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HEMOPTYSISHEMOPTYSIS
DefinitionDefinition
Expectoration of blood from the respiratory tractExpectoration of blood from the respiratory tract
The word The word ““HemoptysisHemoptysis”” comes from the comes from the greekgreek word word ““HaimaHaima”” , meaning , meaning ““BloodBlood”” , and , and ““PtysisPtysis”” , which , which means the spitting.means the spitting.
DefinitionDefinition
Bleeding that results in respiratory distress Bleeding that results in respiratory distress and altered gas exchange is lifeand altered gas exchange is life--threatening, threatening, regardless of amount of blood loss.regardless of amount of blood loss.
Amount of blood expectorated not necessarily Amount of blood expectorated not necessarily represents the total amount lost into the represents the total amount lost into the airspaces airspaces
DefinitionDefinition
Assessment of severity of hemoptysis can be Assessment of severity of hemoptysis can be based on amount of blood lost during episodebased on amount of blood lost during episode
MILDMILD: <5cc in 24h: <5cc in 24hMODERATEMODERATE: 5: 5--600cc in 24h600cc in 24hMASSIVEMASSIVE : :
-- >600cc in 24h>600cc in 24h--100cc <24h to 1000 cc over several 100cc <24h to 1000 cc over several
days days -- >50cc in single expectoration>50cc in single expectoration
When blood originates outside of the respiratory tract, the spitting is commonly known as
"pseudohemoptysispseudohemoptysis." ."
PseudohemoptysisPseudohemoptysis
Every patient with problem of hemoptysis should receive a careful evaluation of origin of bleeding from outside of the respiratory tract.
Blood from the throat which comes in contact with larynx can cause coughing and seemingly hemoptysis
Where is it from?Where is it from?Clinical Features Clinical Features HemoptysisHemoptysis Pseudo Hemoptysis Pseudo Hemoptysis
Origin of bloodOrigin of blood Respiratory tractRespiratory tract Oral cavity, Larynx, Oral cavity, Larynx, esophageusesophageus, stomach, , stomach, Factitious Factitious
Cough Cough More likely More likely Less likely Less likely
Respiratory symptoms Respiratory symptoms More likely More likely Less likelyLess likely
EsophagastricEsophagastric SymptomsSymptoms Less likely Less likely More likelyMore likely
Alcohol use, hepatic diseaseAlcohol use, hepatic disease Less likely Less likely More likelyMore likely
Vomiting, NauseaVomiting, Nausea Less likely Less likely More likelyMore likely
HematemesisHematemesis and and malenamalena Less likely Less likely More likelyMore likely
ColourColour of expectorated bloodof expectorated blood Bright redBright red Brown or black Brown or black
Consistency of expectorate Consistency of expectorate Clotted or liquid Clotted or liquid Coffee ground appearance Coffee ground appearance
Frothiness of expectorateFrothiness of expectorate Usually Usually Never or seldom Never or seldom
pH of expectoratepH of expectorate Alkaline Alkaline AcidicAcidic
Alveolar macrophages in sputumAlveolar macrophages in sputum Present Present Absent Absent
Food particles in expectorateFood particles in expectorate Absent Absent Present Present
Asphyxia Asphyxia Common Common Unusual Unusual
Rarely , Rarely , hemoptysishemoptysis may be self inflicted as may be self inflicted as a form of malingering .a form of malingering .
Patients may seek hospital admission late Patients may seek hospital admission late at night by claiming at night by claiming hemoptysishemoptysis ((““Midnight Midnight hemoptysishemoptysis))
SerratiaSerratia MarcescensMarcescens is an aerobic is an aerobic microorganismmicroorganism
Which characteristically produces a red pigment Which characteristically produces a red pigment insoluble in water.insoluble in water.
Broad spectrum antibiotics may so after the Broad spectrum antibiotics may so after the environment that this organism will grow in the environment that this organism will grow in the respiratory tract producing a respiratory tract producing a ““redred
--sputumsputum”” simulating simulating hemoptysishemoptysis..***Gate and Lord ***Gate and Lord –– JAMA 164:1328,1957JAMA 164:1328,1957
*Robinson and *Robinson and WoolleyWoolley –– Lancet Lancet
Where is it from?Where is it from?
Blood from the upper GIT can be aspirated and Blood from the upper GIT can be aspirated and coughed upcoughed up
Blood from the lungs can be swallowed and Blood from the lungs can be swallowed and vomitedvomited
VASCULAR ORIGIN OF HEMOPTYSISVASCULAR ORIGIN OF HEMOPTYSIS
Blood traversing the lungs can arrive from Blood traversing the lungs can arrive from
pulmonary arteries(arise from rt.ventricle)pulmonary arteries(arise from rt.ventricle)——98%98%
bronchial arteries(arise from desending aorta & bronchial arteries(arise from desending aorta & intercostalintercostal arteries)arteries)------11--2%2%
VASCULAR ORIGIN OF HEMOPTYSISVASCULAR ORIGIN OF HEMOPTYSIS
Virtually the entire cardiac output courses through Virtually the entire cardiac output courses through the lowthe low--pressure pulmonary arteries and arterioles pressure pulmonary arteries and arterioles en route to being oxygenated in the pulmonary en route to being oxygenated in the pulmonary capillary bed capillary bed
In contrast, the bronchial arteries(1In contrast, the bronchial arteries(1--2%), are under 2%), are under much higher systemic pressure but carry only a much higher systemic pressure but carry only a small portion of the cardiac outputsmall portion of the cardiac output
VASCULAR ORIGIN OF HEMOPTYSISVASCULAR ORIGIN OF HEMOPTYSIS
Despite the quantitatively smaller contribution of Despite the quantitatively smaller contribution of the bronchial circulation to pulmonary blood flow, the bronchial circulation to pulmonary blood flow, the bronchial arteries are generally a more the bronchial arteries are generally a more important source of important source of hemoptysishemoptysis..
In addition to being perfused at a higher In addition to being perfused at a higher pressure, they also supply blood to the airways pressure, they also supply blood to the airways and to lesions within the airwaysand to lesions within the airways
SignificanceSignificance
Hemoptysis is an important sign of an underlying Hemoptysis is an important sign of an underlying diseasedisease
Massive hemoptysis is life threatening due to Massive hemoptysis is life threatening due to AsphyxiaAsphyxia
Mortality rate can be as high as 30%Mortality rate can be as high as 30%
Airways diseasesAirways diseases
The most common source of hemoptysis is airways The most common source of hemoptysis is airways disease disease
Inflammatory diseasesInflammatory diseases-- bronchitis , bronchitis , bronchiectasisbronchiectasisNeoplasmsNeoplasms-- 11°° bronchogenic carcinoma, bronchogenic carcinoma, endobronchial metastatic carcinoma or bronchial endobronchial metastatic carcinoma or bronchial carcinoid carcinoid AIDSAIDS-- Kaposi's sarcoma involving the airways or Kaposi's sarcoma involving the airways or the pulmonary parenchymathe pulmonary parenchymaForeign body & Airway traumaForeign body & Airway traumaFistula between a vessel and the tracheobronchialFistula between a vessel and the tracheobronchial
Pulmonary parenchymal diseasesPulmonary parenchymal diseases
InfectionInfection--tuberculosis, pneumonia, aspergilloma, lung tuberculosis, pneumonia, aspergilloma, lung abscessabscess
Hemoptysis, which can be lifeHemoptysis, which can be life--threatening, threatening, complicates the course of 50 to 85 percent of complicates the course of 50 to 85 percent of patients with an aspergillomapatients with an aspergillomaActive disease can cause sudden rupture of a Active disease can cause sudden rupture of a Rasmussen's aneurysm (aneurysm of the pulmonary Rasmussen's aneurysm (aneurysm of the pulmonary artery that slowly expands into an adjacent cavity artery that slowly expands into an adjacent cavity because of inflammatory erosion of the external because of inflammatory erosion of the external vessel wall until it bursts)vessel wall until it bursts)
TuberculosisTuberculosis can cause massive hemoptysis through can cause massive hemoptysis through multiple mechanisms multiple mechanisms --active cavitary or noncavitary active cavitary or noncavitary lung disease can cause small or large amounts of lung disease can cause small or large amounts of
Pulmonary parenchymal diseasesPulmonary parenchymal diseases
Inflammatory or immune disordersInflammatory or immune disordersGoodpasture's syndrome, idiopathic pulmonary Goodpasture's syndrome, idiopathic pulmonary hemosiderosis, and Wegener's hemosiderosis, and Wegener's granulomatosisgranulomatosis
CoagulopathyCoagulopathythrombocytopenia or use of anticoagulantsthrombocytopenia or use of anticoagulants
Iatrogenic Iatrogenic -- percutaneous or transbronchial lung biopsy percutaneous or transbronchial lung biopsy Hemoptysis, which is usually minor and transient, occurs Hemoptysis, which is usually minor and transient, occurs in five to 10 percent of percutaneous lung biopsies, but in five to 10 percent of percutaneous lung biopsies, but massive hemorrhage and death have also been reportedmassive hemorrhage and death have also been reported
Miscellaneous causes of Miscellaneous causes of pulmonary parenchymal hemorrhagepulmonary parenchymal hemorrhage
CocaineCocaine--induced pulmonary hemorrhage induced pulmonary hemorrhage Hemoptysis has been described in six percent of Hemoptysis has been described in six percent of habitual smokers of freehabitual smokers of free--base cocaine ("crack") and base cocaine ("crack") and has been associated with diffuse alveolar has been associated with diffuse alveolar hemorrhagehemorrhage
Catamenial hemoptysisCatamenial hemoptysishemoptysis that is recurrent and coincident with hemoptysis that is recurrent and coincident with menses. The cause is intrathoracic endometriosis, menses. The cause is intrathoracic endometriosis, usually involving the pulmonary parenchyma but usually involving the pulmonary parenchyma but occasionally affecting the airwaysoccasionally affecting the airways
Pulmonary vascular disordersPulmonary vascular disorders
Pulmonary embolismPulmonary embolismPulmonary AV malformation Pulmonary AV malformation --either with or without either with or without underlying Oslerunderlying Osler--WeberWeber--Rendu syndromeRendu syndromeElevated pulmonary capillary pressureElevated pulmonary capillary pressure
mitral stenosis mitral stenosis significant left ventricular failuresignificant left ventricular failureCongenital heart disease Congenital heart disease severe pulmonary hypertensionsevere pulmonary hypertension
IatrogenicIatrogenicpulmonary artery perforation from a Swanpulmonary artery perforation from a Swan--Ganz catheterGanz catheter
CryptogenicCryptogenic
Depending upon the study, up to 30 percent of patients Depending upon the study, up to 30 percent of patients with hemoptysis have no cause identified even after with hemoptysis have no cause identified even after careful evaluationcareful evaluation
In a series of 67 patients with cryptogenic hemoptysis, In a series of 67 patients with cryptogenic hemoptysis, the prognosis was generally good, and most patients had the prognosis was generally good, and most patients had resolution of bleeding within six months of evaluationresolution of bleeding within six months of evaluation
Adelman, M, et al. Cryptogenic hemoptysis. Clinical features, bronchoscopic findings, and natural history in 67 patients. Ann Intern Med 1985; 102:829
Causes of Massive Hemoptysis (<5%)Causes of Massive Hemoptysis (<5%)
TuberculosisTuberculosisBronchiectasisBronchiectasisFungal InfectionsFungal InfectionsOther Lung InfectionOther Lung InfectionBronchogenic CarcinomaBronchogenic CarcinomaChemotherapy and Bone Marrow TransplantationChemotherapy and Bone Marrow TransplantationImmunologic Lung DiseaseImmunologic Lung DiseaseCardiac or Vascular DiseaseCardiac or Vascular Disease
Postgrad Med. 2002 Oct;112(4):101-6, 108-9, 113
Bronchitis and bronchiectasisBronchitis and bronchiectasis
Bronchitis Bronchitis -- mild hemoptysis mild hemoptysis Inflammation of the airways leads to Inflammation of the airways leads to
mucosal hyperemia, and disruption of mucosal hyperemia, and disruption of small mucosal vessels bloodsmall mucosal vessels blood--streaked streaked sputum. sputum.
Dry Dry BronchiectasisBronchiectasis attributed to chronic attributed to chronic granulation or ulcer of bronchi.granulation or ulcer of bronchi.
Moist Moist bronchiectasisbronchiectasis are associated chronicare associated chronicinflammation of the lung, with local bronchialinflammation of the lung, with local bronchialarterial proliferation and increased blood flow.arterial proliferation and increased blood flow.
Inflammation leading to erosion of these Inflammation leading to erosion of these bronchial vessels can result in severe bronchial vessels can result in severe hemorrhage. hemorrhage.
BRONCHIECTASISBRONCHIECTASIS
Lung cancerLung cancer
Hemoptysis is usually mild, resulting in bloodHemoptysis is usually mild, resulting in blood--streaked sputum. streaked sputum.
Cause Cause -- erosion of small, friable mucosal vessels erosion of small, friable mucosal vessels in airways involved by tumor. in airways involved by tumor.
Massive hemoptysis in patients with lung cancer Massive hemoptysis in patients with lung cancer is typically caused by malignant invasion of is typically caused by malignant invasion of central pulmonary vessels by large central central pulmonary vessels by large central tumors. tumors.
Causes of Causes of hemoptysishemoptysis in pulmonary in pulmonary tuberculosis tuberculosis
Bleeding from cavity wall Bleeding from cavity wall Rupture of Rupture of rasmussenrasmussen’’ss aneurysm.aneurysm.Direct erosion of capillaries/arteries by Direct erosion of capillaries/arteries by granulomatousgranulomatous inflammation.inflammation.Tuberculosis Tuberculosis endobronchitisendobronchitis..Post Post ––tuberculosis tuberculosis bronchiectasisbronchiectasis aspergillomaaspergilloma..Broncholith,cavernolithBroncholith,cavernolithScar carcinoma.Scar carcinoma.
TuberculosisTuberculosis
Endobronchial tuberculosis may cause local Endobronchial tuberculosis may cause local airway bleeding. airway bleeding.
Calcified tuberculous lymph nodes can compress Calcified tuberculous lymph nodes can compress and erode lobar and main stem bronchi, causing and erode lobar and main stem bronchi, causing local bleeding and expectoration of gritty calcified local bleeding and expectoration of gritty calcified debris called broncholiths in the sputum.debris called broncholiths in the sputum.
TuberculosisTuberculosis
Large cavitary lesions in patients with Large cavitary lesions in patients with advanced tuberculosis often do not fully advanced tuberculosis often do not fully close despite successful antituberculosis close despite successful antituberculosis treatment; these lesions sometimes are treatment; these lesions sometimes are colonized by colonized by AspergillusAspergillus..
Bronchial arterial bleeding from Bronchial arterial bleeding from inflammation in the walls of cavities inflammation in the walls of cavities containing aspergilloma can be massive. containing aspergilloma can be massive.
Other causesOther causes
Chronically elevated pulmonary venous Chronically elevated pulmonary venous pressure. pressure.
Inflammation in areas of necrotizing Inflammation in areas of necrotizing pneumonia, such as invasive pneumonia, such as invasive aspergillosisaspergillosis
ImmunologicallyImmunologically mediated alveolar mediated alveolar hemorrhage syndromeshemorrhage syndromes-- Goodpasture's Goodpasture's syndrome, Wegener's granulomatosis, SLE, syndrome, Wegener's granulomatosis, SLE, and pulmonary hemosiderosisand pulmonary hemosiderosis
DISEASEDISEASE BLEEDINGBLEEDING TYPETYPE ANATOMICAL ANATOMICAL SOURCESOURCE
RecurrentRecurrent EpisodicEpisodic StreakingStreaking ProfuseProfuse BroncBroncArteryArtery
PulmPulmArteryArtery
PulmPulm. . VeinVein
TuberculosisTuberculosis XX XX XX XX XX XX XX
BronchiectasisBronchiectasis SiccaSicca XX XX XX
BronchiectasisBronchiectasisSuppurativeSuppurative
XX XX XX
Pulmonary AbscessPulmonary Abscess XX XX XXXXXX XX XXXX
Chronic BronchitisChronic Bronchitis XX XX XX
MediastinalMediastinal NeoplasmsNeoplasms XX XX XX XX XX
TraumaTrauma XX XX XX XX XX XX XX
EmpyemaEmpyema XX XX XX XX
CardiacCardiac XX XX XX XX
AdenomaAdenoma XX XX XX XX
PneumoniaPneumonia XX XX XX
PneumonitisPneumonitis XX XX XX XX
IdiopathicIdiopathic XX XX XX XX XX XX XX
Reproduced from Pratt Reproduced from Pratt -- Ann. Ann. OtolOtol. . RhinolRhinol. and . and LaryngolLaryngol. 63; Page 307, 1954. 63; Page 307, 1954
SUMMARY OF TYPES OF HEMOPTYSIS
Hemoptysis with Normal Chest Film
Case 1: Female 55-year-old, cough with hemoptysis infrequently for some months.
A chest CT scan is performed, L apical mass found, confirmed by endoscopic BAL (bronchoalveolar lavage) examination
No mass found in the bronchial lumen, only hemorrhage detected on L upper lobe bronchus (arrow). BAL was done
Case 2: Male 70-year-old, heavy smoker, cough with wheezing, expiratory rale, hemoptysis for some month. Spirometry: Obstructive syndrome improving after bronchodilator
Case 2: Chest CT scan performed: Narrowing of the L main bronchus noted, may be due to a parahilar mass
Case 2 : L main bronchus stenosis due to submucosal induration confirmed by pathological result: adenocarcinoma
Case 3: female patient 31-year-old, small amount hemoptysis for 5 years. Normal chest XR
Case 3 : CT scan 3D recontruction give a nice picture of intraluminal mass (red arrow) confirmed by endoscopic examination
Case 3 : Endoscopic picture of intraluminal mass proved by pathological result as adenoma
Case : Female patient 57-year-old with long lasting moderate hemoptysis.
A Helical CT scan demonstrated metallic FB in L 6th segment
Best of Luck..Best of Luck..
