Feb-march-2016

HEMOPTYSIS: A COMMON RESPIRATORY EMERGENCY

Authors: Dr. Zia Hashim

Hemoptysis is a common respiratory emergency, which means coughing of blood, should never be dismissed without careful evaluation. Haemoptysis should be differentiated from:

  • Haematemesis: Vomiting of blood from the gastrointestinal (GI) tract.
  • Pseudohaemoptysis: Where a cough reflex is stimulated by blood not derived from the lungs or bronchial tubes. This may be from the oral cavity or nasopharynx (eg, following an epistaxis) or following aspiration of haematemesis into the lungs.

Table 1: Difference between hemoptysis and hematemesis:

Hemoptysis

Hematemesis

History

 

Absence of nausea and vomiting

Presence of nausea and vomiting

Pulmonary disease

Gastric or liver disease

Sputum

 

Frothy

Not frothy

Liquid or clotted

Coffee ground

Bright red

Brown to black

Laboratory

 

Alkaline pH

Acidic pH

Mixed with macrophages and neutrophils

Mixed with food particles



Pathophysiology: Most of the lung’s blood (95%) circulates through low-pressure pulmonary arteries whereas about 5% of the blood supply circulates through high-pressure bronchial arteries. In hemoptysis, the blood generally arises from this bronchial circulation, except when pulmonary arteries are damaged by trauma, by erosion of a lymph node or tumor.

Figure 1: Bronchial arteries

Clinical assessment:
Severity:

The severity of haemoptysis has been arbitrarily classified depending on the amount of blood expectorated.
  • Mild: 100 mL in 24 h
  • Moderate: 100-600 mL in 24 h
  • Massive: > 600 mL in 24 h or > 30 mL/h

History of present illness:

It should cover the duration and onset, provoking factors (eg, exertion, position etc), and approximate volume of hemoptysis (eg, streaking, teaspoon, cup etc).

Review of systems:

One should seek symptoms suggesting possible causes, including fever and sputum production (pneumonia); night sweats, weight loss, and fatigue (cancer, TB); chest pain and dyspnea (pneumonia, pulmonary embolism); leg pain and leg swelling (pulmonary embolism) etc. Patients should be asked about risk factors for causes. These risk factors include HIV infection, use of immunosuppressants (TB, fungal infection); exposure to TB; long smoking history (cancer); and recent immobilization or surgery etc

Past medical history

should cover known conditions that can cause hemoptysis, including chronic lung disease (eg, COPD, bronchiectasis, TB, cystic fibrosis), cancer, bleeding disorders, heart failure, thoracic aortic aneurysm etc

Physical examination:

Vital signs are reviewed for fever, tachycardia, tachypnea, and low O2 saturation. Severity of Anemia is assessed. Constitutional signs (eg, cachexia) and level of patient distress (eg, accessory muscle use, pursed lip breathing, agitation, decreased level of consciousness) should also be noted. A full lung examination is done, particularly including adequacy of air entry and exit, symmetry of breath sounds, and presence of crackles, rhonchi, stridor, and wheezing. Signs of consolidation (eg, egophony, dullness to percussion) should be sought. The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy (suggesting cancer or TB). Neck veins should be inspected for distention, and the legs and presacral area should be palpated for pitting edema (suggesting heart failure). Heart sounds should be auscultated with notation of any extra heart sounds or murmur that might support a diagnosis of heart failure and elevated pulmonary pressure. The abdominal examination should focus on signs of hepatic congestion or masses, which could suggest either cancer or hematemesis from potential esophageal varices. The skin and mucous membranes should be examined for ecchymoses, petechiae, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa.

Figure 1: Bronchial arteries


Causes:

Common:

  • Bronchial Ca
  • Tuberculosis
  • Necrotizing Pneumonia
  • Acute Bronchitis
  • Bronchiectasis Lung Abscess
  • Pulmonary Infarctions
Uncommon:

  • Mitral Stenosis
  • Aspergilloma
  • Bronchial Adnoma
  • Foreign body
  • Chest trauma
  • Tracheal tumours
  • Metastatic pulmonary disease
  • Blood dyscrasias & anticoagulants
  • Connective tissue disease
  • Idiopathic pulmonary hemosiderosis
  • Goodpasture’s syndrome
  • Iatrogenic
  • Post transbronchial lung biopsy
  • Post transthoracic biopsy

Investigations:

The investigations of Hemoptysis can often be carried out as outpatient, but patients with significant bleeding should be admitted.

First-line investigations
  • Blood tests: FBC, clotting, grouping. If syst vasculitis is suspected, renal function & urine dip & microscopy for casts are necessary, as well as autoantibodies-ANCA, anti-GBM & ANA
  • Sputum tests: Cytology, AFB, Fungal culture, Bacterial culture etc
  • CXR: To show mass lesion, consolidation, bronchiectasis etc
  • CT Thorax
  • Bronchoscopy: To visualize the airway & to localize the site of bleeding.

Second line Investigations:

Usually done if first line investigations fail to demonstrate a cause.
  • CT Pulmonary angiography to exclude PE
  • Bronchial angiogram: diagnostic & therapeutic. Usually done during an episode of bleeding to maximize the chance of identifying the site of bleeding.
  • Bronchial artery embolization: Therapeutic approach to embolize the bleeding artery usually with coils.
  • Echocardiogram: To rule out cardiac disorder
  • s

Cryptogenic hemoptysis: In approx one third of cases, despite appropriate investigations, no cause for the hemoptysis can be found. However, this has a good prognosis. Often the hemoptysis will settle without treatment & will become less worrying to the patient over time, especially as investigations have failed to determine the cause.

Management:

Massive hemoptysis is a life threatening emergency associated with significant mortality. Initial treatment of massive hemoptysis has two objectives:
  • Prevent aspiration of blood into the uninvolved lung (which can cause asphyxiation)
  • Prevent exsanguination from ongoing bleeding & maintainance of ventilation

Protection of non bleeding lung is vital to maintain adequate gas exchange.

  • This may involve lying on the bleeding side (to prevent blood flowing into unaffected lung)
  • Intubation with double lumen tube.

Cardiovascular Support:

  • Large bore/Central venous access
  • Fluid resuscitation ±transfusion
  • Reverse anticoagulants
  • Inotropes
  • Oral tranexamic acid (500mg three times a day, not if severe renal failure)
  • Early bronchoscopy – diagnostic & therapeutic
  • Rigid bronchoscopy (with GA) is preferable. May allow localization of the site of bleeding; balloon tamponade with a Fogarty cathater.
  • Bronchial artery embolization – therapeutic approach to embolize bleeding artery, usually with coils or glue
  • Surgery – resection of bleeding lobe (if all measures have failed)