Respiratory EmergenciesRespiratory EmergenciesStepwise management of Stepwise management of
HemoptysisHemoptysis
Tarek Mohsen MD, FRCSTarek Mohsen MD, FRCS
Cardiothoracic SurgeonCardiothoracic Surgeon
Cairo UniversityCairo University
DefinitionsDefinitions Hemoptysis is the expectoration of blood or of blood-
stained sputum.
Massive hemoptysis, the amount varies from 200 – 1L / 24 hrs, but is usually defined as 600 / 24 hrs.
Any amount that causes respiratory compromise and/or hemodynamic instability is life threatening and constitutes a medical emergency.
The mortality ranges 7–30% for non-massive, and up to 80% for massive hemoptysis.
Questions and AnswersQuestions and Answers
Is it Hemoptysis?Is it Hemoptysis?What is the Cause?What is the Cause?What is the source?What is the source?
When massive hemoptysis is the caseWhen massive hemoptysis is the case
Resuscitation + search for the cause + Resuscitation + search for the cause + active treatment are held hand in hand active treatment are held hand in hand
Is it Hemoptysis?Is it Hemoptysis?
HemoptysisHemoptysis
HistoryHistoryLung diseaseLung diseaseAsphyxia is possibleAsphyxia is possible
Sputum examinationSputum examinationFrothy, bright red.Frothy, bright red.
LabLabAlkaline pHAlkaline pHMixed with macrophages and Mixed with macrophages and
neutrophilsneutrophils
HematemesisHematemesis
HistoryHistoryNausea and vomitingNausea and vomitingGastric or hepatic diseaseGastric or hepatic disease
Sputum examinationSputum examinationCoffee ground, black or brownCoffee ground, black or brown
LabLabAcidic pHAcidic pHMixed with food particlesMixed with food particles
What is the cause?What is the cause? NeoplasticBronchogenic carcinomaBronchial adenomaPulmonary metastasis
InfectiousTuberculosis #Fungal infectionsNecrotising pneumoniaLung abscessHydatid cyst
PulmonaryBronchiectasis #Cystic fibrosisLAM
VascularPulmonary thrombo-embolismAV malformation Mitral stenosisThoracic aorta aneurysm
Systemic diseasesBehcet’s diseaseWegener’s granulomatosisGoodpasture’s syndromeSLE
CoagulopathiesDIC, Thrombocytopenia, HaemophiliaAnticoagulant therapy
Misc.Catamenial and brocholith
Source of bloodSource of blood
In 90% of cases, hemoptysis originates from the bronchial arteries, in 5% from the pulmonary arteries, and in the remainder from non bronchial collaterals.
Bronchial hemoptysis is usually profuse while pulmonary hemoptysis is not.
Most common cause in EgyptMost common cause in Egypt
In adults exclude TB, bronchiactesis and In adults exclude TB, bronchiactesis and bronchogenic and DON’T forget RTI.bronchogenic and DON’T forget RTI.
In children exclude FB and RTI.In children exclude FB and RTI.
Put in mind AV malformation and Put in mind AV malformation and vasculitisvasculitis
Steps towards diagnosisSteps towards diagnosis
History and clinical examinationsHistory and clinical examinations
LabsLabs
Radiography (HRCT) + contrast.Radiography (HRCT) + contrast.
BronchoscopyBronchoscopy
Bronchial angioBronchial angio
CT pulmonary angioCT pulmonary angio
Echo heart.Echo heart.
Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Physical HistoryPhysical History
Clinical cluesClinical clues
Association with mensesAssociation with menses
Anticoagulant useAnticoagulant use
Dyspnea on exertion, fatigue, Dyspnea on exertion, fatigue, orthopnea, PND, frothy pink sputumorthopnea, PND, frothy pink sputum
Fever, productive coughFever, productive cough
History of chronic lung disease, History of chronic lung disease, recurrent lower RTI, cough with recurrent lower RTI, cough with copious purulent sputumcopious purulent sputum
Pleuritic chest pain, calf tendernessPleuritic chest pain, calf tenderness
Suggested diagnosisSuggested diagnosis
Catamenial hemoptysisCatamenial hemoptysis
Medication effect, coagulation disorderMedication effect, coagulation disorder
Congestive heart failure, left ventricular Congestive heart failure, left ventricular dysfunction, mitral valve stenosisdysfunction, mitral valve stenosis
Upper RTI, acute sinusitis, acute Upper RTI, acute sinusitis, acute bronchitis, pneumonia, lung abscessbronchitis, pneumonia, lung abscess
Bronchiectasis, lung abscessBronchiectasis, lung abscess
Pulmonary embolism or infarctionPulmonary embolism or infarction
Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Physical History IIPhysical History II
Clinical cluesClinical clues
Tobacco useTobacco use
Weight lossWeight loss
History of breast, colon, or renal History of breast, colon, or renal cancerscancers
ImmunosuppressionImmunosuppression
Suggested diagnosisSuggested diagnosis
Acute bronchitis, chronic bronchitis, Acute bronchitis, chronic bronchitis, lung cancer, pneumonialung cancer, pneumonia
Emphysema, lung cancer, tuberculosis, Emphysema, lung cancer, tuberculosis, bronchiectasis, lung abscess, HIVbronchiectasis, lung abscess, HIV
Endobronchial metastatic disease of Endobronchial metastatic disease of lungslungs
Neoplasia, tuberculosis, Kaposi's Neoplasia, tuberculosis, Kaposi's sarcomasarcoma
Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Laboratory TestsLaboratory Tests
TestTest
CBCCBC
INR and PTTINR and PTT
ESR and Tuberculin testESR and Tuberculin test
ABGABG
Sputum for Gram stain, culture Sputum for Gram stain, culture and sensitivity and cytology.and sensitivity and cytology.
D- dimerD- dimer
Diagnostic findingDiagnostic finding
Diagnostic Clues in Hemoptysis: Diagnostic Clues in Hemoptysis: Chest RadiographChest Radiograph
Radiological findingsRadiological findings
Normal or no change from base lineNormal or no change from base line
Cavitary lesionCavitary lesion
Hilar adenopathy or mass lesionHilar adenopathy or mass lesion
Nodules or granulomasNodules or granulomas
Diffuse alveolar infiltrateDiffuse alveolar infiltrate
Patchy alveolar infiltratePatchy alveolar infiltrate
Lobar or segmental infiltrateLobar or segmental infiltrate
HyperinflationHyperinflation
Suggested diagnosisSuggested diagnosis
Sinusitis, bronchitis, PESinusitis, bronchitis, PE
TB, lung abscess, necrotizing ca. TB, lung abscess, necrotizing ca.
Sarcoid, lung ca., infectious processSarcoid, lung ca., infectious process
Carcinoma, mets, Wegener's granulomatosis, septic Carcinoma, mets, Wegener's granulomatosis, septic embolism, vasculitidesembolism, vasculitides
Chronic heart failure, pul. edema, aspiration, toxic Chronic heart failure, pul. edema, aspiration, toxic injury.injury.
Bleeding disorders, idiopathic pulmonary Bleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture's syndromehemosiderosis, Goodpasture's syndrome
Pneumonia, thromboembolism, obstructing carcinomaPneumonia, thromboembolism, obstructing carcinoma
Cavitary lesionsCavitary lesions
Hilar adenopathy and massHilar adenopathy and mass
Nodule or granulomaNodule or granuloma
Lobar or segmental infiltratesLobar or segmental infiltrates
Alveolar infiltrateAlveolar infiltrate
BronchiactesisBronchiactesis
Hydatid cystHydatid cyst
Role of bronchoscopyRole of bronchoscopy Bronchoscopy is useful in both the diagnostic work-up as
well as a therapeutic modality. The timing of performing bronchoscopy is controversial.
One suggestion is to perform urgent bronchoscopy when there is rapid deterioration and elective bronchoscopy within 24–48 h in stable patients.
In patients with massive hemoptysis, rigid bronchoscopy is the method of choice due to its better suction ability. The major limitation of rigid bronchoscopy is that it is difficult or even impossible to visualize the upper lobes or peripheral lesions
Initial management stepsInitial management steps
1) Resuscitation and airway protection are the first priority.
2) Localization of the site and establishing the cause of bleeding is the next step.
3) The final step is directed at specific and definitive treatments to stop the haemoptysis and to prevent rebleeding
Resuscitation
Admit to ICU with full monitoring.Admit to ICU with full monitoring.
Position the patient with the bleeding site down.Position the patient with the bleeding site down.
Estimate of blood Loss (Hb, Hct and CVP).Estimate of blood Loss (Hb, Hct and CVP).
Stable patient are investigated.Stable patient are investigated.
Unstable patients are intubated and ventilated.Unstable patients are intubated and ventilated.
Airway protection Selective intubation of one
lung can be performed by a rotational technique. After intubating the trachea, the tube is rotated through 90 in the direction of the desired placement until resistance is felt. The tube placement should be confirmed both clinically and radiologically.
Alternatively, a double-lumen endotracheal tube can be passed to protect the unaffected lung.
Localization of the site
Localization of the bleeding site directs
definitive treatment. This can be achieved by combining the various imaging techniques with bronchoscopy.
Definitive and specific treatments.
Bronchoscopic treatment.Bronchoscopic treatment.
Bronchial Embolization.Bronchial Embolization.
Surgery.Surgery.
Disease specific approach. Disease specific approach.
Bronchoscopic managementBronchoscopic management
When bleeding is mild to moderate instillation of cold When bleeding is mild to moderate instillation of cold saline, adrenaline (1: 20.000). I.V or local ornipressin 5 saline, adrenaline (1: 20.000). I.V or local ornipressin 5 IU in 20 ml normal saline.IU in 20 ml normal saline.
If massive bleeding, rigid bronchoscopy or combined If massive bleeding, rigid bronchoscopy or combined bronchoscopy is needed.bronchoscopy is needed.
Bronchial tamponade may be needed in some cases, Bronchial tamponade may be needed in some cases, Fogarty size 4 – 6, 170 cm can be placed via Fogarty size 4 – 6, 170 cm can be placed via bronchoscopy. Up to 7 days until definitive treatment is bronchoscopy. Up to 7 days until definitive treatment is establishedestablished
Bronchoscopic interventionBronchoscopic intervention
The use of laser, The use of laser, electrocauteryelectrocautery
Coagulation– laser– electrocautery– cryotherapy
Mechanical debulking
twist&
push
Bronchoscopic interventionBronchoscopic intervention
Bronchoscopic interventionBronchoscopic intervention
Bronchial artery embolisation.
BAE is a technically demanding procedure and should always be performed by skilled
interventional radiologists. Multi-detector row helical CT angiography could be used as a
road map guiding the interventional radiologist.
The most commonly used agent is polyvinyl alcohol (PVA) with particles sized 350–500 mm in diameter.
Immediate response rates after BAE range 73–98%.
Complications are chest pain and is transient, Spinal cord injury in 1 %.
SurgerySurgery Currently, surgery represents one of a few
treatment options, but still represents the only definitive one.
Surgical mortality ranges 1–50%.
Surgery remains the procedure of choice in patients with localised bronchiectasis, trauma, hydatid cyst, arteriovenous malformations, thoracic aneurysm and aspergilloma, because it is curative for these underlying diseases.
Disease-specific approaches.
Aspergilloma.A patient with an aspergilloma should undergo surgical resection.
Unfortunately, such patients often have significant concomitant bronchiectasis that may preclude them from surgery due to insufficient pulmonary reserves. In these patients intracavitary Na of K iodide is curative. In some series external beam irradiation was used.
Immunological diseases. Some of the immunological diseases, such as Goodpasture’s disease, can present with massive haemoptysis. These diseases do
not need invasive procedures and are usually treated with high-dose corticosteroids, cytotoxic agents or plasmapheresis.
In practice tailored management for In practice tailored management for hemoptysis is neededhemoptysis is needed
Case ICase I
58 yrs old male presented with frank 58 yrs old male presented with frank hemoptysis and heart failure.hemoptysis and heart failure.
History of old TB, asthmatic bronchitis, History of old TB, asthmatic bronchitis, previous cardiac catheterization and previous cardiac catheterization and MarevanMarevan
Examination revealed features of heart Examination revealed features of heart failure, and murmur of AS. failure, and murmur of AS.
InvestigationInvestigation
Hb 7gm%, CT scan, Echocardiography, Hb 7gm%, CT scan, Echocardiography, PFTs.PFTs.
CT scan revealed bilateral epical fibrotic CT scan revealed bilateral epical fibrotic lesions, pulm edema and bilateral pl lesions, pulm edema and bilateral pl effusion. Calcified Ao. Valveeffusion. Calcified Ao. Valve
Echo revealed AS with a gradient of 60 Echo revealed AS with a gradient of 60 mmHg and ejection fraction of 38 % mmHg and ejection fraction of 38 %
ManagementManagement
Resuscitation with Blood to restore HbResuscitation with Blood to restore HbUpright positionUpright positionCoagulantsCoagulantsAnti failure measuresAnti failure measuresNo bronchodilators or cough sedativesNo bronchodilators or cough sedatives
Hemoptysis decreased in amount but did not stop on the 3Hemoptysis decreased in amount but did not stop on the 3rdrd day of admission.day of admission.
Bronchoscopy was done revealing right upper lobe a Bronchoscopy was done revealing right upper lobe a source of bleeding. source of bleeding.
What NextWhat Next
a)a) Consider RUL followed by AVRConsider RUL followed by AVR
b)b) Consider AVR followed by RULConsider AVR followed by RUL
c)c) Combined procedureCombined procedure
d)d) Embolization followed by AVREmbolization followed by AVR
What Valve is suitable for this patient?What Valve is suitable for this patient?
Final managementFinal management
Because we considered the patient for valve Because we considered the patient for valve replacement his marginal pulmonary functions replacement his marginal pulmonary functions and bilateral lesion we decided to do bronchial and bilateral lesion we decided to do bronchial angiography and possible embolization. angiography and possible embolization.
Four weeks later the patient had dobutamine Four weeks later the patient had dobutamine stress echo and cardiac catheterization.stress echo and cardiac catheterization.
Ao. Valve replacement with a tissue valve was Ao. Valve replacement with a tissue valve was
then done.then done.
Bronchial embolizationBronchial embolization
Case IICase II
72 yrs old female presented with repeated 72 yrs old female presented with repeated attacks of hemoptysisattacks of hemoptysis
History of CAD, hypertension, DM, left History of CAD, hypertension, DM, left mastectomy for Ca breast 10 yrs ago with mastectomy for Ca breast 10 yrs ago with post resection chemo and radiotherapy.post resection chemo and radiotherapy.
Angina class IIIAngina class III
InvestigationInvestigation
Routine investigations were normalRoutine investigations were normal
CT scan showed a Rt lower lobe mass, CT scan showed a Rt lower lobe mass, adenoca. was confirmed by TBLB. Patient adenoca. was confirmed by TBLB. Patient was staged as stage IIBwas staged as stage IIB
Coronary angio revealing 3 Vs disease with Coronary angio revealing 3 Vs disease with critical proximal LAD.critical proximal LAD.
Problem ListProblem List
CAD + other co-morbidity.CAD + other co-morbidity.
Hemoptysis due to operable malignant Hemoptysis due to operable malignant mass.mass.
High mortality if resection is done in CAD.High mortality if resection is done in CAD.
So what next?So what next?
ManagementManagement
In our patient hemoptysis didn’t respond to In our patient hemoptysis didn’t respond to conservative therapy.conservative therapy.
Options left wereOptions left were
a)a) Lobectomy followed by CABGLobectomy followed by CABG
b)b) CABG followed by lobectomyCABG followed by lobectomy
c)c) Combined procedureCombined procedure
d)d) Stenting followed by RLLStenting followed by RLL
Definitive managementDefinitive management
A drug eluding stent to LAD and mid RCA A drug eluding stent to LAD and mid RCA were done.were done.
Patient developed left hemiparesis few Patient developed left hemiparesis few hours after the procedure.hours after the procedure.
On the 3On the 3rdrd day significant attack of day significant attack of hemoptysis. hemoptysis.
OptionsOptions
Urgent RLL.Urgent RLL.
Urgent wedge resection of the mass (not Urgent wedge resection of the mass (not oncologically radical).oncologically radical).
Rigid bronchoscopy and packing.Rigid bronchoscopy and packing.
Rigid bronchoscopy and Rigid bronchoscopy and tamponadetamponade
Urgent rigid Urgent rigid bronchoscopy bronchoscopy with packing of with packing of the Rt the Rt intermediate intermediate bronchus, using bronchus, using Fogarty size 6 Fogarty size 6 hemoptysis was hemoptysis was then controlled.then controlled.
Two weeks later uneventful RLL was done.Two weeks later uneventful RLL was done.
Case IIICase III
Male 48 yrs old chronic heavy cigarette Male 48 yrs old chronic heavy cigarette smokersmoker
Hemoptysis responded to conservative Hemoptysis responded to conservative managementmanagement
All investigations were normalAll investigations were normal
Multi slice Pulmonary angioMulti slice Pulmonary angio
BronchoscopyBronchoscopy
White light bronchoscopy revealed bleeding White light bronchoscopy revealed bleeding middle lobe but no lesion.middle lobe but no lesion.
EBUS revealed distraction of cartilage and EBUS revealed distraction of cartilage and biopsy revealed grade II dysplasiabiopsy revealed grade II dysplasia
Patient was diagnosed as stage 0 caPatient was diagnosed as stage 0 ca
He underwent middle lobectomyHe underwent middle lobectomy
EBUSEBUS
Thank YouThank You