Hemoptysis jack

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  • HEMOPTYSIS

    Dr. ZAKIR HUSSAIN

  • HEMOPTYSIS definition

    HEMOPTYSIS

    Expectoration of blood from da resp tract below da level of vocal cords.

    can range from blood-streaking of sputum to the presence of gross blood.

    Depending on da amount of blood loss, it has been categorized as minor, moderate, n massive.

  • Classification of hemoptysis

    MINOR HEMOPTYSIS - bloodloss is 20ml/day

    MODERATE HEMOPTYSIS 20-100 ml/day

    MASSIVE HEMOPTYSIS - 100- 600 ml/day

    MASSIVE HEMOPTYSIS : bleeding is potentiallly life threatening & blood loss is significant to compromise

    resp function.

  • Anatomy

    PULMONARY ARTERY :

    entire cardiac output Low-pressure pulmonary arteries & arterioles oxygenated in the pulmonary capillary bed Pulm @ only 5% of hemoptysis

    BRONCHIAL ARTERY: higher systemic pressure but carry a small portion of the cardiac output. Arise from aorta. Nutitional source to airways, n lungs.

    95% of hemoptysis.

  • D/D of HEMOPTYSIS

    diff, from hemoptysis from other causes

    R/o NON PULMONARY like upper resp tract bleeding,

    Bleeding from GI tract.

    Alkaline pH, frothy, or the presence of pus may sometimes suggest the lungs as the primary source of bleeding

    differenciate hemoptysis from hemetemisis

  • HEMOPTYSIS vs HEMETEMESIS

  • Past HISTORY

    Is there a history of prior lung, cardiac, or renal disease?

    Is there a history of cigarette smoking?

    Has the patient had prior hemoptysis, other pulmonary symptoms, or infectious symptoms?

    Is there a family history of hemoptysis or brain aneurysms (suggesting hereditary hemorrhagic telangiectasia)?

    Is there a history of skin rash? (Vasulitis, SLE)

    What is the patient's travel history?

    Does the patient have a history of asbestos exposure?

  • Previous HISTORY

    Is there a history of bleeding disorders or use of aspirin, NSAIDS, or anticoagulants?

    Is there a history of upper airway or upper G.Icomplaints or diseases?

    Is pt having any liver disease.

  • Physical Examination

    Skin rash -- vasculitis, systemic lupus erythematosus, fat embolism, or infective endocarditis.

    Telangiectasias -- hereditary hemorrhagic telangiectasia

    Splinter hemorrhages -- endocarditis or vasculitis.

    Clubbing is nonspecific, since it can occur in many chronic lung diseases

  • Physical Examination

    Audible chest bruit or murmur that increases with inspiration -- large pulmonary AV malformations .

    Cardiac murmurs -- congenital heart disease, endocarditis with septic emboli, or mitral stenosis.

    Legs should be examined carefully for possible deep venous thrombi.

  • Evaluation

  • Causes of HEMOPTYSIS

  • Tuberculosis Active tubercular pneumonitis-

    bronchiolar erosion

    Rupture of Rasmussens aneurysm (pulm. art)

    Healed calcified LNE-eroding through bronchial arteries into airway

    Scar carcinoma

    Development of bronchiectasis

    Mycetoma formation

  • Bronchiectasis Pathologically it is destruction of the cartilaginous support of bronchial wall

    and bronchial dilatation owing to parenchymal retraction from alveolar fibrosis

    ANATOMICAL CHANGES: o Bronchial artery hypertrophy o Expansion of peribronchial & sub

    mucosal bronchiolar arteriolar plexus o Augmentation of anastomoses with

    the pulmonaryarterial bed

  • MYCETOMA

  • MYCETOMA Mechanical trauma of the vascular

    granulation tissue by the movement of the fungal ball in the cavity

    Vascular injury from aspergillus associated endotoxin

    Aspergillus related proteolytic activity

    Vascular damage from a type 3 hypersensitivity reaction

  • Fungal ball

  • Lung abscess

    Due to necrotizing effect of primary

    infection and the inflammation that involves pulmonary vasculature

  • MITRAL STENOSIS Before valvotomy and mitral valve

    replacement hemoptysis occurred in 20-50% of patients

    In M.S - Lt atrial pressure pulm veins -pulmonary capillary bed-if pressure exceeded inthe rt. atrial pressure- blood flows in the retrograde direction in the bronchial veins through the bronchopulmnary anastomosis

  • carcinoma 83% with hemoptysis squamous ca.

    centrally located ,48% cavitate

    Mechanism:

    necrosis and inflammation of vessels within tumour bed

    Direct tumor invasion of the pulmonary vasculature is rare

  • LOCALIZATION

    o Physical examination

    o CXR

    o CT chest

    o Bronchoscopy

    o Arteriography

    o RBC scan

    o Bronchography

  • LOCALIZATION o Physical examination and chest x-ray

    were equivocal and not helpful in 55%-60% of patients

    o This poor localization of bleeding reflects the fact that blood may be widely distributed in the lung by coughing

  • LOCALIZATION Early bronchoscopy :(48 hrs)

    o Diagnostic yield is higher

    o Likely hood of localizing site is more

    o Accurate localization may direct therapeutic interventioin

    CT chest during active bleeding may be misleading because aspirated blood may mask underlying pathology or incorrectly appear as a parenchymal mass

  • CT Scan o Use of early chest CT to help localize

    the bleeding site and diagnose the cause of hemoptysis

    o The advantage of CT diagnosing bronchiectasis, lung abscess, and mass lesions, including cancer, mycetomas, and AVMS

    o The disadvantage of chest CT

    diff in shiftin pt from ICU

  • LOCALIZATION

    RBC SCAN

    o Tc 99m-sulfur colloid isotope-labeled RBC

    o Reserved for the patients in whom bronchoscopy couldnt be performed

    BRONCHOGRAPHY: replaced by HRCT

  • bronchoscopy vs HRCT o Fiberoptic bronchoscopy and HRCT , each with

    specific advantages in certain clinical situations

    o HRCT picks all tumors seen by bronchoscopy as well as several which were beyond bronchoscopic range. On the other hand, HRCT could not detect bronchitis or subtle mucosal abnormalities which could be seen by bronchoscopy

    o HRCT was useful in diagnosing bronchiectasis and aspergillomas, while bronchoscopy was diagnostic of bronchitis and mucosal lesions such as Kaposi's sarcoma

  • MANAGEMENT o Adequate airway protection, ventilation,

    and cardiovascular function

    o Intubate if pt. has poor gas exchange, rapid ongoing hemoptysis, hemodynamic instability, severe SOB.

    o protection of the nonbleeding lung

    o Spillage of blood into the non-bleeding lung can either block the airway with clot or fill the alveoli and prevent gas exchange.

    o Need to know site of bleeding

  • MANAGEMENT o Place bleeding lung in the dependant

    position

    o Selectiely intubate the nonbleeding lung.

    o Placement of a double lumen ETT specially designed for selective intubation of the right or left mainstem bronchi

  • MANAGEMENT

  • MANAGEMENT BRONCHOSCOPIC MEASURES:

    BRONCHIAL IRRIGATION

    VASOCONSTRICTIVE AGENTS

    TOPICAL COAGULANTS

    LASERS

    ENDOBRONCHIAL BLOCKADE

    BALOON TAMPONADE

    UNILATERAL LUNG VENTILATION

    DOUBLE-LUMEN ET TUBES

    EMBOLOTHERPY

    SURGERY

  • Bronchoscopic measures BRONCHIAL IRRIGATION: o Cold saline lavage (4c) o Colon et al studied 25 pts Bleeding stopped in 23 patients,, 2 patients rebleed VASOCONSTRICTIVE AGENTS: o Topical epinephrine (1:2000) o Intravenous vasopressin

  • Bronchoscopic measures ELECTROCAUTERY

    ARGON PLASMA COAGULATION

    BRONCHOSCOPIC BRACHYTHERAPY

    TOPICAL COAGULANTS:

    o Tsukamoto et al- 19 pts-

    o 60% hemostasis with topical thrombin

    o 100% - fibrinogen-thrombin solution (re bleeding in 1 pt)

  • LASER COAGULATION o Nd YAG laser therapy for endobronchial

    tumors

    o Thermal effects vaporizes the superficial layers and coagulate the deeper layers

    o Seal vessels upto 1.5mm in diameter but larger vessels maynot be adequately controlled

    o Even highly vascular tumors have a propensity to bleed when subjected to laser therapy

  • BALLOON TAMPONADE o 4 Fr 100 cm Fogarthy balloon catheter

    placed by the fibreoptic bronchoscope and is inflated in the segmental and sub segmental bronchus

    o Inflated for 24-48 hrs

    Advantages:

    o Allows gas exchange

    o Supports patient before embolization or surgery

  • BALLOON TAMPONADE o Disadvantages:

    Ischemic mucosal injury

    Post obstructive pneumonia

    o Saw et al- 6/10 patients effective .

    No rebleeding for 6wks- 9 months

    o Swersky et al- 4/4 pts- effective.

    Rebleeding in 2 pts

  • Title

  • EMBOLIZATION Alternative to surgery in pts with

    bilateral disease, multiple bleeding sites and borderline pulmonary reserve

    o Halted active bleeding and stabilized patients in 84-100%

    o Long-term control of bleeding after embolization range from 70%-88% with f/u per