Haemoptysis

By Dr. Ashish kaushik

JR -3
 Haemoptysis
• Hemoptysis is expectoration of blood or blood
stained sputum that originates from below the
vocal cords fom tracheobronchial tree or
pulmonary parenchyma.
 Haemoptysis
• Spitting of blood derived from the lungs or
bronchial tubes as a result of pulmonary or
bronchial hemorrhage
• Non-massive vs Massive: based on volume of
blood loss  but no uniform definitions
• Massive haemoptysis = potentially life-
threatening haemoptysis
 Haemoptysis
• Massive hemoptysis has been variably defined
as 100ml to more than 1000ml of blood
expectorated from lungs over 24 to 48 hours.
• (more than 600ml in 24 hours )
 Pulmonary circulation
• Lungs are supplied with a dual circulation
• Mostly (95%): pulmonary arteries (arise from
right ventricle to supply pulmonary
parenchyma) in a low-pressure circuit
• Others (5%): bronchial arteries carry blood
under high systemic pressure to arteries,
blood vessels and visceral pleura
– Originate at the aorta
– Supply major airways and supporting structures
 Pulmonary circulation
• Although the bronchial circulation represents
only 1-2% of total pulmonary blood flow, it
can increase dramatically under conditions of
chronic inflammation, e.g., chronic
bronchiectasis and is frequently the source of
hemoptysis.
 Haemoptysis
• Blood usually from bronchial circulation
• Rarely from pulmonary circulation
– Usually produce small-volume haemoptysis
• Others mimickers:
– Pseudohaemoptysis (blood that does not come
from the lungs or bronchial tree)
– Haematemesis
• Blood can fill the airways and the alveolar
spaces causing not only serious disturbance in
gas exchange but also asphyxiation.
 Differential Diagnosis
• Source other than the lower
respiratory tract
– Upper airway (nasopharyngeal) bleeding
– Gastrointestinal bleeding
 DIFFERENTIAL DIAGNOSIS
• Tracheobronchial source
– Neoplasm (bronchogenic carcinoma,
endobronchial metastatic tumor, Kaposi’s
sarcoma, bronchial carcinoid)
– Bronchitis (acute or chronic)
– Bronchiectasis
– Broncholithiasis
– Airway trauma
– Foreign body
 DIFFERENTIAL DIAGNOSIS
• Pulmonary parenchymal source
– Lung abscess
– Pneumonia
– Tuberculosis
– Mycetoma (“fungus ball”)
– Goodpasture’s syndrome
– Idiopathic pulmonary
hemosiderosis
– Wegener’s granulomatosis
– Lupus pneumonitis
– Lung contusion
 Differential Diagnosis
• Primary vascular source
– Arteriovenous malformation
– Pulmonary embolism
– Elevated pulmonary venous pressure
(especially mitral stenosis)
– Pulmonary artery rupture secondary to
balloon-tip pulmonary artery catheter
manipulation
 Differential Diagnosis
• Miscellaneous and rare causes
– Pulmonary endometriosis /Catamenial
hemoptysis
– Systemic coagulopathy or use of
anticoagulants or thrombolytic agents
 Infection
• Most common cause of haemoptysis
• Superficial mucosal inflammation and edema 
rupture of the superficial blood vessels
• Bronchitis, pneumonia, tuberculosis
• Bacteria (e.g. Staph. aureus, Pseudomonas
aeruginosa)
• TB
 Tumour
• Superficial mucosal invasion, erosion into
blood vessels, or highly vascularised tumour
• Obstruction  secondary infection
• Metastatic tumour less likely to bleed
 Idiopathic
• 7-34% patient with haemoptysis has no
identifiable cause even after careful evaluation
• Prognosis is good
• Most had resolution of haemoptysis in 6
months
DIAGNOSIS
 Assessment
• Airway, Breathing, Circulation
• Haemoptysis vs Haematemesis vs
Pseudohaemoptysis (e.g . from naso/oro-
pharynx)
 Assessment
• History usually provides clues for
differentiating haemoptysis vs
haematemesis vs
pseudohaemoptysis
 Haemoptysis vs Haematemesis
Haemoptysis Haematemesis
History
• Absence of nausea and • Presence of nausea and
vomiting vomiting
• Lung disease • Gastric or hepatic disease
• Asphyxia possible • Asphyxia unusual

Sputum examination
• Frothy • Rarely frothy
• Liquid or clotted appearance • Coffee ground appearance
• Bright red or pink • Brown to black
Laboratory
• Alkaline pH
• Mixed with macrophages • Acidic pH
and neutrophils • Mixed with food particles
 Pseudohaemoptysis
• History of epistaxis
• Expectorating without cough

• Usually suggest blood from upper resp tract

 Assessment
• If History and Physical examination findings suggest
haemoptysis
– Amount of blood has to be estimated
• Difficult to quantify clinically and frequently
overestimated
• Nature of haemoptysis
– Blood stained sputum
– Clots
– Fresh blood
 Further history
Clinical clues Suggested diagnosis*
• Anticoagulant use • Medication effect, coagulation
disorder
• Association with menses • Catamenial hemoptysis
• Dyspnea on exertion, • Congestive heart failure, left
fatigue, orthopnea, ventricular dysfunction, mitral
paroxysmal nocturnal valve stenosis
dyspnea, frothy pink
sputum
• Fever, productive cough • Upper respiratory infection,
acute sinusitis, acute
bronchitis, pneumonia, lung
abscess
 Further history
Clinical clues Suggested diagnosis*
• History of breast, colon, or • Endobronchial metastatic
renal cancers disease of lungs

• History of chronic lung • Bronchiectasis, lung abscess

disease, recurrent lower
respiratory track infection,
cough with copious
purulent sputum
• HIV, immunosuppression • Neoplasia, tuberculosis,
Kaposi’s sarcoma
 Further history
Clinical clues Suggested diagnosis*
• Nausea, vomiting, melena, • Gastritis, gastric or peptic
alcoholism, chronic use of ulcer, esophageal varices
nonsteroidal anti-
inflammatory drugs

• Pleuritic chest pain, calf • Pulmonary embolism or

tenderness infarction
 Further history
Clinical clues Suggested diagnosis*
• Tobacco use • Acute bronchitis, chronic
bronchitis, lung cancer,
pneumonia
• Travel history • Tuberculosis, parasites (e.g.,
paragonimiasis, schistosomiasis,
amebiasis, leptospirosis),
biologic agents (e.g., plague,
tularemia, T2 mycotoxin)
• Weight loss • Emphysema, lung cancer,
tuberculosis, bronchiectasis, lung
abscess, HIV
 CXR
• Essential
– Underlying cause
– Site of bleeding, to guide further treatment
 Clues on CXR
CXR findings Suspected diagnosis

• Cardiomegaly, increased • CHF, MS

pulmonary vascular
distribution
• Lung abscess, TB,
• Cavitary lesions necrotizing CA

• Diffuse alveolar infiltrates • CHF, pulmonary edema,

aspiration, toxic injury
 Clues on CXR
CXR findings Suspected diagnosis

• Hilar adenopathy or • CA, met, infections,

mass sarcoid

• Hyperinfilation • COPD

• Lobar or segmental • Pneumonia,

infiltrates thromboembolism,
obstructing CA
 Clues on CXR
CXR findings Suspected diagnosis

• Mass lesion, nodules, • CA, met, Wegener’s

granulomas granulomatosis, septic
embolism, vasculitis

• Normal or no change • Bronchitis, URI, sinusitis,

from baseline pulmonary embolism

• Patchy alveolar • Bleeding disorders,

infiltrates (multiple idiopathic pulmonary
bleeding sites) haemosiderosis,
Goodpasture’s syndrome
 Laboratory findings
White cell count/differential Elevated WCC & left shifts  infections
Hb, Hct Anaemia

Plt Thrombocytopenia

PT/INR/APTT Anticoagulant use/coagulopathy

ABG Hypoxia/hypercarpnia

D-dimer PE

Sputum C/ST, AFB smear, C/st Pneumonia, abscess, TB

Sputum cytology Neoplasia

ESR Infections, autoimmune disorders, +/-

neoplasia
 Management
• Acute treatment depends on the
amount/cause of haemoptysis
 Massive haemoptysis
• No standardised magic figures for amount of
blood loss
• Usually quoted as >100ml/24hr
 Massive Haemoptysis
• Mortality rate from massive hemoptysis depends on the
bleeding rate and etiology
• Airway protection
– Primary mechanism of death is asphyxiation, not exsanguination
– Positioning maneuvers: decubitus position if one is sure of the
site of bleeding
– Intentional single lung intubation/use of double lumen ET tube
– Obstruction of the bronchus leading to the bleeding lung, e.g.
bronchial blocker
• Ventilatory support
• Circulatory support
 Treatment
• Emergency treatment for control of
haemoptysis
• Treatment targeting underlying aetiology
– E.g. treatment of infection in haemoptysis
associated with infective exacerbation of
bronchiectasis
 Bronchial Arterial Embolisation
• Main stay for emergency management of
massive haemoptysis
• Effective, long and short term bleeding control
• Safe: complication rates generally low and
minor; major complications infrequent
 Fibreoptic Bronchoscopy
• Limited in massive haemoptysis
– Localisation of bleeding site
– diagnosis
– Guide intubation
– Cold saline
– Adrenaline
– Tamponade
– Argon plasma coagulation, electrocautery, laser
 Rigid Bronchoscopy
• Merits of rigid bronchoscopy over flexible
bronchoscopy:
– Better airway control
– Larger field of view
– Better suctioning
– Better for therapeutic interventions
• Direct pressure
• Laser therapy
• Cauterization
• Adrenaline/vasopressin injection
• Isolation of the bleeding pulmonary segment
• Not readily available!!!
 Surgery
• Lobectomy
• Pneumonectomy

• Others surgical treatments directed to

underlying causes, e.g.
– Emergent mitral valvulotomy for haemoptysis due
to severe MS
THANK YOU