Dr. ZAKIR HUSSAIN
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
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
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?
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.
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
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.
Causes of HEMOPTYSIS
Tuberculosis Active tubercular pneumonitis-
Rupture of Rasmussens aneurysm (pulm. art)
Healed calcified LNE-eroding through bronchial arteries into airway
Development of bronchiectasis
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 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
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
necrosis and inflammation of vessels within tumour bed
Direct tumor invasion of the pulmonary vasculature is rare
o Physical examination
o CT chest
o RBC scan
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
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
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 BRONCHOSCOPIC MEASURES:
UNILATERAL LUNG VENTILATION
DOUBLE-LUMEN ET TUBES
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
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
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
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
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