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omar elrefy

on 31 October 2012

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Transcript of Haemoptsis

Haemoptsis cough


Respiratory Symptoms

Gastric or Hepatic Disease

Vomiting& Nausea



Laboratory Parameters 1-Definition
3-Vascular Origin
5-An Approach To A Case Of Haemoptsis
6-Bronchoscopic And Airway Management
7-Bronchial Artery Embolization Definition Haemoptsis
(Gr. Haema : blood Ptsis : spitting Classification Sources Of Bleeding Bronchial Arteries (90%)

Pulmonary Arteries The spitting of blood derived from the lungs or the bronchial tubes as a result of pulmonary or bronchial haemorrhage Grade amount/24 hrs mild moderate severe massive exsinguinating life-threatening <50 ml 50-200 ml >200 ml >600 ml 150 ml per 12 hrs or>400 ml per 24 hrs 200 ml/h or 50 ml/h in a patient with chronic respiratory failure Haemoptsis Haematemesis + _ Frothy
Bright red -pink
Liquid or clotted






Alkaline pH; Mixed
with macrophages
and neutrophils Rarely frothyBrown to blackCoffee ground





Acidic pH; Mixed
with food particles In adults, 70 to 90% of cases are caused by: Bronchitis
Necrotizing pneumonia
Primary lung cancer is an important cause in smokers 40 yr, but metastatic cancer rarely causes hemoptysis.
Cavitary Aspergillus infection is increasingly recognized as a cause but is not as common as cancer In children , common causes are :- Lower respiratory tract infections

Foreign body aspiration Massive Haemoptsis :- The most common causes have changed over time and vary by geographic region but include the following:

1- Bronchogenic carcinoma


3-Tuberculous and other pneumonias Etiology 1- Bronchial disease

2- Parenchymal disease

3- Lung vascular disease

3- Vasculitis

4- Cardiovascular disease

5- Hematological Bronchial Diseases 1-Carcinoma*

2-Bronchial adenoma


4-Foreign body

5-Acute bronchitis Parenchymal Diseases 1-Tuberculosis*

2-Necrotizing pneumonia and lung abscess

3-Bacterial endocarditis with septic emboli

4-Parasitic (paragonimiasis, hydatid cyst)

5-Trauma Lung Vascular Diseases 1-Pulmonary infarction*

2-Congenital cardiac or pul. vascular malformations

3-Airway-vascular fistula

4-AV Malformations 5-Idiopathic pulmonary
6-Pulmonary artery aneurysm

7-Bronchial artery aneurysm

8-Pulmonary hypertension

9-Pulmonary mets. Vasculitis 1-Wegener’s granulomatosis

2-Goodpasture’s syndrome

3-Behçet’s disease

4-Systemic lupus erythematosus

5-Polyarterites nodosa Cardiovascular Diseases 1-Acute left ventricular failure*

2-Aortic aneurysm

3-Mitral stenosis Haematological 1-Coagulopathy

2-Platelet disorders


4-Platelet dysfunction

5-Anticoagulant therapy

6-Leukemia Complications Of Haemoptsis 1-Asphyxia



4-Renal failure


6-Pulmonary infection Predictors Of Mortality ** 71% in patients who lost =>600 ml of blood in 4 h

** 22% in patients with =>600 ml within 4–16 h

** 5% in those with 600 ml of within 16–48 h

** Life-threatening massive : 5 to 15%. Diagnosis Active granulomatous disease (tuberculous, fungal, parasitic, syphilitic) or mycetoma (fungus ball) C/P

Fever, cough, night sweating and weight loss in patients with known exposures
Often history of immunosuppression Diagnostic Approach 1-Chest x-ray
2-Chest CT
3-Microbiologic testing of sputum samples or bronchoscopy washings Tumor (bronchogenic, bronchial metastatic, Kaposi's sarcoma): C/P

-Night sweating
-Weight loss
-History of heavy smoking
-Risk factors for Kaposi's
sarcoma (e.g HIV ) Diagnostic Approach 1-Chest x-ray
3-Bronchoscopy Bronchitis (acute or chronic) C/P Acute: Productive or nonproductive cough

Chronic: Cough on most days of the month or for 3 mon per year for 2 successive years in patients with known COPD or smoking history Diagnostic Approach Acute: Clinical evaluation

Chronic: Chest x-ray Bronchiectesis C/P Chronic cough and mucus production in patients with ahistory of recurrent infections Diagnostic
Approach High-resolution chest CT & Bronchoscopy Broncholithiasis C/P Calcified lymph nodes in patients with history of prior granulomatous disease Diagnostic Approach 1-Chest CT
2-Bronchoscopy Foreign body (typically chronic and undiagnosed) C/P Chronic cough (typically in an infant or young child) without URI symptoms
Sometimes fever Diagnostic Approach 1- Chest x-ray

2- Sometimes bronchoscopy Lung Abcess C/P fever
Night sweats
Weight loss Diagnostic Approach Chest x-ray or CT showing irregularly shaped cavity with air-fluid levels Pneumonia C/P - Fever, productive cough, dyspnea, pleuritic chest pain
- Decreased breath sounds or egophony
- Elevated WBC count Diagnostic Approach 1-Chest x-ray
2-Blood and sputum cultures in hospitalized patients Pulmonary Embolism C/P Abrupt onset of sharp chest pain, increased respiratory rate and heart rate, particularly in patients with known risk factors for pulmonary embolism. Diagnostic Approach CT angiography or V/Q scanning
Doppler or duplex studies of extremities showing findings of DVT Elevated pulmonary venous pressure (especially mitral stenosis, left-sided heart failure) C/P - Crackles
- Signs of central or peripheral volume overload (eg, elevated neck veins, peripheral edema)
- Dyspnea while lying flat (orthopnea) or appearing 1–2 h after falling asleep (paroxysmal nocturnal dyspnea) Diagnostic Approach 1- ECG

2- BNP measurement

3-Echocardiography Aortic aneurysm with leakage into the pulmonary parenchyma C/P Back pain Diagnostic Approach 1- Chest x-ray showing widened mediastinum

2- Chest CT angiography Systemic Coagulopathy or Use of Anticoagulants or Thrombolytics C/P - Patients receiving systemic anticoagulants for treatment of pulmonary embolism, DVT, or atrial fibrillation

- Patients receiving thrombolytics for treatment of stroke or MI

- Sometimes a family history Diagnostic Approach 1- PT/PTT or anti-factor Xa levels

2- Cessation of hemoptysis with correction of coagulation deficit Management & Its Difficulties GOALS - three fold:

1)Resuscitation and protecting the airway

2)Localizing the site and cause of bleeding

3)Definitive treatment to prevent recurrence. Airway Breathing Circulation provide suction provide O2 Crystalloid Solutions Prognostic Factors BAD:
-Bleeding rate: ~1,000 ml /24-hrs

-Aspiration in to contralateral lung

-Massive bleeding requiring single-lung ventilation

-Bronchogenic carcinoma as an underlying etiology Treatment for hemoptysis depends on the cause and the quantity of blood.
mild hemoptysis
usually does not require specific, immediate treatment, but it should always be thoroughly investigated in case the underlying disorder is life threatening. There is no way to predict whether a patient with mild hemoptysis will experience massive, life-threatening hemoptysis, so it is very important that the underlying cause be determined and treated. Massive or Major Haemoptsis
is a medical emergency. Death can result, usually from asphyxiation (impaired gas exchange in the lungs, leading to a lack of oxygen and excess of carbon dioxide in the body). In massive hemoptysis, steps are usually taken to localize the source of the bleeding, control the bleeding, and assure that the patient is able to breathe. Conservative Management Suppressing cough (codeine based)


Antifibrinolytics like tranexemic acid.

Sedation (Avoid over sedation)

Coagulation disorders should be rapidly reversed. Protection Of Non Bleeding Lung If bleeding side is known
Keep patient at:


-Lateral decubitus

-Bleeding side down

-Head tilted down. Selective Intubation SINGLE LUMEN ETT

Selectively intubate
the non bleeding lung Selective intubation of Lft Main bronchus
in Rt sided massive hemoptysis Left main brochus flooded with blood Some methods of controlling bleeding include:

Bronchial artery embolization,

surgical resection,

bronchoscopic laser therapy Left Upper Lobe Bronchial Artery Bronchial artery aneurysm PVA particles Before Embolization After Embolization Tortuous & hypertrophied vessel Decreased vascularity & hypertrophy Pre-embolization post-embolization Hypervascular lesion & aneurysm No vascular lesion or aneurysm References Davidson`s principles & practice of medicine, 21th edition.

Kumar and Clark (2009): Kumar &clark clinical medicine, 7th edition.

Stedman TL. Stedman's Medical dictionary. 27th ed. Philidelphia: Lipincott Williams & Wilkins, 2000.

Thompson AB, Teschler H, Rennard SI. Pathogenesis, evaluation, and therapy for massive hemoptysis. Clin Chest Med 1992;13:69-82. Knott-Craig CJ, Oostuizen JG, Rossouw G, Joubert JR, Barnard PM. Management and prognosis of massive hemoptysis. Recent experience with 120 patients. J Thorac Cardiovasc Surg 1993;105:394-7.

Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994;15:147-67.

Harrison TR, Braunwald E. Hemoptysis. In: Harrison's Principles of internal medicine. 15th ed. New York: McGraw-Hill Surgical Management Indications Procedure Of Choice in :- Bronchial adenoma


Hydatid cyst Iatrogenic pulmonary rupture

Chest trauma

AV malformation Contraindications For Surgery Unresectable carcinoma

Instability to lateralize the bleeding site

Diffuse disease

Multiple AVM

Cystic fibrosis Arterial hypoxia

CO2 retention

Marginal pulmonary reserve

Dyspnea at rest

Non localizing bronchiectesis
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