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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.
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
What is the first test you order?
Evaluation and Diagnosis of Hemoptysis
What is the first test you order?
CXR
Evaluation and Diagnosis of Hemoptysis
What is the first test you order?
CXR What is the next step if CXR is normal?
Evaluation and Diagnosis of Hemoptysis
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
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
• 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 smoker 56%
• There is a long debate whether CT should be done first before bronchoscopy or reverse. • Most experts advocate CT as complementary to flex bronchoscopy.
• Flex bronchoscopy has lower yield in mild to moderate hemoptysis.
• Optimal timing of flex bronchoscopy (early vs late) is controversial.
• No difference in outcome and therapeutic decisions in non-massive hemoptysis. • Flex bronchoscopy may not be a right choice in massive hemoptysis.
Gong Jr H, et al. Am Rev Respir Dis. 1981. Dweik R, et al. Clin Chest Med. 1999.
Management of Hemoptysis
Management of Hemoptysis
• Non-massive hemoptysis
• Massive hemoptysis
Management of Hemoptysis
• Non-massive hemoptysis
• Massive hemoptysis
• Goals - Cessation of bleeding - Prevention of aspiration - Treatment of underlying cause
Management of Hemoptysis
• Non-massive hemoptysis - usually self limiting - out-patient f/u with close monitoring for low risk patients normal CXR - Out-pt CT of chest for high risk patient with normal CXR
Next Question
2. A 35-year-old man with history of chronic cough comes to your office and is very concerned after having 2 episodes of prolonged coughing that produced blood-streaked sputum. He also reports subjective fever for 4 days and cough productive of yellow sputum. This is the first time he has experienced this constellation of symptoms. The patient denies dyspnea. He reports no history of smoking, weight loss, travel abroad, or exposure to sick contacts or tuberculosis. He has no other medical problems and takes no medications. What Is the Most Likely Diagnosis? 1. Lung cancer 2. Acute bronchitis 3. Tuberculosis 4. Pulmonary embolism
Bidwell JL, et al. Diagnosis and management. Am FamPhysician. 2005.
Management of Hemoptysis • Massive hemoptysis - Airway protection and hemodynamic instability - If bleeding side known, position patient in lateral decubitus with bleeding site down - correct coagulopathy - Pulmonary consult - Flex & Rigid bronchoscopy - cold saline - epinephrine instillation - Laser, APC - Topical procoagulants (fibrin-thrombin combination) - Bronchial blocker device
Management of Hemoptysis • Massive hemoptysis - Airway protection and hemodynamic instability - If bleeding side known, position patient in lateral decubitus with bleeding site down - correct coagulopathy - Pulmonary consult - Flex & Rigid bronchoscopy - cold saline - epinephrine instillation - Laser, APC - Topical procoagulants (fibrin-thrombin combination) - Bronchial blocker device - Endobronchial sealing (glue) - CT surgery consult - IR consult
Thank You
