Hemoptysis

definition larynx

Hemoptysis
Bleeding below the level of
the larynx that being
coughed out
HEMOPTYSIS
Coughing up blood is a frightening event to both:
Health-care Providers Patients & families
 Can occur as:
 Blood streaked sputum
 Pink sputum
 Frank blood ( W or W/O clots)
 massive gross blood, even leading to airway

occlusion (apnea ) & shock.

The latter is much less seen.

 Blood Circulation in the lungs :
2 Components

Low pressure High pressure

Pulmonary Circulation
SBP = 15-20 mmHg
DBP = 5-10 mmHg
Patients with normal PAP ( no
PAH) rarely bleed: only 5% of
massive hemoptysis
Bronchial Circulation
= systemic pressures
Bronchial arteries & collaterals
originate from the aorta
The source of bleeding in most
cases

Bleeding mechanisms

Inflammation  Erosion of the vessel wall

Increased pressure in the vessel  Increase vessel size  Rupture 
Aneurysm formation
Severity
Determined by
Amount & Rapidity of bleeding
Cardio-respiratory reserve : Effect on gas exchange

MASSIVE HEMOPTYSIS
Medical Emergency:
Occur in 1-5% of patients
Asphyxiation rather than exsanguination
Flooding of tracheobronchial tree
Respiratory arrest
Amount reported to range from
[ > 100 – 250 – 500 – 600 – 1000 ] cc / 24 hrs
Etiology
Make sure it is Hemoptysis

DDx:
 Hematemesis
 Epistaxis
 Other nasopharyngeal bleeding
Differentiating from hematemesis

hemoptysis hematemesis
Coughed up & frothy Vomited without frothy
Preceded by stimulating Preceded nausea,
cough vomiting
Bright red Dark red or brown
alkaline acid
History of coughing Gastric, liver disease
Blood-tinged sputum Tar stool
Mixed with sputum Mixed with food
Anemia variable Blood loss common
Etiology
 Infectious
 Malignancy
 Trauma
 Cardiac/pulmonary vascular
 Factitious
 Cryptogenic
 Etiology: Classification by site
Pulmonary Parenchymal
Tracheobronchial source Source
Bronchitis Lung abscess
Bronchiactasis Pneumonia
Neoplasm TB
Broncholithiasis Mycetoma (Fungus Ball)
Airway trauma GPS
Foreign body Idiopathic pulmonary hemosederosis
Pulmonary Vascular source WG
Lupus pneumonitis
Pulmonary embolism Lung contusion
Arteriovenous malformations
Pulmonary arterial hypertension Miscellaneous/rare causes
Pulmonary venous hypertension Pulmonary endometriosis
(Mitral stenosis)
Systemic coagulopathy
Pulmonary artery rupture
Use of anticoagulants or
thrombolytics
 Incidence & Frequency
 Varies in different study populations
 May reflect incidence of certain disease in that
certain population
Most common etiologies:
Bronchitis (acute/chronic)
Pneumonia
TB
Bronchiactasis
CA
Etiology
Etiology
Approach to Patient with hemoptysis
History & Physical Examination:

Assess Severity & Urgency

 Duration of bleeding
 Extent of bleeding
 Reliability

Assess the Cardio-Respiratory reserve

Prior Episodes of bleeding
Clues to the cause
 Clues from the Hx
Blood streaking of mucopurulent or Bronchitis
purulent sputum

Chronic sputum production + Acute

Recent change in quantity or Exacerbation of
appearance COPD
Fever & chills + Blood streaking of Pneumonia
purulent sputum

Putrid smell of purulent sputum Lung abscess

Sudden chest pain &/ SOB PE
 Clues from the Hx
Risk Factors for Smoking
Bronchogenic CA Asbestosis

Risk Factors for Alcohol

Lung Abscess Coma
Poor dental hygiene
Risk Factors for Drug Abuse
HIV Infection Sexual Practices
Hx of blood transfusion
Clues from the Hx
History of previous or co-existing disease
Renal disease GPS
WG
SLE Lupus Pneumonitis
Malignancy Primary
Metastatic
AIDS Endobronchial
Kaposi’s Sarcoma
Previous bleeding Bleeding diathesis
Anticoagulant use
Thrombocytopenia
 Diagnostics
After comprehensive Hx & P/E
Goals: LABS
 Identify the cause
 Localize the site of bleeding CBC
 Assess the general condition PT, PTT & INR
of the patient
Sputum Studies
Cultures
Basics
KFT
Labs
UA
Radiologic studies
ABG’s
Endoscopic studies
CVD studies
Bronchial disease ：
bronchiectasis
Bronchogenic carcinoma(lung cancer)
Lung
disease ：
lung
TB
pneumonia
Cardiovascular
disease ：

mitral stenosis
Haemotology
disease ：
Thrombocytopen
ic purpura

leukemia

hemophilia
Management
Varies with
 the severity of bleeding
 The cause of bleeding
 General condition /Cardio-resp. Reserve
Management of Non-Massive Hemoptysis

Monitor until stable

Find the cause

Treat the cause:

Antibiotics
Immunosupression
Chemotherapy
Radiotherapy
FB removal
……etc
Management of Massive Hemoptysis
Priorities
Airway protection
MEDICAL EMERGENCY
ETT / MVS

ICU ALWAYS Patient Stabilization

Find the site /cause of
bleeding
Urgent need for
treatment by: Attempt to stop bleeding
Rapidity of bleeding Prevent recurrence of
Respiratory function bleeding

Specific therapy
Management of Massive Hemoptysis
Keep NPO
Positioning of the patient
Cough suppressant
Large IV access + Fluid resuscitation
Identification the location of bleeding

ICU MONITORING
 Next : DYSPNEA