Hemoptysis - Department of Medicine Conference1...  • Symptoms other than hemoptysis (fever, night

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Hemoptysis

Bahman Saatian, M.D. VA Long Beach Healthcare System

Assistant Professor, UC Irvine School of Medicine September 21, 2016

Objectives

Definition Pulmonary vasculature anatomy Source of hemoptysis Differential diagnosis Evaluation Management

Hemoptysis Defines as expectoration of blood from lung parenchyma or

airways.

Originates from the respiratory tract below the level of larynx. It is important to establish that the lung is the source of

bleeding, exclude nasopharynx and GI tract.

Incidence 1/1000 patient per year.

Massive hemoptysis 5-15% of all hemoptysis. Jones R, et al. BMJ. 2009 Sakr L, et al. Respiration. 2008

Hemoptysis Incidence of hemoptysis in lung cancer patient 20%. Incidence of massive hemoptysis in lung cancer patients 3%.

Incidence of massive hemoptysis in CF patient 4.1%.

Associated mortality is related to the rate of bleeding.

Mortality rate of massive bleeding 9-38% Kvale PA, et al. Palliative care in lung cancer. CHEST 2007 Flume PA, et al. CHEST 2005 Crocco JA, et al. Arch Intern Med 1968

Types of Hemoptysis Frank hemoptysis: expectoration of blood only, massive and

fatal blood loss may occur.

Blood tinged sputum: large quantities of foul smelling sputum and blood suggests suppurative lung disease.

Pseudohemoptysis: - due to Serratia marcescens pigment (prodigiosin) - Upper GI tract - Upper respiratory tract

Massive or Nonmassive Hemoptysis No generally accepted definition of the volume of blood that

constitutes a massive hemoptysis. Studies quoted volumes ranging from 100mL to 1000mL per

day (200mL/h in pt with normal lung function, 50mL/h in pt with chronic respiratory failure, x2 episodes of 30mL/24h).

Anatomic dead space of major airways is 100-200mL. More relevant definition is the volume that is life threatening. Life-threatening (abnormal gas exchange, airway obstruction, hemodynamic instability).

Pulmonary Vasculature Anatomy

Pulmonary Vasculature Anatomy Pulmonary artery circulation Bronchial artery circulation

Pulmonary Vasculature Anatomy Pulmonary artery circulation - Low pressure system - Low resistance to flow, very distensible - Follows bronchial tree - Hypoxia leads to vasoconstriction ( flow), shunts blood away from poorly ventilated areas. Bronchial artery circulation - Hypoxia leads to vasodilation ( blood flow) - Usual source of major/massive hemoptysis - Supply blood down to terminal bronchioles, intrapulmonary blood vessel wall and the lymphatics - R bronchial artery: originates from 3th and 4th intercostal artery - L bronchial artery: originates from directly from aorta. - Drains to azygous (R) and hemizygous (L) veins.

Source of Hemoptysis

Exclude other sources of bleeding (nasopharynx, GI tract).

Origin of massive hemoptysis:

- Bronchial artery (90%) - Aorta (aortobronchial fistula, ruptured aortic aneurysm), Nonbronchial systemic circulation (intercostal arteries, thoracic arteries originating from axillary or subclavian arteries) (5%) - Pulmonary artery (5%)

Source of Hemoptysis

- Pulmonary artery (5%) Necrotizing pulmonary infections (active TB) Lung abscess Mycetoma Necrotic cavitary lung carcinoma Hodgkin lymphoma Vasculitis Trauma to PA Pulmonary AVM Peripheral PA aneurysm Bronchovascular fistula post lung transplant (ischemia/ infection) Iatrogenic (TBBX, endobronchial brachytherapy, radiofrequency abalation)

History and Physical Examination

History and Physical Examination Onset Duration Quantity Frequency Symptoms other than hemoptysis (fever, night sweat, cough,

sputum, weight loss ) Smoking history Underlying respiratory diseases (CF, bronchiectasis, COPD,

TB) Co-morbidities (CHF) Medications (anticoagulation) Recent surgery/immobilization History of malignancy Recent trauma

Earwood JS, et al. Am Fam Physician. 2015

History and Physical Examination Cardiopulmonary status - HR, RR, BP, SpO2 Needs for resuscitation and ICU admission

Nose / oral exam Adenopathy Lung / heart sounds Cyanosis / clubbing

Bidwell JL, et al. Diagnosis and management. Am FamPhysician. 2005.

Prediction of in-Hospital Mortality

Prediction of in-Hospital Mortality

Prediction of in-Hospital Mortality

Single center retrospective study ICU and step down unit Tertiary teaching hospital 1995-2009 (14 years) Primary outcome: - v/s at hospital discharge Derivation sample (67%, 717) Validation sample (33%, 370)

Prediction of in-Hospital Mortality

Prediction of in-Hospital Mortality Low risk (score 0-1) - Step down unit Intermediate risk (score 2) - Admit to ICU - Consider IR intervention High risk (score 5) - Urgent IR intervention

Differential Diagnosis

Differential Diagnosis

Differential Diagnosis

Bidwell JL, et al. Diagnosis and management. Am FamPhysician. 2005.

PresenterPresentation NotesBroncholiths are calcified peribronchial lymph nodes that encroach upon adjacent airways and cause clinical and roentgenographic abnormalities.

Differential Diagnosis

Questions

1. A 60-year-old male presents to the ED with hemoptysis. He states he first noticed blood-tinged sputum several weeks ago, but over the past week, has noticed significantly more blood. He has a 25 pack-year history of tobacco use, but has not smoked for 15 years. He denies fever, chills, or chest pain. He is otherwise healthy and has no other complaints. Vital signs are T 37C, HR 80, BP 125/85, RR 14, O2 99%. On exam, lung fields are clear to auscultation. Which of the following is the most appropriate next step in management? 1. CT scan of chest 2. Chest X-ray 3. Pulmonary consult 4. Bronchoscopy 5. Upper GI endoscopy

Evaluation and Diagnosis of Hemoptysis

PresenterPresentation NotesBroncholiths are calcified peribronchial lymph nodes that encroach upon adjacent airways and cause clinical and roentgenographic abnormalities.

What is the first test you order?

Evaluation and Diagnosis of Hemoptysis

PresenterPresentation NotesBroncholiths are calcified peribronchial lymph nodes that encroach upon adjacent airways and cause clinical and roentgenographic abnormalities.

What is the first test you order?

CXR

Evaluation and Diagnosis of Hemoptysis

PresenterPresentation NotesBroncholiths are calcified peribronchial lymph nodes that encroach upon adjacent airways and cause clinical and roentgenographic abnormalities.

What is the first test you order?

CXR What is the next step if CXR is normal?

Evaluation and Diagnosis of Hemoptysis

PresenterPresentation NotesBroncholiths are calcified peribronchial lymph nodes that encroach upon adjacent airways and cause clinical and roentgenographic abnormalities.

What is the first test you order?

CXR What is the next step if CXR is normal?

CT scan of chest

Evaluation and Diagnosis of Hemoptysis

PresenterPresentation NotesBroncholiths are calcified peribronchial lymph nodes that encroach upon adjacent airways and cause clinical and roentgenographic abnormalities.

What is the first test you order?

CXR What is the next step if CXR is normal?

CT scan of chest What if CT of chest is normal?

Evaluation and Diagnosis of Hemoptysis

PresenterPresentation NotesBroncholiths are calcified peribronchial lymph nodes that encroach upon adjacent airways and cause clinical and roentgenographic abnormalities.

Retrospective study 275 episodes of hemoptysis in 270 consecutive patients Presented with hemoptysis and normal CXR West York shire-UK, between 5/2001 12/2005 Active or former smoker 90% 257 patients had CT of chest w/ contrast

Rate of respiratory malignancy 9.6%

What is the role flexible bronchoscopy in evaluation of hemoptysis in a patient

with normal CT scan of chest?

Retrospective study between 2003 2009 University hospital in South Korea 228 patient presented with hemoptysis Never