Haemoptysis

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 Massive hemoptysis = potentially life-threatening. Therefore the amount varies among individuals.

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

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

Differential diangoses Broad range of DDx

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

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

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) I don’t think aspergillus is the commonest infective agent. It is less common than bacterial and TB in our locality.

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

Pulmonary venous hypertension Left ventricular systolic heart failure Mitral stenosis

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

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

Assessment History usually provides clues for differentiating haemoptysis vs haematemesis vs pseudohaemoptysis

Haemoptysis? Haematemesis? 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

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

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

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 Please match the two columns

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

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

Laboratory findings White cell count/differential Elevated WCC & left shifts  infections Hb, Hct Anaemia Plt Thrombocytopenia PR/INR/APTT Anticoagulant use/coagulopathy ABG Hypoxia/hypercarpnia D-dimer PE Sputum C/ST, AFB smear, C/st Pneumonia, abscess, TB Sputum cytology Neoplasia HIV serology TB, Kaposi’s sarcoma ESR Infections, autoimmune disorders, +/-neoplasia

Management Acute treatment depends on the amount/cause of haemoptysis

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

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

Double lumen ET tube

Double lumen ET tube

Double lumen ET tube

Endobronchial Blocker

Endobronchial blocker

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

Fibreoptic Bronchoscopy Limited in massive haemoptysis Localisation of bleeding site diagnosis Guide intubation Cold saline Adrenaline Tamponade Argon plasma coagulation, electrocautery, laser Argon plasma coagulation, electrocautery, laser: can be done using the flexible bronchoscope

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!!! What do you mean by embolization using a rigid bronchoscope?

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

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