, non-productive cough, hypoxemia and focal/diffuse alveolar infiltrate Recommendation: high-dose corticotherapy

Medium and mild hemoptysis possible etiologies

Vascular congenital anomalies

Rendu-Osler-Weber syndrome which may feature diffuse manifestations, accompanied by hemoptysis

Rare bronchial causes

Bronchial angioma diagnosis is set by bronchoscopy and arteriography. Usually, it is an exclusion diagnosis. Bronchial carcinoid tumor is rare, affecting generally young subjects. Chest X-ray may reveal atelectasis and bronchoscopy confirms the diagnosis Foreign objects in this case bronchoscopy plays a therapeutic role can be taken out

Even if there are many etiological ways to explain hemoptysis, roughly 10% of the cases remain without an obvious cause. This is why patients must be placed under careful surveillance.

Seemingly insulated hemoptysis

Chest X-ray

Abnormal

Normal

Cancer CT Tuberculosis Angiography Artery/vein aneurysm Hydatid cyst Pulmonary sequester: CT, angiography, surgery Goodpasture syndrome: renal biopsy

bronchoscopy

Abnormal

Normal

Evocative context Cardiovascular etiologic treatment Pneumopathy o Antibiotics o Bronchoscopy COPD CT Allergic bronchopulmonary aspergillosis o Serodiagnosis o IgE o CT o Corticoids

CT Secondary bronchoscopy Bronchography Angiography

surveillance

surveillance