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H e m o p t y s i s Prepared by Dr. Tahany Mahmoud Banha Chest
Department Banha University
References . 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
Reisz G, Stevens D, Boutwell C, Nair V. The causes of
hemoptysis revisited. A review of the etiologies of hemoptysis
between 1986 and 1995. Mo Med 1997;94:633-5 .
Bond D, Vyas H. Viral pneumonia and hemoptysis. Crit Care Med
2001;29:2040-1 .
Nelson JE, Forman M. Hemoptysis in HIV-infected patients. Chest
1996;110:737-43 .
Santiago S, Tobias J, Williams AJ. A reappraisal of the causes
of hemoptysis. Arch Intern Med 1991;151: 2449-51 .
Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis:
etiology, evaluation, and outcome in a tertiary referral hospital.
Chest 1997;112:440-4 .
Anish EJ, Mayewski RJ. Pulmonary embolism. In: Black ER, ed.
Diagnostic strategies for common medical problems. Philadelphia:
American College of Physicians, 1999:325-37 .
Hemoptysis Hemoptysis is coughing up blood from the respiratory
tract. The blood can come from the nose, mouth, throat, the airway
passages leading to the lungs. The word "hemoptysis" comes from the
Greek "haima," meaning "blood," and "ptysis," which means "a
spitting"
Pseudohemoptesis
Causes:
Blood not from lower respiratory tract it come from above the
vocal cords:
Mouth
Pharynx
Nose
Aspiration of hematemsis
Colonization by grame negative bacteria (seratia blue)
Massive Hemoptesis: It is the amount of blood that can not be
cleared from the dead space (150ml). It is about 600ml blood/24 h
X-sanguating Hemoptesis: Rate of bleeding >150ml/h
Pathophysiologic Factors: 1-Dual Circulation: The lungs have a
dual blood supply. The pulmonary arterial circulation, a
high-compliance, low-pressure system that terminates in the
pulmonary capillary bed, is responsible for gas exchange.
In addition, the lungs are supplied by the bronchial arteries,
branches of the aorta that bring nutrients to the lung parenchyma
and major airways. The bronchial arteries, like all systemic
arteries, are a high-pressure system. Most cases of hemoptysis
result from disruption of branches of the bronchial arterial
tree.
2- Vascular Mechanisms :
Aneurysm formation
Vasculitis
Pulmonary Embolism
Inflammation
Broncholithiasis
Direct invasion central pulmonary artery trauma
Causes Blood-tinged mucus in a healthy nonsmoker usually
indicates a mild infection and is generally no cause for concern.
Indeed, the most common cause of Hemoptysis is the least serious a
ruptured small blood vessel caused by coughing and/or a bronchitic
infection In patients with a history of smoking or who are
otherwise at risk for lung disease, however, Hemoptysis is often a
sign of serious illness, including cancer
Cardiovascular Severe left ventricular heart failure Mitral
stenosis Pulmonary embolism or infarction Septic pulmonary embolism
or right-sided endocarditis Aortic aneurysm or bronchovascular
fistula
Miscellaneous Idiopathic Pulmonary Hemosiderosis Aspirated
foreign body Pulmonary contusion or trauma Posttransthoracic needle
biopsy or transbronchial lung biopsy Factitious hemoptysis
Bleeding Diathesis
Anticoagulant therapy
Deficiency of vitamin Kdependent factors: prothrombin (II),
Stuart factor (X), factor VII, Christmas factor (IX)
Disseminated intravascular coaulation
Fibrinolytic therapy: urokinase , streptokinase.
Evaluation of Hemoptysis
1-Types of Hemoptesis:
Blood tinged sputum
Blood streaked
Red current jully
Frank Hemoptesis
Rusty sputum
2-Degree of Hemoptysis:
Massive
Non massive
Causes of Blood streaked Sputum :
Upper respiratory inflammation
Nose or Nasopharynx
Gums
Larynx
Severe coughing paroxysms
Trauma
Causes of Pink Sputum :
Blood and secretions mix in alveoli, small bronchioles
Conditions associated with pink Sputum
Pneumonia
Pulmonary edema
Causes of Heavy Bleeding into Respiratory tree :
Pulmonary Tuberculosis
Lung Abscess
Bronchiectasis
Pulmonary infarction
Pulmonary Embolism
Bronchogenic Carcinoma
Broncholithiasis
Mitral Stenosis
Actinomycosis Lung Abscess
Blastomycosis Lung Abscess
Diagnosis
History:
To differentiate between source of Hemoptysis:
Respiratory
Gastrointestinal
Anticoagulant therapy
Mitral valve disease
Physical Examination
The doctor will examine the patient's nose, throat, mouth, and
chest for bleeding from these areas and for signs of chest trauma.
The doctor also listens to the patient's breathing and heart beat
for indications of heart abnormalities or lung disease .
Laboratory Tests
Laboratory tests include blood tests to rule out clotting
disorders, and to look for food particles or other evidence of
blood from the stomach. Sputum can be tested for fungi, bacteria,
or parasites .
X - Ray and Bronchoscopy
Chest x rays and bronchoscopy are the most important studies
for evaluating hemoptysis. They are used to evaluate the cause,
location, and extent of the bleeding.
Value of Bronchoscope
1-Dignostic:
Localize site of bleeding
F.B aspiration
Adenoma
2-Therapeutic:
Arrest bleeding
Suction and lavage
Preservation ventilation of non bleeding lung
Type of Bronchoscope
The rigid bronchoscope is more preferable than fiber optic one
due to it has wide channel for suction of blood and for therapeutic
treatment to arrest bleeding.
Imaging and other tests
Computed Tomography scans (CT scans) are used to detect
aneurysms and to confirm x-ray results.
Ventilation-perfusion scanning is used to rule out pulmonary
embolism. The doctor may also order an angiogram to rule out
pulmonary embolism, or to locate a source of bleeding that could
not be seen with the bronchoscope .
In spite of the number of diagnostic tests, the cause of
Hemoptysis cannot be determined in 20-30% of cases .
Complication of Hemoptysis
Asphyxia
Shock
Anemia
Renal failure
Atelectasis
Pulmonary infection
Management
Three Goals of Therapy :
Prevent asphyxiation
Stop bleeding
Treat primary disease
Airway Control
Supplemental oxygen
Positioning
Cough control
Endotracheal intubation a. selective intubation
Volume Resuscitation
Laboratory Evaluation
Hematocrit
Platelet count
Coagulation profile
Arterial blood gas, if appropriate
Renal function testing
Type and cross match blood
Smear, culture and cytology of sputum
DLCO for pulmonary hemorrhage
Consultations
Surgical
Definitive: resection
Medical
Antibiotics if indicated
Medical management if nonlocalized bleeding, severely impaired
pulmonary function, disseminated terminal carcinoma, advanced
bilateral pulmonary disease, vasculitis
Modalities
Bronchial artery Embolization
Balloon Tamponade
Intracavitary Anti-fungal therapy
Mortality
Medically managed patients with massive Hemoptysis: 75%
Surgically managed patients with massive Hemoptysis: 23%