hemoptysis

H e m o p t y s i s Prepared by Dr. Tahany Mahmoud Banha Chest Department Banha University

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Hemoptysis Hemoptysis is coughing up blood from the respiratory tract. The blood can come from the nose, mouth, throat, the airway passages leading to the lungs. The word "hemoptysis" comes from the Greek "haima," meaning "blood," and "ptysis," which means "a spitting"

Pseudohemoptesis

Causes:

Blood not from lower respiratory tract it come from above the vocal cords:

Mouth

Pharynx

Nose

Aspiration of hematemsis

Colonization by grame negative bacteria (seratia blue)

Massive Hemoptesis: It is the amount of blood that can not be cleared from the dead space (150ml). It is about 600ml blood/24 h X-sanguating Hemoptesis: Rate of bleeding >150ml/h

Pathophysiologic Factors: 1-Dual Circulation: The lungs have a dual blood supply. The pulmonary arterial circulation, a high-compliance, low-pressure system that terminates in the pulmonary capillary bed, is responsible for gas exchange.

In addition, the lungs are supplied by the bronchial arteries, branches of the aorta that bring nutrients to the lung parenchyma and major airways. The bronchial arteries, like all systemic arteries, are a high-pressure system. Most cases of hemoptysis result from disruption of branches of the bronchial arterial tree.

2- Vascular Mechanisms :

Aneurysm formation

Vasculitis

Pulmonary Embolism

Inflammation

Broncholithiasis

Direct invasion central pulmonary artery trauma

Causes Blood-tinged mucus in a healthy nonsmoker usually indicates a mild infection and is generally no cause for concern. Indeed, the most common cause of Hemoptysis is the least serious a ruptured small blood vessel caused by coughing and/or a bronchitic infection In patients with a history of smoking or who are otherwise at risk for lung disease, however, Hemoptysis is often a sign of serious illness, including cancer

Infectious: Chronic bronchitis Bronchiectasis Tuberculosis Nontuberculous mycobacteria Lung abscess Necrotizing pneumonia Mycetoma Cystic fibrosis

Common Causes of Hemoptysis

Neoplastic Lung cancer Bronchial adenoma Metastatic disease (osteogenic sarcoma, choriocarcinoma)

Vasculitic Wegener's granulomatosis Systemic lupus erythematosus

Churge Strauss syndrome

Cardiovascular Severe left ventricular heart failure Mitral stenosis Pulmonary embolism or infarction Septic pulmonary embolism or right-sided endocarditis Aortic aneurysm or bronchovascular fistula

Miscellaneous Idiopathic Pulmonary Hemosiderosis Aspirated foreign body Pulmonary contusion or trauma Posttransthoracic needle biopsy or transbronchial lung biopsy Factitious hemoptysis

Bleeding Diathesis

Anticoagulant therapy

Deficiency of vitamin Kdependent factors: prothrombin (II), Stuart factor (X), factor VII, Christmas factor (IX)

Disseminated intravascular coaulation

Fibrinolytic therapy: urokinase , streptokinase.

Evaluation of Hemoptysis

1-Types of Hemoptesis:

Blood tinged sputum

Blood streaked

Red current jully

Frank Hemoptesis

Rusty sputum

2-Degree of Hemoptysis:

Massive

Non massive

Causes of Blood streaked Sputum :

Upper respiratory inflammation

Nose or Nasopharynx

Gums

Larynx

Severe coughing paroxysms

Trauma

Causes of Pink Sputum :

Blood and secretions mix in alveoli, small bronchioles

Conditions associated with pink Sputum

Pneumonia

Pulmonary edema

Causes of Heavy Bleeding into Respiratory tree :

Pulmonary Tuberculosis

Lung Abscess

Bronchiectasis

Pulmonary infarction

Pulmonary Embolism

Bronchogenic Carcinoma

Broncholithiasis

Mitral Stenosis

Actinomycosis Lung Abscess

Blastomycosis Lung Abscess

Diagnosis

History:

To differentiate between source of Hemoptysis:

Respiratory

Gastrointestinal

Anticoagulant therapy

Mitral valve disease

Physical Examination

The doctor will examine the patient's nose, throat, mouth, and chest for bleeding from these areas and for signs of chest trauma. The doctor also listens to the patient's breathing and heart beat for indications of heart abnormalities or lung disease .

Laboratory Tests

Laboratory tests include blood tests to rule out clotting disorders, and to look for food particles or other evidence of blood from the stomach. Sputum can be tested for fungi, bacteria, or parasites .

X - Ray and Bronchoscopy

Chest x rays and bronchoscopy are the most important studies for evaluating hemoptysis. They are used to evaluate the cause, location, and extent of the bleeding.

Value of Bronchoscope

1-Dignostic:

Localize site of bleeding

F.B aspiration

Adenoma

2-Therapeutic:

Arrest bleeding

Suction and lavage

Preservation ventilation of non bleeding lung

Type of Bronchoscope

The rigid bronchoscope is more preferable than fiber optic one due to it has wide channel for suction of blood and for therapeutic treatment to arrest bleeding.

Imaging and other tests

Computed Tomography scans (CT scans) are used to detect aneurysms and to confirm x-ray results.

Ventilation-perfusion scanning is used to rule out pulmonary embolism. The doctor may also order an angiogram to rule out pulmonary embolism, or to locate a source of bleeding that could not be seen with the bronchoscope .

In spite of the number of diagnostic tests, the cause of Hemoptysis cannot be determined in 20-30% of cases .

Complication of Hemoptysis

Asphyxia

Shock

Anemia

Renal failure

Atelectasis

Pulmonary infection

Management

Three Goals of Therapy :

Prevent asphyxiation

Stop bleeding

Treat primary disease

Airway Control

Supplemental oxygen

Positioning

Cough control

Endotracheal intubation a. selective intubation

Volume Resuscitation

Laboratory Evaluation

Hematocrit

Platelet count

Coagulation profile

Arterial blood gas, if appropriate

Renal function testing

Type and cross match blood

Smear, culture and cytology of sputum

DLCO for pulmonary hemorrhage

Consultations

Surgical

Definitive: resection

Medical

Antibiotics if indicated

Medical management if nonlocalized bleeding, severely impaired pulmonary function, disseminated terminal carcinoma, advanced bilateral pulmonary disease, vasculitis

Modalities

Bronchial artery Embolization

Balloon Tamponade

Intracavitary Anti-fungal therapy

Mortality

Medically managed patients with massive Hemoptysis: 75%

Surgically managed patients with massive Hemoptysis: 23%

Role of Surgery in Hemoptysis

Surgery is indicated in the following situations:

Leaky thoracic aneurysm

Chest trauma

A-V fistula

Localized bronchiectasis

Chronic lung abscess