HAEMOPTYSIS

ALVIN KOSASIH

INTRODUCTION AND DEFINITION Hemoptysis or haemoptysis is the expectoration (coughing up) of bloo or of bloo ! staine sputum from the bronchi" larynx" trachea" or lungs (e#g# in tuberculosis or other respiratory infections)# Although there is no generally accepte efinition of the $olume of bloo that constitutes a massi$e haemoptysis" stu ies ha$e %uote $olumes ranging from &'' ml up to or more than &''' ml per ay#( As the anatomical ea space of the ma)or air*ays is &''+('' ml" a more rele$ant efinition of massi$e haemoptysis is the $olume that is life threatening by $irtue of air*ay obstruction or bloo loss#,Haemoptysis may be the presenting symptom of a number of iseases"&( *ith an associate mortality ranging from ./ to 0'/#0+, Although fe*er than ,/ of patients presenting *ith haemoptysis expectorate large $olumes of bloo " the explosi$e clinical presentation an the unpre ictable course of life threatening haemoptysis eman s prompt e$aluation an management# 1e ha$e re$ie*e the aetiology of massi$e haemoptysis an al$eolar haemorrhage" *ith particular reference to current iagnostic an therapeutic strategies# AETIOLOGY 2his can be ue to bronchitis or pneumonia most commonly" but also to lung neoplasm (in smo3ers" *hen hemoptysis is persistent)" aspergilloma" tuberculosis" bronchiectasis" cocci ioi omycosis" pulmonary embolism" or pneumonic plague# 4arer causes inclu e here itary hemorrhagic telangiectasia (HH2 or 4en u!Osler!1eber syn rome)" or 5oo pasture6s syn rome an 1egener6s granulomatosis# In chil ren it is commonly ue to a foreign bo y in the respiratory tract# It can result from o$er!anticoagulation from treatment by rugs such as *arfarin# 7ar iac causes li3e congesti$e heart failure an mitral stenosis shoul be rule out# 2he origin of bloo can be 3no*n by obser$ing its color# 8right re " foamy bloo comes from the respiratory tract *hile ar3 re " coffee!colore bloo comes from the gastrointestinal tract# 9xtensi$e in)ury can cause one to cough up bloo # :or massi$e haemoptysis" it is important to establish that the lung is the source of blee ing" in part by exclu ing the nasopharynx or gastrointestinal tract# 2he most common causes of massi$e haemoptysis are liste in box &# Haemoptysis originates from the bronchial an pulmonary circulation in ;'/ an ,/ of cases" respecti$ely#. 8lee ing from the bronchial arteries has the propensity to cause massi$e haemoptysis as it is a circulation at systemic pressure# Al$eolar haemorrhage is a recognise cause of haemoptysis" but rarely causes massi$e blee ing as the al$eoli ha$e the capacity to accommo ate a large $olume of bloo #< A more common presentation is mil haemoptysis" pulmonary infiltrates" an anaemia#( 7hronic inflammatory con itions (inclu ing bronchiectasis" tuberculosis" lung abscess) an lung malignancies are the most common causes of massi$e haemoptysis#; &' Similarly" blee ing may occur from a mycetoma in the presence of ca$itating lung isease#&& &( 2he concurrent e$elopment of haemoptysis an menstruation points to a iagnosis of catamenial haemoptysis# 2he presence of haemoptysis an spontaneous pneu!mothorax in a *oman of chil bearing age *ith iffuse interstitial abnormalities on the chest ra iograph shoul raise the suspicion of lymphangioleiomyomatosis#&2he presence of a sa le nose" rhinitis" or perforate nasal septum may suggest a iagnosis of 1egener=s granulomatosis#&. :eatures of 8eh!cet=s isease inclu e oral or genital ulceration" u$eitis" cutaneous no ules" an pulmonary artery aneurysm *hich is associate *ith a 0'/ ( year mortality rate#&< Although haematuria may be present in association *ith 5oo pasture=s isease" ,+&'/ of patients present *ithout clinical e$i ence of renal isease#<

DIAGNOSTIC PROCEDURES Sputum shoul be sent for microbiological in$estigation" inclu ing staining an culture for mycobacteria" an cytologi!cal examination if the patient is a smo3er an o$er >' years of age# 7hest ra iography may help to i entify causati$e lesions or infiltrates resulting from pulmonary haemorrhage" but fails to localise the lesion in ('+>-/ of patients *ith haemoptysis#&; A 72 scan may sho* small bronchial carcinomas or localise bronchiectasis#&0 (' (& 2he use of contrast may help to i entify $ascular abnormalities such as arterio$enous malformations or aneurysms#&> (( ?espite all in$estigati$e proce ures" the aetiology of haemoptysis is un3no*n in up to ,+&'/ of patients#. All the proce ures sho*n in :igure (A

Figure 2A. Diagnosti !ro e"ures #or $e%o!t&sis on"ition MANAGEMENT OF MASSI'E HAEMOPTYSIS 2he initial approach to managing life threatening haemorrhage in$ol$es resuscitation an protecting the air*ay (fig 0)" the secon step is irecte at localising the site an cause of blee ing" an the final step in$ol$es the application of efiniti$e an specific treatments to pre$ent recurrent blee ing# Air(a& !rote tion an" resus itation All patients *ith massi$e haemoptysis shoul be monitore in an intensi$e care unit (I7@) or

high epen ency unit (H?@) an the patient=s fitness for surgery establishe # Attempts shoul be ma e to etermine the si e of blee ing an the patient positione *ith the blee ing si e o*n to pre$ent aspiration into the unaffecte lung# 8loo loss shoul be treate *ith $olume resuscitation" bloo transfusion" an correction of coagulopathy# If large $olume blee ing continues or the air*ay is compromise " the patient=s trachea shoul be intubate *ith as large an en otracheal tube as is possible to allo* a e%uate suctioning an access for bronchoscopy#( If the blee ing can only be localise to the right or left lung" unilateral lung intubation may protect the non!blee ing lung#(0 :or right si e blee ing a bronchoscope may be irecte into the left main bronchus *hich can then be selecti$ely intubate o$er the bronchoscope *ith the patient lying in the right lateral position (fig >)# 2he left lung is then protecte from aspiration an selecti$ely $entilate # :or a left si e blee ing source the patient is place in the left lateral position an selecti$e intubation of the right lung may be performe " but this may lea to occlusion of the right upper lobe bronchus#( An alternati$e strategy is to pass an en otracheal tube o$er the bronchoscope into the trachea# A :ogarty catheter (siAe &> :renchB&'' cm length) may then be passe through the $ocal cor s besi e the en otracheal tube" irecte by the broncho!scope into the left main bronchus an inflate (fig ,)# 2his pre$ents aspiration of bloo from the left lung an the en otracheal tube positione in the trachea allo*s $entilation of the unaffecte right lung# An alternati$e strategy for unilateral blee ing is to pass a ouble lumen en otracheal tube" *hich allo*s isolation an $entilation of the normal lung an pre$ents aspiration from the si e in$ol$e by blee ing (fig -)#( Ho*e$er" inserting ouble lumen tubes shoul only be performe by experience operators to a$oi the serious conse%uences of poor positioning#(>

I"enti#&ing t$e site an" ause o# )*ee"ing Crecise localisation of the blee ing site irects efiniti$e treatment# :ibreoptic bronchoscopy an angiography are the mo alities of choice to localise the site of blee ing an to allo* therapeutic inter$ention" although the timing of broncho!scopy is contro$ersial#(, (9arly compare *ith elaye bronchoscopy gi$es a higher yiel for localising the site of blee ing#(- In contrast to mil haemoptysis" localisation of the site of blee ing is essential in the management of massi$e haemoptysis an urgent bronchoscopy shoul be consi ere #. :ibreoptic bronchoscopy can be performe at the be si e an allo*s $isualisation of more peripheral an upper lobe lesions" but has a limite suction capacity#(, (- 4igi broncho!scopy pro$i es superior suction to maintain air*ay patency" but it has a limite ability to i entify peripheral lesions an oes not permit goo $ie*s of the upper lobes#0 It is usually performe un er general anaesthetic but can be performe un er local anaesthesia an se ation in experience han s#(. 2he techni%ues can be combine *hen the fibreoptic bronchoscope is passe through the lumen of the rigi bron!choscope# +ron $os o!i treat%ent Instillation of epinephrine (&D(' ''') is a $ocate to control blee ing" although its efficacy in life threatening haemoptysis is uncertain#( 2he topical application of thrombin an thrombin!fibrinogen solutions has also ha some success" but further stu y is re%uire before *i esprea use can be recommen e #(< In massi$e haemoptysis" isolation of a blee ing segment *ith a balloon catheter may pre$ent aspiration of bloo into the large air*ays" thereby maintaining air*ay patency an oxygenation# Ha$ing i entifie the segmental bronchus that is the source of blee ing" the bronchoscope is *e ge in the orifice# A siAe >+. :r ('' cm balloon catheter is passe through the *or3ing channel of the bronchoscope an the balloon is inflate in the affecte segment" isolating the blee ing site (fig .)#( A ouble lumen balloon catheter (- :r" &.' cm long) *ith a etachable $al$e at the proximal en has recently been esigne that passes through the bronchoscope channel an allo*s the remo$al of the bronchoscope *ithout any mo ification of the catheter#(; 2he secon channel of the catheter may also be use to instil $asoacti$e rugs to help control blee ing# 2he bronchoscope can then be remo$e o$er the catheter" *hich is left in place for (> hours# 2he balloon may be eflate un er controlle con itions *ith bronchoscopic $isualisation an the catheter remo$e if the blee ing has stoppe # 2he prolonge use of balloon tampona e catheters shoul be a$oi e to pre$ent ischaemic mucosal in)ury an post!obstructi$e pneumonia# 9n obronchial tampona e shoul only be applie as a temporary measure until a more efiniti$e therapeutic proce ure can be eploye # Neo ymium!yttrium!aluminium!garnet (N !EA5) laser photocoagulation has been use *ith some success in the management of massi$e haemorrhage associate *ith irectly $isualise en obronchial lesions#0' Ho*e$er" targeting the culprit $essel *ith the laser beam can be ifficult in the presence of ongoing blee ing#

+ron $ia* arter& e%)o*isation ,+AE2his *as first reporte by 4emy an colleagues in &;.00& an management of life threatening haemoptysis#('

is increasingly use

in the

2he proce ure in$ol$es the initial i entification of the blee ing $essel by selecti$e bronchial artery cannula!tion" an the subse%uent in)ection of particles (poly$inyl alcohol foam" isobutyl!(!cyanoacrylate" 5ianturco steel coils or absorbable gelatin ple gets) into the fee ing $essel (fig ()# A number of features pro$i e clues to the bronchial artery as the source of blee ing" inclu ing the infre%uent i entification of extra$asate ye or the $isualisation of tortuous $essels of increase calibre or aneurysmal ilatation#0( 2he imme iate success rates for control of massi$e haemoptysis is excellent" ranging from ->/ to &''/" although recurrent non!massi$e blee ing has been reporte in &-+>-/ of patients#0(+0, 2echnical failure of 8A9 occurs in up to &0/ of cases an is largely cause by non!bronchial artery collaterals from systemic $essels such as the phrenic" intercostal" mammary" or subcla$ian arteries#0, 7omplications of 8A9 inclu e $essel perforation" intimal tears" chest pain" pyrexia" haemoptysis" systemic embolisation" an neurological complications# 1hen the anterior spinal artery is i entifie as originating from the bronchial artery" embolisation is often eferre o*ing to the :ogariy catheter can be passe $ia suction channel of fibreoptic bronchoscope or rigi bronchoscope an inflate in a segmental bronchus to isolate the source of blee ing ris3 of infarction an paraparesis#0(

2he e$elopment an application of coaxial microcatheter systems allo*s more selecti$e catheterisation an embolisation of branches of the bronchial arteries" thereby re ucing the ris3 of occlu ing branches such as the anterior spinal artery#0> Surgi a* %anage%ent Surgery is consi ere for the management of localise lesions# Surgical mortality ranges from &/ to ,'/ in ifferent series epen ing on selection criteria" but bias in the selection of can i ates for surgery limits a irect comparison *ith me ical treatment#( Surgery is contrain icate in patients *ith ina e%uate respiratory reser$e or those *ith inoperable lung cancer ue to irect thoracic sprea # Surgical resection is in icate *hen 8A9 is una$ailable or the blee ing is unli3ely to be controlle by embolisation# It remains the treatment of choice for the management of life threatening haemoptysis ue to a lea3ing aortic aneurysm" selecte cases of arterio$enous malformations" hy ati cyst" iatrogenic pulmonary rupture" chest in)uries" bronchial a enoma" or haemoptysis relate to mycetoma resistant to other treatments#. (0 Culmonary artery rupture relate to the use of pulmonary artery catheters may be temporarily controlle by *ith ra*ing the catheter slightly an reinflating the balloon to compress the blee ing $essel more proximally#0- Ho*e$er" surgical resection of the blee ing $essel is the efiniti$e management# 2he onset of massi$e haemoptysis in a patient *ith a tracheostomy may be associate *ith the e$elopment of a tracheal!arterial fistula" usually the innominate artery#0. 2he prompt

application of anterior an o*n*ar pressure on the tracheal cannula an o$erinflation of the tracheostomy balloon may help to tampona e the blee ing $essel" an imme iate surgical re$ie* shoul be re%ueste # ?eflation of the tracheostomy balloon an remo$al of the tracheal cannula shoul be performe in a controlle en$ironment#

Ot$er treat%ent 2he oral antifibrinolytic agent tranexamic aci " an inhibitor of plasminogen acti$ation" is fre%uently use to control recurrent haemoptysis# Intra$enous $asopressin has also been use but caution is a $ise in patients *ith coexistent coronary artery isease or hypertension# Vasoconstriction of the bronchial artery may also hamper effecti$e 8A9 by obscuring the site of blee ing" lea ing to ifficulties in cannulation of the artery#( Systemic antifungal agents ha$e been trie in the management of haemoptysis relate to mycetoma" but the results ha$e been poor# 8y contrast" the irect instillation of antifungal rugs such as amphotericin 8 *ith or *ithout N!acetylcysteine or io ine by means of a percutaneous or transbronchial catheter in the ca$ity has resulte in satisfactory control of haemoptysis in some cases#&( 0< 2his techni%ue shoul be consi ere in patients *ith ongoing blee ing follo*ing attempte 8A9 *ho are not other*ise fit for surgical resection# In$asi$e therapeutic proce ures ha$e no role in the management of pulmonary haemorrhage relate to coagu!lopathy" bloo yscrasias" or immunologically me iate al$eolar haemorrhage# Appropriate me ical treatment is usually sufficient#0; On the rare occasion *hen an immunologically me iate al$eolar haemorrhage lea s to massi$e haemoptysis" the a ministration of systemic corticosteroi s" cytotoxic agents" or plasmapheresis may be useful#< 2he long term a ministration of anaAol or gona otrophin releasing hormone agonists may pro$e useful in the management of catamenial haemoptysis#>' 4a iation therapy has been use in the management of massi$e haemoptysis associate *ith $ascular tumours or mycetoma by in ucing necrosis of fee ing bloo $essels an $ascular thrombosis ue to peri$ascular oe ema#>&

OUTCOME Fortality has been closely correlate *ith the $olume of bloo expectorate " the rate of blee ing" the amount of bloo retaine *ithin the lungs an premorbi respiratory reser$e" in epen ent of the aetiology of blee ing#&> 2he mortality rate is ,</ *hen the rate of bloo loss excee s &''' mlB(> hours" compare *ith ;/ if blee ing is less than &''' mlBhour#. 0; 2he mortality rate in patients *ith malignancy is ,;/" *hich increases to <'/ in the presence of a combination of malignant aetiology an a blee ing rate of more than &''' mlB(> hours# A better outcome has been note for massi$e haemorrhage ue to bronchiectasis" lung abscess" or necrotising pulmonary infections" *ith a mortality rate of less than &/ in some series#0; REFERENCES &# Gor an GL" 5ascoigne A" 7orris CA# 2he pulmonary physician in critical care H Illustrati$e case .D Assessment an management of massi$e haemoptysis# 2horax (''0I,<I<&>!<&;# (# 7ahill 87" Ingbar ?H# Fassi$e hemoptysis# Assessment an management# 7lin 7hest Fe &;;>I&,D&>.+-.# 0# ?*ei3 4A" Stoller GK# 4ole of bronchoscopy in massi$e hemoptysis# 7lin 7hest Fe &;;;I('D<;+&',# ># 7onlan AA" Hur*itA SS" Krige L" et al# Fassi$e hemoptysis# 4e$ie* of &(0 cases# G 2horac 7ar io$asc Surg&;<0I<,D&('+># ,# Eeoh 78" Hubaytar 42" :or GF" et al# 2reatment of massi$e hemorrhage in pulmonary tuberculosis# G 2horac 7ar io$asc Surg&;-.I,>D,'0+&'# -# Holscla* ?S" 5ran 4G" Sh*achman H# Fassi$e hemoptysis in cystic fibrosis# G Ce iatr &;.'I.-D<(;+0<# .# 5arAon AA" 7erruti FF" 5ol ing F9# 9xsanguinating hemoptysis# G 2horac 7ar io$asc Surg&;<(I<>D<(;+00# <# Gean!8aptiste 9# 7linical assessment an management of massi$e hemoptysis# 7rit 7are Fe ('''I(<D&->(+.# ;# Sch*arA FI" 8ro*n KK# Small $essel $asculitis of the lung# 2horax ('''I,,D,'(+&'# &'# Santiago S" 2obias G" 1illiams AG# A reappraisal of the causes of hemoptysis# Arch Intern Fe &;;&I&,&D(>>;+,&# &&# Hirshberg 8" 8iran I" 5laAer F" et al# HemoptysisD etiology" e$aluation" an outcome in a tertiary referral hospital# 7hest &;;.I&&(D>>'+># &(# Ge*3es G" Kay CH" Caneth F" et al# Culmonary aspergillomaD analysis of prognosis in relation to haemoptysis an sur$ey of treatment# 2horax &;<0I0<D,.(+<# &0# 4umba3 F" Kohler 5" 9astrige 7" et al# 2opical treatment of life threatening haemoptysis from aspergillomas# 2horax &;;-I,&D(,0+,# &># Fc5uinness 5" 8eacher G4" Har3in 2G" et al# HemoptysisD prospecti$e high!resolution 72Bbronchoscopic correlation# 7hest&;;>I&',D&&,,+ -(# &,# :erence 8A" Shannon 2F" 1hite 4I Gr" et al# Life!threatening pulmonary hemorrhage *ith pulmonary arterio$enous malformations an here itary hemorrhagic telangiectasia# 7hest&;;>I&'-D&0<.+;'# &-# Kalra S" 8ell F4" 4ihal 7S# Al$eolar hemorrhage as a complication of treatment *ith abciximab# 7hest(''&I&('D&(-+0&#

&.# <&; &<# Gohnson S# 4are iseasesJ&D LymphangioleiomyomatosisD clinical features" management an basic mechanisms# 2horax &;;;I,>D(,>+-># &;# Langfor 7A" Hoffman 5S# 4are iseasesJ0D 1egener=s granulomatosis# 2horax &;;;I,>D-(;+0.# ('# 9r3an :" 5ul A" 2asali 9# Culmonary manifestations of 8ehcet=s isease# 2horax(''&I,-D,.(+<# (&# Farshall 2G" :lo*er 7?" Gac3son G9# 2he role of ra iology in the in$estigation an management of patients *ith haemoptysis# 7lin 4a iol &;;-I,&D0;&+>''# ((# Haponi3 9:" :ein A" 7hin 4# Fanaging life!threatening hemoptysisD has anything really change K 7hest('''I&&<D&>0&+,# (0# Fillar A8" 8oothroy A9" 9 *ar s ?" et al# 2he role of compute tomography (72) in the in$estigation of unexplaine haemoptysis# 4espir Fe &;;(I<-D0;+>># (># Cennington ?1" 5ol 1F" 5or on 4L" et al# 2reatment of pulmonary arterio$enous malformations by therapeutic emboliAation# 4est an exercise physiology in eight patients# Am 4e$ 4espir ?is &;;(I&>,D&'>.+,&# (,# 5ourin A" 5arAon AA# 7ontrol of hemorrhage in emergency pulmonary resection for massi$e hemoptysis# 7hest &;.,I-<D&('+&# (-# Klein @" KarAai 1" 8loos :" et al# 4ole of fiberoptic bronchoscopy in con)unction *ith the use of ouble!lumen tubes for thoracic anesthesiaD a prospecti$e stu y# Anesthesiology&;;<I<<D0>-+,'# (.# 5ong H Gr" Sal$atierra 7# 7linical efficacy of early an elaye fiberoptic bronchoscopy in patients *ith hemoptysis# Am 4e$ 4espir ?is &;<&I&(>D((&+,# (<# Saumench G" 9scarrabill G" Ca ro L" et al# Value of fiberoptic bronchoscopy an angiography for iagnosis of the blee ing site in hemoptysis# Ann 2horac Surg &;<;I><D(.(+># (;# Helmers 4A" San erson ?4# 4igi bronchoscopy# 2he forgotten art# 7lin 7hest Fe &;;,I&-D0;0+;# 0'# 2su3amoto 2" Sasa3i H" Na3amura H# 2reatment of hemoptysis patients by thrombin an fibrinogen!thrombin infusion therapy using a fiberoptic bronchoscope# 7hest &;<;I;-D>.0+-# 0&# :reitag L" 2e3olf 9" Stamatis 5" et al# 2hree years experience *ith a ne* balloon catheter for the management of haemoptysis# 9ur 4espir G &;;>I.D('00+.# 0(# 9 mon stone 1F" Nanson 9F" 1oo coc3 AA" et al# Life threatening haemoptysis controlle by laser photocoagulation# 2horax &;<0I0<D.<<+;# 00# 4emy G" Arnau A" :ar ou H" et al# 2reatment of hemoptysis by emboliAation of bronchial arteries# 4a iology &;..I&((D00+.# 0># @flac3er 4" Kaemmerer A" Cicon C?" et al# 8ronchial artery emboliAation in the management of hemoptysisD technical aspects an long!term results# 4a iology &;<,I&,.D-0.+>># 0,# 8rinson 5F" Noone C5" Fauro FA" et al# 8ronchial artery emboliAation for the treatment of hemoptysis in patients *ith cystic fibrosis# AmG4espir 7rit 7are Fe &;;<I&,.D&;,&+ <# 0-# 2ana3a N" Eama3a o K" Furashima S" et al# Superselecti$e bronchial artery emboliAation for hemoptysis *ith a coaxial microcatheter system# G Vasc Inter$ 4a iol&;;.I<D-,+.'# 0.# Keller :S" 4osch G" Loflin 25" et al# Nonbronchial systemic collateral arteriesD significance in percutaneous embolotherapy for hemoptysis# 4a iology&;<.I&->D-<.+ ;(# 0<# 2homas 4" Siprou his L" Laurent G:" et al#Fassi$e hemoptysis from iatrogenic balloon catheter rupture of pulmonary arteryD successful early management by balloon tampona e# 7rit 7are Fe &;<.I&,D(.(+0# 0;# Schaefer OC" Ir*in 4S# 2racheoarterial fistulaD an unusual complication of tracheostomy# G Intensi$e 7are Fe &;;,I&'D->+.,# >'# Shapiro FG" Albel a SF" Fayoc3 4L" et al# Se$ere hemoptysis associate *ith pulmonary aspergilloma# Cercutaneous intraca$itary treatment# 7hest&;<<I;>D&((,+0&# >&# 7orey 4" Hla KF# Fa)or an massi$e hemoptysisD reassessment of conser$ati$e management# AmGFe Sci &;<.I(;>D0'&+;# >(# Fatsubara K" Ochi H" Ito F# 7atamenial hemoptysis treate *ith a long!acting 5n4H agonist# IntG5ynaecol Obstet &;;<I-'D(<;+;'# >0# Shneerson GF" 9merson CA" Chillips 4H# 4a iotherapy for massi$e haemoptysis from an aspergilloma# 2horax &;<'I0,D;,0+>#