HEMOPTYSIS
Hemoptysis is defined as the spitting of blood
derived from the lungs or bronchial tubes as a
result of pulmonary or bronchial hemorrhage.
Hemo- Latin-Blood
Ptysis- Greek- Spitting
Stedman TL. Stedman’s Medical dictionary. 27th ed. Philidelphia: Lipincott Williams &
Wilkins
Mild- <100 ml/day
Mod- 100-150 ml/day
Severe- 150-200 ml/day
Massive- >500ml/day; 150ml/hr; 100ml/day for
more than 3 days.
Non massive- <200 ml/day
Massive- > 200ml/day. (1-5%)- Mortality-80%.
American academy of family Physicians.
• Source of bleeding:
Bronchial artery- 90%
Pulmonary artery
Bronchial artery
Blood Circulation in the lungs :
2 Components
Low pressure High pressure
Pulmonary Circulation Bronchial Circulation
SBP = 15-20 mmHg = systemic pressures
DBP = 5-10 mmHg
Bronchial arteries & collaterals
Patients with normal PAP ( no originate from the aorta
PAH) rarely bleed: only 5% of
The source of bleeding in most
massive hemoptysis
cases
• Inflammation Erosion of the vessel wall
• Increased pressure in the vessel Increase vessel size Rupture
Aneurysm formation
Make sure it is Hemoptysis
DDx:
• Hematemesis
• Epistaxis
• Other nasopharyngeal
bleeding
Hemoptysis Hematemesis
1 Cough + -
2 Sputum Frothy Rarely frothy Brown to black
Bright red -pink Liquid or Coffee ground
clotted
3 Respiratory + -
symptoms
4 Gastric or Hepatic - +
disease
5 Vomiting & - +
Nausea
6 Melena - +
7 Asphiyxia usual unusual
8 Laboratory Alkaline pH;Mixed with Acidic pH;Mixed with food
Parameters macrophages and particles
20
neutrophils
Causes
• Infections remain the major cause of hemoptysis
of which Bronchitis is the major cause.
CAUSES
Involvement of Bronchi and Bronchioles:
1) Bronchitis
2) Adenoma
3) Carcinoma
4) Bronchiectasis
5) Foreign body
6) Tuberculosis
• Involvement of Lung parenchyma
1) Tuberculosis
2) Trauma
3) Lung abscess
4) Pneumonia
5) Parasites ( Hydatid, fluke)
6) Invasive fungal infection.
• Involvement of lung Vasculature
1) Pulmonary embolism
2) Goodpasture’s syndrome
3) mPAN
4) Granulomatous polyangitis.
5) Bronchial artery aneurysm
6) AV malformations
7) SLE
• Cardiovascular causes
1) Acute LV failure
2) Mitral stenosis
• Hematological causes
1) Thrombocytopenia
2) Leukemia
3) Hemophilia/Clotting disorder
• Other causes
1) Uremia- Platelet dysfunction.
2) Catamenial hemoptysis
3) Inhalation of toxic fumes
INITIAL STEPS
1. IDENTIFY WHICH SIDE IS BLEEDING
2. POSITION THE PATIENT
3. ESTABLISH A PATENTAIRWAY
4. ENSURE ADEQUATE GAS EXCHANGE
5. ENSURE ADEQUATE CVS FUNCTION
6. CONTROL THE BLEEDING
Selective Intubation
SINGLE LUMEN ETT
Selectivelyintubate
the non bleeding lung.
Selective intubation of L Main bronchus
in R sided massive hemoptysis
History
• Does the patient have known pulmonary, cardiac, or renal
disease?- smoke?
• Prior hemoptysis, other pulmonary symptoms, or
infectious symptoms?
• FH of hemoptysis, brain aneurysms, epistaxis, or GI ? a
skin rash?
• Exposed to asbestos?
• Bleeding disorder? DVT risk?
• DRUGS?
• Has the patient had (TB) or been exposed to TB?
Physical Examination
• Telangiectasias
• Skin rashes.
• An audible chest bruit or murmur- a large
pulmonary AV malformation.
• P2, TR ,Heart murmurs –MS.
• DVT signs
Laboratory
tests
• Type and cross-matching
• CBC ,COAG
• Electrolytes, BUN
• ABG
• Liver function tests
• Urinalysis
• Special tests
Reference
• Clinical Anatomy by regions, [Link], 9th edition.
• Guyton and Hall textbook of medical Physiology, 13th edition.
• Fishman’s Pulmonary diseases and disorders, 5th edition.
• Davidson’s principle and practice of medicine, 21st edition.
• American academy of family Physicians.
• Harrisons Principles of Internal Medicine, 19 edition.
• A Clinician’s guide to Tuberculosis, Michael D Iseman.
THANK YOU
