Management of Haemoptysis

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بسم الله الرحمن الرحيم

Management of Hemoptysis: 

Management of Hemoptysis By Chest Department Ainshams university

Definition: 

Definition Coughing up of blood or bloody sputum. Frightening event: Patients & ± Doctors Manifestation of underlying disease process. Amount varies: Trivial  large amount. Hemoptysis

Causes of hemoptysis : 

Causes of hemoptysis Common: Bronchitis Tuberculosis Bronchiectasis Bronchogenic carcinoma Pneumonia / Lung abscess Pulmonary embolism & infarction Left ventricular failure / MS Hemoptysis

Causes of hemoptysis : 

Causes of hemoptysis Uncommon: Other 1ry lung neoplasm / Metastatic malignancy Traumatic or Iatrogenic lung injury: Chest injury/ Bronchoscopy/ Lung biopsy/ Pulmonary artery catheterization. Rare: Fungal & parasitic infections - FB aspiration Alveolar hemorrhage syndromes Sarcoidosis - Endometriosis A-V malformation Idiopathic Thrombocytopenia / Coagulopathy Drug induced: Thrombolytics/Penicillamine/ Amiodarone Hemoptysis

Approach to management: 

Approach to management Does the patient truly have hemoptysis? Severity of hemoptysis? Presenting Clinical manifestation (s)? Diagnostic tests? Therapy of hemoptysis? Hemoptysis

Does the patient truly have hemoptysis? : 

Does the patient truly have hemoptysis? Upper airways: Spurious hemoptysis Spurious hemoptysis above vocal cords Teeth / Gums / mouth Factitious hemoptysis Nose / Pharynx / larynx History: Feeling of blood pooling in the mouth The need to clear the throat Epistaxis Not preceded by cough  Rhinoscopy / Laryngoscopy Hemoptysis

Does the patient truly have hemoptysis? : 

Does the patient truly have hemoptysis? GIT: Hematemesis Hemoptysis Hemoptysis Hematemesis History Chest or Cardiac disease Dyspepsia, Vomiting Retching, Epigastric pain Blood Bright red, alkaline with froth & sputum Coffee-ground, acidic + Food particles of vomitus Sputum Remains blood tinged for few days after the attack No sputum Stools Usually normal Melena Examination Evidence of chest or cardiac disease Epigastric tenderness, Liver cirrhosis, splenomegaly  Endoscopy

Does the patient truly have hemoptysis?: 

Does the patient truly have hemoptysis? Lower airways & Lung parenchyma True hemoptysis below vocal cords Hemoptysis  Lesions receive blood supply from Bronchial arteries and other systemic arteries Pulmonary circulation Communication between bronchial & pulmonary circulation. Mechanisms: Inflammation  congestion  erosion bleeds Engorged Vessels  bleeds Erosion or Rupture of Vessels bleeds Hemoptysis

? Severity of hemoptysis? : 

? Severity of hemoptysis? Volume of hemoptysis > 200 ml / day large Respiratory reserve Respiratory function & Gas exchange Massive hemoptysis: > 600 ml / 24 hour. Severe hemoptysis  Emergency intervention needed Hemoptysis

PowerPoint Presentation: 

Category Feature Disorder History Smoking Asbestos exposure Bronchogenic carcinoma Risk factors for aspiration (alcohol,swallowing disorder, loss of consciousness) Lung abscess, Pneumonia, FB aspiration Recent chest trauma or procedure Traumatic or Iatrogenic lung injury Medication & drug use Drug toxicity Previously diagnosed Pulmonary, Cardiac or Systemic disease Important clue Presenting Clinical manifestation (s)? Hemoptysis

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Category Feature Disorder Symptoms Hoarseness of voice Bronchogenic carcinoma Purulent-appearing sputum Pneumonia Lung abscess Bronchiectasis Bronchitis PND / Orthopnea MS/LVF Dyspnea & Pleuritic chest pain Pneumonia Pulmonary embolism Weight loss, Night sweats, Cough, Fever TB Bronchogenic carcinoma Presenting Clinical manifestation (s)? Hemoptysis

Presenting Clinical manifestation (s)? : 

Presenting Clinical manifestation (s)? Physical examination: Hemodynamic state Examination of Oropharynx & nasopharynx Careful cardiac auscultation Abdominal examination Local chest examination Hemoptysis

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Category Feature Disorder Signs Localized decrease in intensity of breath sounds, Localized wheeze Bronchogenic carcinoma, FB aspiration Bronchial breath sounds Pneumonia Pleural rub Pneumonia, Pulmonary embolism Diastolic murmur MS Clubbing of fingers Supprative lung disease S3 gallop LVF Presenting Clinical manifestation (s)? Hemoptysis

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Chest x-ray Localizing site & cause  60% Abnormal & Localizing  40% Normal or non localizing Hemoptysis Diagnostic tests?

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Radiographic findings Disorder (s) Nodule(s) or Mass (s) Bronchogenic carcinoma, Wegner`s granulomatosis, Fungal infection Atelectasis Bronchogenic carcinoma, FB aspiration Dilated peripheral airways Bronchiectasis Hilar / Mediastinal adenopathy Bronchogenic carcinoma, Fungal infection, Sarcoidosis Recticulonodular densities TB, Sarcoidosis Cavity / Cavities TB, fungal infection, Mycetoma Lung abscess, Bronchogenic carcinoma Air space consolidation Pneumonia, Alveolar hemorrhage, Pulmonary contusion Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

Diagnostic tests?: 

Diagnostic tests? Hemoptysis Computed Tomographic (CT) scan: Normal or non localizing C-XR  CT diagnose 50% e.g. (SPN, Bronchiectasis or cavity) After non diagnostic bronchoscopy  CT diagnose 30% Localizing C-XR  CT provides new source / additional information Special imaging techniques High resolution CT (1-3mm thickness section) Bronchiectasis Spiral CT with pulmonary angiography  Pulmonary embolism

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

Diagnostic tests?: 

Diagnostic tests? Hemoptysis Bronchoscopy Fiberoptic bronchoscopy (FOB) Localizing & Diagnosing source of hemoptysis. Central airways lesions  Direct visualization Peripheral lesions  Blood emerging from a segmental bronchi. Timing is debatable  within 24 hour of onset of bleeding.

Diagnostic tests?: 

Diagnostic tests? Hemoptysis Fiberoptic bronchoscopy (FOB) Non massive hemoptysis  Instillation of diluted adrenaline. Iced cooled saline. Wedging and temponade  Fogarty catheter balloon Bronchogenic carcinoma Localizing CXR  FOB 80% of malignancies Non Localizing CXR + CT  FOB 60% of malignancies Non malignant cause  FOB < 10%

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Hemoptysis

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Interventional equipments: Laser. Cryotherapy. Electrocautery . Hemoptysis

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Before After Hemoptysis

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Before After Hemoptysis

Diagnostic tests?: 

Diagnostic tests? Hemoptysis Laboratory examination Coagulation studies Arterial blood gasses (ABG) Complete blood picture (CBC) & ESR Urine analysis & renal function Collagen profile

Diagnostic tests?: 

Diagnostic tests? Hemoptysis Sputum examination Gross blood  infectious conditions Acid fast bacilli Culture Cytology PH

Diagnostic tests?: 

Diagnostic tests? Hemoptysis Angiography & Endovascular embolization Localizing site  bleeding blush or abnormal vasculature Pulmonary embolism Endovascular Embolization Bronchial artery & related collateral vasculature Embolization of Spinal arteries  paralysis Indications: Not responding to conservative measures. Recurrent or persistent hemoptysis

Therapy of hemoptysis?: 

Therapy of hemoptysis? Hemoptysis Severity of hemoptysis Specific cause of hemoptysis Goals Protect airways Identify bleeding site & protect uninvolved lung Control bleeding Treat primary cause

Therapy of hemoptysis?: 

Therapy of hemoptysis? Hemoptysis Non massive hemoptysis Initial evaluation Sputum studies: gram, ZN, Culture CT scan chest: Conventional ,HRCT, with pulmonary angiography Laboratory investigations: Coagulation studies, ABG, CBC, ESR, Urine analysis, renal function & Collagen profile Echocardiography Fiberoptic bronchoscopy Treatment is Directed to underlying cause

Therapy of hemoptysis?: 

Therapy of hemoptysis? Hemoptysis Massive hemoptysis Conservative Medical treatment Endotracheal tube : risk of asphyxiation Single wide bore or double lumen IV line : Blood, plasma transfusion, fluids Positioning : sitting or disease site down most Cough suppressant : Codeine sulphate 15 mg Oxygen supplementation / Assisted ventilation Benzodiazepime Treatment of Coagulopathy if present Pitressin (Vasopressin)??

Therapy for hemoptysis?: 

Therapy for hemoptysis? Hemoptysis Endobronchial treatment Aim: identify Source, Rate & to Slow or Stop bleeding Rigid bronchoscopy Endovascular Angiography embolization Surgical Lung resection (emergency) Mortality 30% Elective surgery after stabilization Collapse therapy

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Patient with hemoptysis History & physical examination Establish true hemoptysis Exclude Hematemesis ENT source Chest x-ray CBC , Coagulation studies Blood transfusion matching ABG Severity of hemoptysis

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Severity of hemoptysis Mild Intermittent bleeding Moderate Actively bleeding Massive Elective work up Sputum studies CT scan chest Other laboratory invest. Fiberoptic bronchoscopy Establish etiology & treat specific disease Admit for observation Conservative therapy Sputum studies CT scan chest Other laboratory invest. Treat infection, if present Fiberoptic bronchoscopy Hemoptysis stopped Hemoptysis continues Resection / Embolization Emergency ICU admission

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Massive hemoptysis co Conservative medical treatment • IV line • Positioning • Cough suppressant • Oxygen supplementation / Assisted ventilation • Benzodiazepime • TTT of Coagulopathy if present Rigid bronchoscopy • Special catheters & tubes : ET, double lumen ET, Fogerty • Wash, suction , iced saline, diluted adrenaline • Interventional procedure: laser,electro, Cryo Emergency ICU admission Hemoptysis stopped Hemoptysis continue Resection / Embolization Sputum studies CT scan chest Other laboratory invest. Establish etiology & treat specific disease

Thank You: 

Thank You Hemoptysis