HEMOPTYSIS

Dr. J. RoigPulmonary Division

Hospital N. Sra. de MeritxellAndorra

Life threatening hemoptysis (LTH)

LTH better than “massive” hemoptysis Value of clinical history Physical findings Laboratory data Chest X-ray Optionally other image techniques Bronchoscopy

Causes of hemoptysis Infections

Bronchitis Tuberculosis Fungus Pneumonia Lung abscess Bronchiectasis

Tumors Bronchial cancer Carcinoid

Cardiovascular Lung infarct Mitral stenosis

Trauma Other

Foreign body Hemorrhagic diatesis Goodpasture and

other immunological disorders

Orriols R et al. Aetiology of Life-threatening hemoptysis. Eur Resp J 1996;9(S23):315-16

Intubation: 7% (80 cases). Mortality rate 3.4% Causes: Active tuberculosis 14 (12.1%)

Sequels post TBC 22 (18.9%)Bronchiectasis 27 (23.3%)Unsure diagnosis 27 (23.3%)Bullous emphysema 10 (8.6%)Tumors 7 (6.1%)Aspergilloma 6 (5.2%)Mucoviscidosis 2 (1.9%)

Uncommon, sometimes neglected, causes of LTH: infections

Viral lung or bronchial infection (usually associated with disseminated iv coagulation and bleeding diathesis)

Necrotizing bronchial fungal infection Bacterial endocarditis Mycotic intrathoracic aneurisms Hirudo medicinalis (common leech)

S. aureus infection in healthy •Gillet Y. Association between S. aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients. Lancet 2002;359:753-59.•Boussaud V. Life-threatening hemoptysis in adults with CAP due to PV leukocidin-secreting S. aureus. Intensive Care Med 2003;29:1840-3.•Francis J. Severe Community-onset pneumonia in healthy adults caused by methicillin-resistant S. aureus carrying the PV leukocidin genes.CID2005

Tuberculosis - LTH

Active infection Rasmussen pulmonary artery aneurism Sequels post-tuberculosis:

BronchiectasisBroncholitiasisMycetoma in residual cavities

“Scar carcinoma”

Aspergillus - Hemoptysis

Aspergilloma Invasive aspergillosis Chronic necrotizing aspergillosis or semiinvasive Necrotizing pseudomembranous

tracheobronchitis Stump aspergillosis after lung resection Bronchocentric granulomatosis

Lung abscess and LTH Thomas NW. Life-threatening hemoptysis in

primary lung abscess. Ann Thorac Surg 1972;14:347

Sequential filling-emptying pattern is a warning sign of massive hemoptysis in lung abscess: urgent surgery must be considered

Philpott NJ. Lung abscess: a neglected cause of

life-threatening hemoptysis. Thorax 1993;48:674 Recommends surgery if LTH in chronic abscess

Uncommon, sometimes neglected, causes of LTH: cardiovascular

Eisenmenger syndrome Mitral stenosis Left ventricle pseudoaneurysm Aortobronchial fistulas Vascular pulmonary abnormalities

associated with liver disease

Vascular diseaseBRONCHIAL CIRCULATION Angiomes and aneurisms of bronchial arteries Varicosities in chronic liver disease Vasculitides Arterial hypervascularization secondary to:

Inflammatory process Tumors Congenital heart disease Chronic stenosis of pulmonary artery

Vascular diseaseSYSTEMIC CIRCULATION Aortic dissection Systemic Hypervascularization

Intercostal arteriesOther as mamary artery

Vasculitides

Vascular diseasePULMONARY CIRCULATION Pulmonary disease Arteriovenous fistula Tumors (angiosarcoma) Aneurysms (micotic or not) Primary pulmonary hypertension Varicosities in chronic liver disease Vasculitides

Vascular abnormalities in chronic liver disease Man KM et al. Pulmonary varices presenting as

a solitary lung mass in a patient with end-stage liver disease. Chest 1994;106:294-6.

Schnader J et al. Hemoptysis, hepatopulmonary syndrome and respiratory failure. Clinical conference on management dilemmas. Chest 1997;111:1724-32.

Youssef A et al. Hemoptysis secondary to bronchial varices associated with alcoholic liver cirrhosis and portal hypertension. Am J Gastroenterol 1994;89:1562-3.

Uncommon, sometimes neglected, causes of LTH: vasculitis

Tracheobronchial form of Wegener Behçet vasculitis Hughes-Stovin syndrome Takayasu arteritis

Uncommon, sometimes neglected, causes of LTH: congenital abnormalities

Agenesis of pulmonary artery Congenital anomalies of large mediastinal

vessels, such as hemitruncus Cystic disease with/without laryngeal

papylomatosis Pulmonary sequestration Accessory cardiac bronchus

Uncommon, sometimes neglected, causes of LTH: tumors

Some pulmonary metastasis (angiosarcoma and hepatocellular carcinoma)

Some endobronchial metastasis (thyroid papillar carcinoma)

Cystic mediastinal mass Inflammatory pseudotumor Pulmonary cavernous hemangiomatosis

Uncommon, sometimes neglected, causes of LTH: other bronchial abnormalities

Broncholithiasis Tracheopatia osteochondroplastica Aspiration of foreign body

Causes of Diffuse Alveolar Hemorrhage (DAH) - 1 Bone marrow transplantation, especially

autologous Drug-induced pulmonary hemorrhage Isolated pulmonary capillaritis with negative

antineutrophil cytoplasmic antibodies Pulmonary arterial fibromuscular dysplasia DAH associated with high altitude edema DAH with positive antiglomerular basement

membrane antibodies without renal involvement Idiopathic pulmonary hemosiderosis

Causes of Diffuse Alveolar Hemorrhage (DAH) - 2 Systemic vasculitides, collagen vascular diseases Negative pressure alveolar hemorrhage Serious group A streptococcal infections Ehlers-Danlos syndrome Crack-cocaine inhalation Severe bleeding diathesis (DIC) Trimellitic anhydride inhalation Primary antiphospholipid syndrome Lung transplant rejection Pulmonary-renal syndrome Pulmonary infection in immunocompromised Pulmonary veno-occlusive disease

Keypoints in DAH DAH may be the initial form of

presentation There is no correlation between the

amount of expectorated blood and the real volume of alveolar bleeding

If glomerular involvement, deterioration of renal function may be very quick

Value of progressively hemorrhagic BAL Value of sequential DLCO in non-acute

setting

Uncommon, sometimes neglected, causes of LTH: miscellaneaous Lymphangioleimyomatosis Uremia Exogenous lipid pneumonia Intrathoracic Recklinghausen disease Extreme breath-hold diving Bullous emphysema Broncholitis obliterans organizing pneumonia Sarcoidosis Respiratory bronchiolitis associated interstitial

lung disease Subphrenic abscess penetrating the diaphragm

LTH –Miscellaneous (1)

Thoracic trauma Broncholitiasis Foreign body Hemorrhagic diathesis Vasculitis – alveolar hemorrhage Old, chronic scars (sequels):

Middle lobe syndromeEmphysema (bullae)

LTH - Miscellaneous (2)

Fibrosing mediastinitis Mediastinal tumors: teratoma Esophageal cancer Sarcoidosis Septal diffuse amiloidosis Fictitious hemoptysis

General measures in LTH Immediate intubation and mechanical ventilation if

Asphyxia Hypovolemic shock

Evaluate admission to the respiratory and ICU Nothing by mouth Ipsilateral decubitus lying on the alleged bleeding site Intravenous line Evaluate local applicability of the general algorithmic

approach Provision to allow rapid blood replacement Control of bleeding speed and volume of expectorated

blood Chest radiograph Routine blood tests: consider specialized tests if indicated Consider specialized diagnostic procedures if indicated

Hemoptysis, X-ray and FOB

Misdiagnoses if classical criteria are followed Hemoptysis > 7 days Age > 40 Smoking habit

FOB in any hemoptysis without diagnosis: Increasing incidence of tumor even in age < 40 Overall % of cancer on long-term follow-up: 4% A variety of other non-tumor diagnoses by FOB LTH is unpredictable Low morbidity (0.08%) and mortality (0.01) of FOB

LTH: technical aspects of FOB

ENT evaluation is mandatory Aspiration channel > 2.6 mm of Ø Avoid FOB-related bleeding iatrogenia:

BronchiectasisCarcinoid tumorBronchial angiomasAneurysms of pulmonary arteryRemoval of old foreign body

Iatrogenic causes of LTH - 1 Surgical corrections of congenital heart disease Endobronchial brachytherapy Self-expanding, indwelling airway and esophageal stent-

related fistulas Bronchoscopy-related bleeding complications Migration to lung of vascular and heart (cardioverter

defribillator) patches Aortobronchial fistula after vascular aortic thoracic graft Coronary angiography with abciximab infusion Late bleeding after anticoagulation therapy in pulmonary

embolism Bronchial artery infusion of cytostatic therapy to treat

pulmonary metastasis

Iatrogenic causes of LTH - 2 Pulmonary irradiation Lymphoma and other mediastinal tumors

irradiation Catheter-induced pulmonary artery lesion Transtracheal aspiration Percutaneous lung aspiration Long-standing tracheostomy with

tracheoinnominate artery fistula Thrombolytic therapy, especially with

unsuspected cavitary lung disease Retained intrathoracic old gauze (“gauzeoma”) or

sponge

Iatrogenic causes of LTH - 3 Bronchovascular fistula after lung transplantation Drug-induced bleeding diathesis: DAH Intravascular migration of fractured sternal wire

after median sternotomy Positive pressure ventilation in patients with

cavitary tuberculosis Bronchovascular fistula after lung transplantation Bronchial stump aspergillosis in old

endobronchial silk thread sutures Hemoptysis secondary to veno-occlusive

pulmonary disease (VOPD) after Glen operation Pulmonary venous stenosis after catheter

radiofrequency ablation

Hellical CT in LTH

Great blood vessels disease Usually X-ray, FOB and BAE are first options Often confusing “mass-like” images in lung

parenchima Frequent accumulation of blood at the bottom of

both lungs. Relevance of accurate technique: thin section,

“helical CT”,…

General measures in LTH Immediate intubation and mechanical ventilation if

Asphyxia Hypovolemic shock

Evaluate admission to the respiratory and ICU Nothing by mouth Ipsilateral decubitus lying on the alleged bleeding site Intravenous line Evaluate local applicability of the general algorithmic

approach Provision to allow rapid blood replacement Control of bleeding speed and volume of expectorated

blood Chest radiograph Routine blood tests: consider specialized tests if indicated Consider specialized diagnostic procedures if indicated

LTH

General measures

Transitory measures to stop bleeding

Angiography with embolization

Identification of the anatomical origin of bleeding

Bronchoscopic measures

+

Is the patient stable and is resection technically feasible?

Is surgery 1st ? Appropriate medical treatment

Surgery

YES NO

YES

NO

Bronchial artery embolization (BAE) Anatomic variability both in number and localization Direct visualization of site of bleeding is very

difficult Sometimes hypervascularized areas are extensive

and bilateral Sometimes origin of bleeding is in collateral

systemic circulation Percentage of origin of bleeding in pulmonary

circulation is very low Risk if anterior spinal artery from bronchial artery

(<5%)

Complications of BAE Spinal complication (paraplegia) Chest pain Dysphagia Main-stem bronchus infarction Bronchial stenosis Splenic or other systemic infarct Bronchial-esophageal fistula Paradoxic embolization or migration of coil Pulmonary hypertension (if left-to-right shunt) Referres pain to the ipsilateral forehead and orbit

Drugs reported to be potentially effective in some causes of LTH Tranexamix acid, especially in mucoviscidosis* Vasopressin* Immunosupressive drugs and steroids in some

cases of DAH and vasculitis Recombinant activated factor VII (rFVIIa) Percutaneous intracavitary treatment in lung

fungal infection Cidofovir in juvenile laryngeal papillomatosis-

related multicystic disease Anticoagulant therapy in embolism Hormone: LAM; thoracic endometriosis Corrective therapy of coaguloptahies

* Anecdotal reports and uncontrolled studies