JR1 MED DEFINITION Expectoration of blood from the respiratory tract Can arise from anywhere in the respiratory tract from glottis to alveolus The word HEMOPTYSIS comes from the Greek word ID: 1047581
Download Presentation The PPT/PDF document "APPROACH TO HEMOPTYSIS DR.ARABHI SAJI" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. APPROACH TO HEMOPTYSISDR.ARABHI SAJIJR1 MED
2. DEFINITIONExpectoration of blood from the respiratory tractCan arise from anywhere in the respiratory tract from glottis to alveolusThe word HEMOPTYSIS comes from the Greek word “haima” meaning “blood” and “ptysis” which means “spitting”.
3. Massive Hemoptysis>400ml of blood in 24hour OR >150ml at one time
4. ANATOMY AND PHYSIOLOGYThe lungs are supplied with a dual circulationThe pulmonary arteries arise from the right ventricle to supply the pulmonary parenchyma in a low-pressure circuitThe bronchial arteries arise from the aorta or intercostal arteries and carry blood under high systemic pressue to the airways,blood vessels and visceral pleura
5. ANATOMY AND PHYSIOLOGYAlthough the bronchial circulation represents only 1-2% of total pulmonary blood flow, it can increase dramatically under conditions of chronic inflammation (eg; chronic bronchiectasis) and is frequently the source of hemoptysisBlood can fill the airways and the alveolar spaces causing not only serious gas exchange disturbance but also asphyxiation.
6. Causes of HemoptysisTRACHEOBRONCHIAL CAUSESBronchitis ( acute and chronic)BronchiectasisForeign bodyTumors (Bronchial carcinoma, Tracheal and laryngeal tumors)Bronchial telangectasia
7. Causes of HemoptysisPULMONARY CAUSESTuberculosisTumorsPneumoniaAbscessInfarctionTraumaVasculitis and Collagen disordersCystic fibrosisAlveolar hemorrhageAVM
8. Causes of HemoptysisCARDIOVASCULAR CAUSESLeft ventricular failureMitral stenosisAortic aneurysmOTHER CAUSESBlood disordersAnticoagulant therapy
9.
10. Mechanism and sources of HemoptysisSourcesBronchial Circulation (mc)Pulmonary circulationAnastamosis between pulmonary and bronchial circulationMECHANISMSVessel engorgementErosion or rupture of vesselsMucosal ulcerationsVascular granulation tissue
11. Clinical approach for management of hemoptysisMake sure that it is True hemoptysisIdentify the severity of hemoptysisClinical clues in history and examinationDiagnostic investigationsAppropriate treatment
12. True hemoptysis vs. Spurious (false) hemoptysisTRUE HEMOPTYSISFALSE HEMOPTYSISBelow vocal cordsAbove vocal cordsPersists as blood tinged sputumDoes not persistMay be mixed with sputumNot mixed with sputumHistory of cardiopulmonary dsObvious by ENT examinationCXR may be abnormalNormal CXR
13. Hemoptysis vs. HemetemesisHEMOPTYSISHEMETEMESISCoughing of bloodVomiting of bloodH/o cardiopulmonary dsh/o GIT dsBright red in colourDark brown in colourSputum remains blood stained after the attack for few daysUsually followed by melenaBlood mixed with sputumMixed with gastric contentsAlkalineAcidic Blood is frothyAirless Sputum contains hemosiderin laden macrophagesAbsent
14. Important points to address in historyCLINICAL CLUESSUGGESTED DIAGNOSISAnticoagulant useMedication effect, coagulation disorderAssociated with mensesCatamenial hemoptysisDOE, fatigue, orthopnea,PND, frothy pink sputumCHF, LV dysfunction, MSFever, productive coughURTI, Acute bronchitis, pneumonia, lung abscessh/o breast, colon, renal cancersEndobronchial metastatic lung dsh/o chronic lung ds, recurrent LRTI, cough with copious sputumBronchiectasis, lung abscessMelena, alcoholism, chronic use of NSAIDsGastritis, gastric or peptic ulcers, esophageal varicesPleuritic chest pain, calf tendernessPE or infarctionTobacco useA/c or c/c bronchitis, lung CA, pneumoniaEvening rise of temp, coughTBWeight lossEmphysema, TB, lung CA, bronchiectasis, lung abscess
15. Clinical clues in ExaminationCLINICAL CLUESSUGGESTED DIAGNOSISCachexia, clubbing, hoarseness, cushing’s syndrome, hyperpigmentation, horner’s syndromeBronchogenic CA, SCLCClubbing Lung CA, bronchiectasis, lung abscessDullness to percussion, fever, crepitationsPneumonia Fever, tachypnea, hypoxia, working accessory respiratory muscles, barrel chest, intercostal retractions, pursed lip breathing, rhonchiCOPDGingival thickening, saddle nose, nasal septum perforationWegener’s granulomatosisMid diastolic rumbling murmurMSLN enlargement, cachexia, violaceous skin lesionsKaposi’s sarcoma 2ry to HIVTachypnea, tachycardia, dyspnea, S1Q3T3, pleural friction rub, unilateral leg pain, edemaPulmonary thromboembolismOrofacial and mucous membrane telangiectasia, epistaxisOsler – weber- rendu dsTachycardia , tachypnea, hypoxia, congested neck veins, S3 gallop, bilateral fine basal crepitationsCHF caused by LV dysfunction or MS
16. Investigations1.Chest X-ray 2.CT scan of chest3.Sputum for - AFB stain and culture -Gram stain and culture - Malignant cells4. Full blood count5. Other hematological studies including coagulation profile6.Bronchoscopy : Flexible and rigid7. Bronchial arteriography8. Pulmonary angiography9. Ventilation – perfusion lung scan
17. Diagnosis – Chest radiographCHEST RADIOGRAPHSUGGESTIVE DIAGNOSISCardiomegaly, increased pulmonary vascular distributionCHF, MSCavitatory lesionsLung abscess, TB, necrotizing pneumoniaDiffuse alveolar infiltratesHeart failure, pulmonary edema, aspirationHilar adenopathy or massCarcinoma, metastatic ds, infectionHyperinflation COPDLobar or segmental infiltratesPneumonia, thromboembolism, obstructing carcinomaMass lesion, nodules, granulomasCarcinoma, metastatic ds, wegener’s granulomatosis, septic embolismPatchy alveolar infiltratesBleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture’s syndrome
18. Diagnosis – CT scanTomography is valuable in selected cases to better show the presence of lung cavities, solid masses and mediastinal & hilar lymphadenopathyIts complementary use with Fibreoptic bronchoscopy gives a greater positive yield of pathology and is useful for excluding malignancy in high-risk patientsAllows application of special imaging techniques EG; 1. HRCT (1-3mm thickness section ) : Bronchiectasis 2. Spiral CT with pulmonary angiography : PE
19. Diagnosis – Fiberoptic Bronchoscopy (FOB)ADVANTAGESIt is diagnostic for central endobronchial lesions.Allows direct visualisation of bleeding site.Permits tissue biopsy, bronchial lavage or brushings for pathologic diagnosisFOB also can provide direct therapy in cases of non-massive hemoptysis - Instillation of diluted adrenaline - Ice cooled saline - Wedging and tamponade using Fogarty balloon
20.
21. Diagnosis : Rigid bronchoscopyADVANTAGESWide suction channelEnsures ventilationAllows Interventional procedure application in cases of massive hemoptysis ( Eg: Laser, Electrocautery, Cryotherapy)DISADVANTAGESRequires general anesthesiaNeeds special skills.
22.
23. Diagnosis : AngiographyADVANTAGESGold standard diagnostic tool for suspected PE.Diagnosis of arteriovenous malformationAllows management of some cases of hemoptysis using endovascular embolizationDISADVANTAGESEmbolization of spinal arteries – ParaplegiaNeeds special skills.
24.
25. MANAGEMENTManagement of hemoptysis depends on the primary conditionIn mild/ non- massive hemoptysis with preserved gas exchange establishing a diagnosis is the first priority followed by treatment of the causeKeeping the patient at rest and partially suppressing cough may help the bleeding to subside
26. Management of Massive HemoptysisGOALSEvaluate the severity of hemoptysisAirway protection and patencyIdentify the site of bleedingProtect the contralateral uninvolved lungStop the bleedingTreat the cause of bleeding
27. Management of Massive HemoptysisAIRWAY PROTECTION AND VENTILATIONProtection of the non-bleeding lung is vital to maintain adequate gas exchangeThis may involve either sitting the patient up or lying on the bleeding side (to prevent blood from flowing into the unaffected lung and causing asphyxiation) , or intubation with a double-lumen tube.If intubation is not needed or not appropriate, give high flow oxygen
28. Management of Massive HemoptysisCARDIOVASCULAR SUPPORTFluid resuscitation +/- TransfusionCorrect clotting (Vit K, Platelets)Inotropes if requiredNebulization with adrenaline (1ml of 1:1000 – made 5ml with normal saline)Oral or IV Tranexamic acidIV Terlipressin 2mg, then 1-2mg every 4-6hr if continued bleeding
29. Management of Massive HemoptysisEarly diagnostic or therapeutic bronchoscopyRigid bronchoscopy is preferable. May allow localization of the site of bleeding – balloon tamponade with a Fogarty catheterOther modalities for control of significant bleeding : - Laser phototherapy - Electrocautery - Bronchial arteriography and embolisation
30. Management of Massive HemoptysisSURGICALSurgical procedures are classified into 4 groups :Pulmonary resections (Pneumonectomy, Lobectomy, Wedge resections, Segmentectomy)Collapse therapyCavernostomiesIntrathoracic vascular ligatures
31. Urgent surgery (ie; within 24 – 48 hours after initial control) is required only in cases of fungal ball, lung abscess , failure of any control method, presence of cavity, obstruction of the main or lobar bronchus with a clot that cannot be suctioned during a rigid bronchoscope.Medically treated patients probably have a higher risk of re-bleeding within the first 6 months.
32.
33. THANK YOU