Haemoptysis

1. Haemoptysis

2. Haemoptysis • Spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage • Non-massive vs Massive: based on volume of blood loss  but no uniform definitions • Massive haemoptysis = potentially life-threatening haemoptysis

3. Pulmonary circulation • Mostly (95%): low-pressure pulmonary arteries  pulmonary capillary bed • Others (5%): high-pressure bronchial arteries • Originate at the aorta • Supply major airways and supporting structures

4. Haemoptysis • Blood usually from bronchial circulation • Rarely from pulmonary circulation • Usually produce small-volume haemoptysis • Others mimickers: • Pseudohaemoptysis (blood that does not come from the lungs or bronchial tree) • Haematemesis

5. Differential diangoses • Broad range of DDx

7. Differential Diagnoses • Source other than the lower respiratory tract • Upper airway (nasopharyngeal) bleeding • Gastrointestinal bleeding • Tracheobronchial source • Neoplasm (bronchogenic carcinoma, endobronchial metastatic tumor, Kaposi’s sarcoma, bronchial carcinoid) • Bronchitis (acute or chronic) • Bronchiectasis • Broncholithiasis • Airway trauma • Foreign body • Pulmonary parenchymal source • Lung abscess • Pneumonia • Tuberculosis • Mycetoma (“fungus ball”) • Goodpasture’s syndrome • Idiopathic pulmonary hemosiderosis • Wegener’s granulomatosis • Lupus pneumonitis • Lung contusion

8. Differential Diagnoses • Primary vascular source • Arteriovenous malformation • Pulmonary embolism • Elevated pulmonary venous pressure (especially mitral stenosis) • Pulmonary artery rupture secondary to balloon-tip pulmonary artery catheter manipulation • Miscellaneous and rare causes • Pulmonary endometriosis /Catamenial hemoptysis • Systemic coagulopathy or use of anticoagulants or thrombolytic agents

9. Infection • Most common cause of haemoptysis • Superficial mucosal inflammation and edema  rupture of the superficial blood vessels • Bronchitis, pneumonia ,tuberculosis • Bacteria (e.g. Staph. aureus, Pseudmonas aeruginosa) • TB • Rarer cause: fungi (e.g. Aspergillus)

10. Tumour • Superficial mucosal invasion, erosion into blood vessels, or highly vascularised tumour • Obstruction  secondary infection • Metastatic tumour less likely to bleed

11. Pulmonary venous hypertension • Left ventricular systolic heart failure • Mitral stenosis

12. Idiopathic • 7-34% patient with haemoptysis has no identifiable cause after careful evaluation • Prognosis is good • Most had resolution of haemoptysis in 6 months

13. Assessment • Airway, Breathing, Circulation • Haemoptysis vs Haematemesis vs Pseudohaemoptysis (e.g . from naso/oro-pharynx)

14. Assessment • History usually provides clues for differentiating haemoptysis vs haematemesis vs pseudohaemoptysis

15. Haemoptysis? Haematemesis? Haemoptysis History • Absence of nausea and vomiting • Lung disease • Asphyxia possible Sputum examination • Frothy • Liquid or clotted appearance • Bright red or pink Laboratory • Alkaline pH • Mixed with macrophages and neutrophils Haematemesis • Presence of nausea and vomiting • Gastric or hepatic disease • Asphyxia unusual • Rarely frothy • Coffee ground appearance • Brown to black • Acidic pH • Mixed with food particles

16. Pseudohaemoptysis • History of epistaxis • Expectorating without cough • Usually suggest blood from upper resp tract

17. Assessment • If Hx and PE findings suggest haemoptysis • Amount of blood has to be estimated • Difficult to quantify clinically and frequently overestimated • Nature of haemoptysis • Blood stained sputum • Clots • Fresh blood • Use of graduated container • ?On-going haemoptysis • Amount or frequency of bleeding DOES NOT correlate with the diagnosis or incidence of cancer

18. Further history Clinical clues • Anticoagulant use • Association with menses • Dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, frothy pink sputum • Fever, productive cough • History of breast, colon, or renal cancers • History of chronic lung disease, recurrent lower respiratory track infection, cough with copious purulent sputum • HIV, immunosuppression • Nausea, vomiting, melena, alcoholism, chronic use of nonsteroidal anti-inflammatory drugs • Pleuritic chest pain, calf tenderness • Tobacco use • Travel history • Weight loss Suggested diagnosis* • Medication effect, coagulation disorder • Catamenial hemoptysis • Congestive heart failure, left ventricular dysfunction, mitral valve stenosis • Upper respiratory infection, acute sinusitis, acute bronchitis, pneumonia, lung abscess • Endobronchial metastatic disease of lungs • Bronchiectasis, lung absces • Neoplasia, tuberculosis, Kaposi’s sarcoma • Gastritis, gastric or peptic ulcer, esophageal varices • Pulmonary embolism or infarction • Acute bronchitis, chronic bronchitis, lung cancer, pneumonia • Tuberculosis, parasites (e.g., paragonimiasis, schistosomiasis, amebiasis, leptospirosis), biologic agents (e.g., plague, tularemia, T2 mycotoxin) • Emphysema, lung cancer, tuberculosis, bronchiectasis, lung abscess, HIV

19. CXR • Essential • Underlying cause • Site of bleeding, to guide further treatment

20. Clues on CXR CXR findings • Cardiomegaly, increased pul vascular distribution • Cavitary lesions • Diffuse alveolar infiltrates • Hilar adenopathy or mass • Hyperinfilation • Lobar or segmental infiltrates • Mass lesion, nodules, granulomas • Normal or no change from baseline • Patchy alveolar infiltrates (multiple bleeding sites) Suspected diagnosis • CHF, MS • Lung abscess, TB, necrotizing CA • CHF, pul edema, aspiration, toxic injury • CA, met, infections, sarcoid • COPD • Pneumonia, thromboembolism, obstructing CA • CA, met, Wegener’s granulomatosis, septic embolism, vasculitides • Bronchitis, URI, sinusitis, pul embolism • Bleeding disorders, idiopathyic pulmonary haemosiderosis, Goodpasture’s syndrome

21. Laboratory findings

22. Management • Acute treatment depends on the amount/cause of haemoptysis

23. Massive haemoptysis • No standardised magic figures for amount of blood loss • Usually quoted as >200ml/24hr

24. Massive Haemoptysis • Mortality rate from massive haemotpysis depends on the bleeding rate and aetiology • Airway protection • Primary mechanism of death is asphyxiation, not exasnguination • Positioning maneurvers: decubitus position if one is sure of the site of bleeding • Intentional single lung intubation/use of double lumen ET tube • Obstruction of the bronchus leading to the bleeding lung, e.g bronchial blocker • Ventilatory support • Circulatory support

25. Double lumen ET tube

26. Double lumen ET tube

27. Double lumen ET tube

28. Endobronchial Blocker

29. Endobronchial blocker

30. Treatment • Emergency treatment for control of haemoptysis • Treatment targeting underlying aetiology • E.g. treatment of infection in haemoptysis associated with infective exacerbation of bronchiectasis

31. Fibreoptic Bronchoscopy • Limited in massive haemoptysis • Localisation of bleeding site • diagnosis • Guide intubation • Cold saline • Adrenaline • Tamponade • Argon plasma coagulation, electrocautery, laser

32. Rigid Bronchoscopy • Merits of rigid bronchoscopy over flexible bronchoscopy: • Better airway control • Larger field of view • Better suctioning • Better for therapeutic interventions • Direct pressure • Laser therapy • Cauterization • Adrenaline/vasopressin injection • Isolation of the bleeding pulmonary segment • Not readily available!!!

33. Surgery • Lobectomy • Pneumonectomy • Others surgical treatments directed to underlying causes, e.g. • Emergent mitral valvulotomy for haemoptysis due to severe MS

34. Bronchial Arterial Embolisation • Main stay for emergency management of massive haemoptysis • Effective, long and short term bleeding control • Safe: complication rates generally low and minor; major complications infrequent