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 Rasmussen’s 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 AVM’S

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 couldn’t 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 period of 1- 60 m

EMBOLIZATION COMPLICATIONS:

o Chest pain-(24-91%)

o Dysphagia-(0.7-18.2%)

o Subintimal dissection of aorta or bronchial artery

o Bronchoesophageal fistula

o Reflux of embolic material into systemic

circulationnecrosisofsmallbowel,occlusion ofanterior tibial artery,seizure

o Anterior spinal artery (A. of Adamkiewicz)

o ischemia – 1.4- 6.5%

SURGERY • Conservative management of massive

hemoptysis carries a mortality rate of 50-100%

o Mortality rate for surgery performed for massive hemoptysis- 7.1-18.2%

o However mortality rate increases

significantly upto 40% when surgery is

undertaken as an emergency procedure

SURGERY SURGERY IS PROCEDURE OF CHOICE

o BRONCHIAL ADENOMA

o ASPERGILLOMA RESISTANT OT OTHER

TREATMENT

o HYDATID CYST

o THORACIC VASCULAR INJURY

Sx - contraindications o Unresectable carcinoma

o Inability to lateralize the bleeding site

o Diffuse disease

Multiple AVM

Cystic fibrosis

o Arterial hypoxia

o Co2 retention

o Dyspnea at rest

o Severe dyspnea at exertion

Sx - complications o Morbidity-23-54%

o Post- op BPF-10-14%

o Empyema

o Hemorrhage requiring re-exploration

o Hemothorax

o Resp insufficiency req proloned vent

o Mortality-10-50%

o -Gourin & garzon’s study:37% of active bleeding died in comparision with 8% with minimal bleeding

THANK YOU