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

• 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 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
• 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 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 is-
a)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 present-
a)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
Dx-
a)Sputum cytology
b)Bronchoscopy
c)Thoracoscopy
d)HRCT Thorax