Haemoptysis

Department of Pulmonology
EMCH
 Definition
• Haemoptysis is coughing of blood from a
source below the glottis. The term derived
from the ancient Greek words haima, meaning
blood, and, ptysis, meaning spitting.
• There is lack of universal consensus on the
quantification and severity of haemoptysis
event.
 Severity classification
Grade Amount /
24hrs
Mild <50 ml

Moderate 50-200 ml

Major/Severe >200 ml 150 ml per 12 hr or >400

ml /24 hrs
Massive >600 ml

Life- 200ml/hr or 50 ml/hr

threatening with respiratory failure
 Massive haemoptysis/Life-
threatening haemoptysis
• Various causes.
• A COMMON definition is the expectoration of
blood from source below glottis exceeding 600
(100 ml to more than 1000) ml of blood over
24 hours or more than 25ml/hr.
• Only 5% are massive with 80% mortality.
• Given the unreliability in both the patients and
physicians estimates of expectorated blood and
lack of consensus cut-off volume definition
massive haemoptysis can also be defined by
its clinical effects:
1. Airway compromise: obstruction,
aspiration, hypoxemia, need for intubations.
2. Homodynamic instability
3. Need for blood transfusion
 Cause of death
Definition Cause of death

Massive haemoptysis Asphyxiation

>600 ml in 24 hours

Exsanguinating Both hypotension and

haemoptysis Asphyxiation
>1000 ml in 24 hours

>150 ml blood/hours
 Pseudo (spurious) haemoptysis
• The coughing of blood from a source other
than lower respiratory tract.
1. Haematemesis is aspirated into the lungs
2. Bleeding from upper airway or the mouth
stimulates a cough reflex
3. Materials is expectorated that looks like
blood but is not .( Serratia marcescens
infection)
 Factitious haemoptysis
• Factitious haemoptysis is a manifestation of
Munchausen syndrome that describe a group
of patients who intentionally produce
symptoms or disabilities.
 Frank haemoptysis
• Characterized by sputum that is grossly bloody
but of low volume of blood around 100-200
ml/24hrs
 Cryptogenic haemoptysis
• Haemoptysis of unknown aetiology. It occurs
in 30-40% patients. After extensive
investigation no cause is found.
 Causes
• Tracheobronchial source
Bronchiectasis
Neoplasm ( occurs in 20% of patients)
Bronchitis
Broncholithiasis
Airway trauma
FB
• Pulmonary parenchymal source
PTB
Pneumonia
Lung abscess
Aspergilloma (Mycetoma)
Good pasture syndrome
Wegener's granulomatosis
Lupus pneumonitis
Lung contusion
• Pulmonary vascular source
Arteiovenous malformations
Pulmonary embolism, infarction
Elevated pulmonary venous pressure
(especially mitral stenosis, LVF)
Pulmonary arterial rupture secondary to
balloon tip pulmonary artery catheter
manipulation
• Miscellaneous and rare causes
Pulmonary endometriosis (Catamenial
haemoptysis)
Systemic coagulopathy
Anticoagulant use
Bevacizumab
 History
• Establish the onset of cough and haemoptysis: It is
useful to establish when the cough started (Acute
onset of cough- generally under 3 weeks and may be
caused by pneumonia, PE, pulmonary edema;
Chronic cough- may be caused by malignancy, TB,
bronchiectasis)
• Establish the course of the cough and
haemoptysis: It is episodic (eg Bronchiectasis,HF,
Wegeners granulomatosis) or persistent ( eg
pneumonia, malignancy, bronchiectasis)
 History
• Establish the timing of cough and
haemoptysis: It is worse at certain times of the
day (HF – worse at night, lying down)
• Establish the character of the cough: If it is
chesty ( production of sputum- seen in
pneumonia, pulmonary edema, bronchiectasis)
or it is dry/tickly ( asthma, URTI, malignancy)
 History
• Ask about any sputum production and its
colour: ( Green –bacterial infection; rusty
brown- pneumococcal infection; pink and
frothy-pulmonary edema)
• Establish the presence of
exacerbating/relieving factor( eg pulmonary
edema- coughing after lying down)
 Ask about haemoptysis
• Volume of blood: lots (bronchiectasis, lung
abscess, PTB) small amounts ( PE, pulmonary
edema, prolonged coughing)
• Fresh or altered blood
• Mixed with sputum ( eg pneumonia)
 Review of risk factors
• Risk factors for HIV infection
• Use of Immunosuppressants (TB, fungal
infection)
• Exposure to TB infection
• Long smoking history ( COPD, cancer)
• Recent immmobilization or surgery, known
cancer, prior or family H/O clotting,
pregnancy, use of estrogen containing drugs.
 Systemic review
• Wheeze Respiratory cause
• Fever and sputum production may indicate infection
(pneumonia, TB, bronchiectasis, lung abscess).
• Chest pain and dyspnea examples include Pleuritic
type of chest pain caused by PE, Infection.
• WT loss, fatigue, night sweat, anorexia may
indicate malignancy or TB.
• Leg pain, leg swelling ( pulmonary embolism)
• Haematuria ( Goodpasture syndrome)
• Bloody nasal discharge (Wegeners granulomatosis)
• Ankle swelling and PND seen in pulmonary
edema
• Hoarseness of voice URTI, malignancy
 Past medical;/surgical history
• Past medical history: especially ask if the patient has
any chronic lung condition, bleeding disorder, heart
condition.
• Medication history/allergy: ask specifically about
any new medication started such as ACE inhibitors or
anticoagulants, anti platelets.
• Travel history foreign travel may predispose a
patient to legionnaires disease, parasitic disease and
long journeys may predispose a patient to DVTs
• Ask about smoking and recreational drug
abuse
• Ask about family history.
 Physical examination
• Vital signs are reviewed for fever,
tachycardia, tachypnea, and low oxygen
saturation.
• Constitutional sings eg Cachexia
• Level of distress eg accessory muscle use,
pursed lip breathing, decreased level of
consciousness.
• A full chest examination is done, particularly
adequacy of air entry and exit, symmetry of
breath sounds and presence of crakcles,
stridor, wheeze. The cervical and
supraclavicular areas should be inspected and
palpated for lymphadenapathy ( suggesting
cancer or TB)
• Neck veins should be inspected for distension
and the legs and pre sacral areas should be
palpated for pitting edema (suggesting heart
failure). Pre cordium should be auscultated
with notation of any extra heart sounds or
murmurs that might support the diagnosis of
heart failure and elevated pulmonary pressure.
• Abdominal examination should focus on
signs of hepatic congestion or masses which
could suggest either cancer or haematemesis
from potential esophageal varices.
• The skin and mucus membrane should be
examined for ecchymoses, petechiae,
gingivitis or evidence of bleeding from the
oral or nasal mucosa
 Red flag signs
• Massive haemoptysis
• Back pain
• Tracheostomy
• Malaise, wt loss or fatigue
• Smoking history 20 pack years.
• Dyspnea at rest during examination.
 Investigations
• The investigations of choice to diagnose the cause
and localize the source of haemoptysis will vary
depending on past medical history and current
presentation of the patient.
• CXR : The initial test in majority of the patients. It
determines the site of bleeding in 45-65% of the cases
and the causes in 25-35% cases. However , as much
as 10% of pulmonary malignancies are occult on
CXR, 96% of which will be detected by CT CHEST
• CT scan of the chest: Better than
Bronchoscopy to determine the cause of
haemoptysis( 86% vs 70%). CT is also an
important tool to guide FNAC and to guide
embolization.
• Bronchoscopy: Is important for diagnostic
and treatment purpose. It can be performed at
bedside with direct visualization of the lesion
to take biopsy.
• CBC, Coagulation profiles, ABG, D-dimer,
Sputum for AFB, Gram staining and
culture. Sputum cytology, MT, Anti HIV.
 Treatment of Haemoptysis
There are two types of Haemoptysis:
1. Non-life threatening Haemoptysis
2. Life threatening Haemoptysis:
i. Unstable patients
ii. Stable patients
 Treatment of Haemoptysis (Cont.)
(Non-life-threatening)
Non-life-threatening

Known Cause

CT Chest General Measures

or HRCT
Diagnostic Non-Diagnostic
↓ ↓
Specific Treatment Bronchoscopy
Treatment of Haemoptysis (Cont.)
(Life-threatening)
Unstable Stable
↓ ↓
Bronchoscopy Angio-MDCT
↓
CT Chest or ↓
Angiography Pathological Arteries
↓
Not Controlled Embolization
or Recurrence ↓
↓ Controlled
i. Re-embolization ↓
ii. Surgery Specific Treatment
 Treatment
• BAE: The most commonly haemoptysis
originate from bronchial circulation 90%, 5 %
may originate from the pulmonary circulation.
Recent studies have showen the effectiveness
of BAE in wide array of pathologies including
tuberulosis, bronchiectasis, aspergilloma, and
malignncy. Embolizing agents are numerous
but polyvinyl alcohol ( usually 300-600
microgm) is most frequently used.
nonabsorbable and available in different sizes.
• Endoscopic treatment: Both rigid and
flexible bronchoscopy can be used in
haemoptysis.
• Cold saline: Cold saline lavage with rigid
bronchoscope can be done in massive
haemoptysis. Smaller volume of cold saline is
frequently used to control bleeding during
bronchoscopy.
• Vasoactive agent: Terlipressin and ornipressin
an be used to stop bleeding
• Tranexamic acid: Reduce both duration and
volume of bleeding
• Surgery: Pneumanectomy, Lobectomy,
Segmentectomy.
Thank you