APPROACH TO HEMOPTYSIS

Definition: It is defined as expectoration of the blood from the respiratory tract.

Massive hemoptysis: Massive hemoptysis is broadly defined as production of 500-600 ml of blood over 24 hours; 100 ml within 1 hour or bleeding necessitating transfusion or causing hemodynamic compromise.

Pathogenesis:

• Primary origin of the blood comes from bronchial arteries
• Other sources of bleeding might be:
  • aorta
  • intercostals arteries
  • coronary arteries
  • Thoracic  arteries
  • The upper and inferior phrenic arteries
  • Pulmonary vessels
• Hemoptysis may happen following infarction and ischemia of pulmonary parenchyma. It is seen in following conditions:
  • Pulmonary emboli
  • Vasculitis including:
    • Granulomatosis with polyangitis
  • Infections  including:
    • Staphylococcus aureus
    • Pseudomonas aeruginosa
    • Aspergillus fumigatus
    • The phycomycetes
• Another mechanism of hemoptysis is vascular engorgement with erosion. It is seen in following conditions:
  • Acute infection such as:
    • Viral bronchitis
    • Bacterial bronchitis
  • Chronic infection such as:
    • bronchiectasis
  • Toxic exposure
    • Cigarette smoke
    • asbestos
• In some cases underlying cause cannot be identified and they are considered as idiopathic. However, they might present with massive hemoptysis.

Causes:

• Bronchial disease:
• Carcinoma
• Bronchiectasis
• Acute bronchitis
• Bronchial adenoma
• Foreign body
• Parenchymal disease:
• Tuberculosis
• Suppurative pneumonia
• Lung abscess
• Parasites( eg: hydatid, flukes)
• Trauma
• Actinomycosis
• Mycetoma
• Lung vascular disease:
• Pulmonary infarction
• Polyarteritis nodusa
• Good pasture syndrome
• Idiopathic pulmonary hemosiderosis
• Cardiovascular disease:
• Acute left ventricular failure
• Mitral stenosis
• Aortic aneurysm
• Blood disorders:
• Leukemia
• Hemophilia
• Anticoagulants

Other history and symptoms accompanying hemoptysis:

1. h/o fever- duration, timing and pattern

Suggestive of infective origin (eg: bronchiectasis, lung abscess, tuberculosis, suppurative pneumonia, acute bronchitis)

• h/o cough
• h/o repeated small hemoptysis or blood streaking of sputum

Highly suggestive of bronchogenic carcinoma

• h/o fever, night sweats and weight loss

Highly suggestive of tuberculosis

• h/o rusty colored sputum but may cause frank hemoptysis

Highly suggestive of pneumococcal pneumonia

• Catastrophic bronchial hemorrhage with h/o previous tuberculosis or pneumonia in early life

Highly suggestive of bronchogenic carcinoma

• h/o prolonged immobilization, malignant disease of any organ, cardiac failure and pregnancy

Highly suggestive of pulmonary thrombo embolism

On examination:

• Anemic
• Temperature (usually high)
• Clubbing of fingers (highly suggestive of bronchogenic carcinoma or bronchiectasis)
• Cachexia, hepatomegaly with lymphadenopathy: highly suggestive of bronchogenic carcinoma
• Fever, signs of consolidation and pleurisy: highly suggestive of pneumonia, pulmonary infarction
• Signs of cavitation, consolidation and pleural effusion: highly suggestive of tuberculosis
• Legs signs of deep vein thrombosis: highly suggestive of pulmonary infarction
• Rashes, hematuria, splinter hemorrhages, lymphadenopathy or spleenomegaly: highly suggestive of systemic diseases

Investigations:

• Complete blood counts with ESR
• Chest x- ray (gives clear evidence of localized lesion including pulmonary infarction, tumor- malignant or benign, pneumonia, tuberculosis
• Sputum for AFB, gram stain and culture
• Mantoux test
• CT scan of chest and CT guided FNAC from a mass lesion
• Hematological test including bleeding and clotting time
• Bronchoscopy for bronchogenic carcinoma
• Ventilation perfusion lung scan for pulmonary thromboembolic disease

Treatment:

• If massive hemoptysis :

• Otherwise treatment should be according to the cause

Difference between hemoptysis and hematemesis

Contributor- Dr. Bidhata Rayamajhi