by Prof Arvind Mishra MD Department of medicine What is Hemoptysis Expectoration of blood from respiratory tract from streaking to massive amount Massive Hemoptysis Expectoration of gt100600ml over a 24hr period ID: 278025
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Slide1
HEMOPTYSIS
by Prof.
Arvind
Mishra
M.D.
Department of medicineSlide2
What is Hemoptysis
Expectoration of blood from respiratory tract
(from streaking to massive amount)Slide3
Massive Hemoptysis
Expectoration of >100-600ml over a 24hr period
Acute life threatening condition.
Blood can fill the airways and the alveolar spaces.
Seriously disturbing gas exchange and may lead to asphyxia.Slide4
Establish Hemoptysis
Should be differentiated from
hemetemesis
.
Fresh blood and froth on coughing.
Altered blood ( brown) with food particles in vomit.
Associated features.
DilemmaSlide5
Once established, evaluate etiology
Bleeding from tracheobronchial tree
Neoplasms- Bronchogenic CA
Bronchitis – Acute/ Chronic
Bronchiectesis
Airways trauma
Foreign BodySlide6
B. Pulmonary
Parenchymal Diseases
Tuberculosis
Lung Abscess
Pneumonia
Wegner’s
Granulomatosis
Good Pasture’s SyndromeSlide7
C. Primary
Vascular Diseases
Mitral Stenosis
Pulmonary Embolism
A V MalformationsSlide8
D. Miscellaneous
Systemic Coagulopathy
Pt. on Anticoagulants / Thrombolytic agentsSlide9
Approach
HISTORY
Blood streaking with
mucopurelent
sputum -- Bronchitis
Fever with chills+ Blood with rusty sputum – Pneumonia
Blood + putrid sputum - Lung abscess
Blood + copious sputum -
Bronchiectesis
Hemoptysis following acute onset of
pleuritic
Chest pain with
dyspnoea
–
Pulm.Embolism
Slide10
H/O coexisting Disorders
Renal disease-Good Pasture’s Syndrome
Wegner’s
Granulomatosis
Lupus
Eyrthematosus
-Lupus Pneumonia
Non pulmonary malignancy-
Endobronchial
metastasis
AIDS-Kaposi’s Sarcoma
Risk factors for Bronchogenic CA-Smoking
AsbestosisSlide11
Also ask for
previous bleeding disorders
treatment with anticoagulants
use of drugs leading to thrombocytopenia Slide12
PHYSICAL EXAM.
Pleural friction rub-Pulmonary Embolism
Localised
/Diffuse
crepts
-Parenchymal dis.
Evidence of airflow
obstr
.-
Chr.Bronchitis
Ronchi
+Crackles-
Bronchiectesis
CVS-
Pulm.Hpt
., Mitral stenosis, LVFSlide13
Diagnostic Evaluation
Chest radiograph/CT Scan-- mass lesion,
bronchiectatic
Changes, focal areas of pneumonitis.
CBC
Coagulation profile
Assessment of renal profile– urine
analysis,Blood
urea,S.Creatinine
Sputum– Gm. Staining, C/SSlide14
Fibreoptic
bronchoscopy– useful for
localising
the
siteof
bleeding and for visualisation of
endobronchial
lesions.
Rigid bronchoscopy– preferred when bleeding is massive because this procedure has better airways control and greater suction capability.Slide15
Treatment
What determines the urgency of management
-Rapidity of bleeding
-Effect on gas exchange
(A) If streaking or small amount of blood-Diagnosis is priority.
(B) If massive—
Mx
. Is top prioritySlide16
Maintaining adequate gas exchange.
Preventing blood spilling into unaffected areas of the lung. Keep the affected lung in the dependent position to avoid aspiration of blood into the unaffected lung.
Avoid asphyxiation
Keep patient at rest/provide codeine containing cough suppressants- may help to stop bleeding.Slide17
Management of massive bleeding
May necessitate -
Endobronchial
intubation
- Mechanical ventilation
to control airways and maintain adequate gas exchange.
To avoid blood spilling into contralateral lung
(1)Selective intubation of non
bleeding lung
(
2)Use of specially designed double lumen endotracheal tubes. Slide18
Another option- Inserting a
ballon
catheter through a bronchoscope under direct vision and inflating the
ballon
to occlude the branches leading to bleeding site.Slide19
Other techniques
Laser Phototherapy
Electrocautery
Bronchial artery embolism
Surgical resectionSlide20
Bronchial artery
embolisation
-it involves an
arteriographic
procedure in which a vessel proximal to bleeding site is
cannulated and a material such as
Gelfoam
is injected to occlude the bleeding vessel.Slide21
Surgical resection of involved area of the lung—(a) Emergency therapy of life threatening hemoptysis that fails to respond to other measures.
(b) For the elective but definitive management of
localised
disease subject to
recurrent bleeding.Slide22
MCQs
1)Hemoptysis in mitral stenosis occurs due to-
a)Left atrial enlargement
b)Right ventricular hypertrophy
c)Bronchial arterial bleed
d)Pulmonary venous congestionSlide23
2)A chronic smoker patient presenting with superior vena
caval
syndrome with hemoptysis.
Most likely cause is-
a)
Intrathoracic
tubercular lymphadenitis
b)Bronchogenic CA
c)Lymphoma
d)Aortic arch syndromeSlide24
3)A patient presenting with high fever ,chest pain and hemoptysis. CXR –Air
bronchogram
sign present-
a)Lobar pneumonia
b)Lung abscess
c)Bronchiectasis
d)Bronchogenic CASlide25
4)A patient of hemoptysis presents with normal CXR. Suggest the next best investigation to help
Dx
-
a)Sputum cytology
b)Bronchoscopy
c)
Thoracoscopy
d)HRCT Thorax