176

FIG 6. Perforation of an acutely anteflexed uterus.

atrophic uterus sbould not be curetted by a novice (Figs. 6and 7).

PeritonitisSepsis may occur even when the operation has beenperformed correctly. Presumably, a focus of infection ispresent prior to the operation in such cases. Initial treat-ment consists of antibiotics but drainage of a pelvicabscess or laparotomy may be needed.

VARIATIONSOutpatient curettageEndometrial biopsy may be done under paracervicalblock using a miniature curette such as a Novak curettewhich has a diameter of 5 mm.

THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 5, NO.4

FIG 7. Perforation of a retroflexed uterus.

Fractional curettageHere the endocervix is curetted before cervical dilatation.This is to diagnose endocervical spread of an endometrialcarcinoma in peri- and post-menopausal women.

Vabra aspirationNarrow curettes are used with a negative pressure sourcefor outpatients.

Evacuation of products of conceptionSuction curettage is used for termination of pregnancy.Even in cases of incomplete abortion, the cervix shouldbe grasped with sponge holders and gentleness used inall movements. An oxytocin drip is advisable during theprocedure.

HaemoptysisM. L. SEETHARAMAN, V. K. ARORA

INTRODUCTIONAlmost every pulmonary disease can lead to haemoptysis--from streaking of the sputum to life-threatening, fatalbleeding. Its general course is unpredictable and theoft-held presumption that haemoptysis usually pursues aself-limiting course is erroneous. Approximately 15% of

Jawaharlal Institute of Postgraduate Medical Education and Research,Pondicherrv 605006, India

M. L. SEETHARAMAN. V. K. ARORADepartment of Tuberculosis and Chest Diseases

Correspondence to M. L. SEETHARAMAN

© The National Medical Journal of India 1992

all patients attending chest clinics present with haemop-tysis and about 5% of such patients present with a massivebleed. Massive haemoptysis has been defined, arbitrarily,as blood loss of 600 ml over a 24-hour period. Themortality of conservative management in such patients isabout 75%.While death from exsanguination does occur the

immediate threat to life is from suffocation and asphyxia-tion due to flooding of the tracheobronchial tree.This aspect of haemoptysis makes it a serious medicalemergency for both the patient and the physician.

AETIOLOGYThe causes of haemoptysis include tuberculosis, bron-chiectasis, lung abscess and bronchogenic cancer.However, their prevalence is changing in different partsof the world and while tuberculosis and other suppurativelung disorders have ceased to be important causes ofhaemoptysis in the West, they continue to be the majorcauses in India. Figs. 1 and 2 list the causes of haemoptysis.

SEETHARAMAN. ARORA: HAEMOPTYSIS

Pseudohaemoptysis I

177

I Haemoptysis I

1. Oxidation of certain bronchodilators2. Pneumonia due to Serratia marcesens

3. Amoebic abscess ruptured in to airways

1. History2. pH, colour of aspirate

3. Microscopy of contents

4. Upper gastrointestinal endoscopy

Normal! non-localizing chest radiograph

Possible lesion

1. Upper airways ?OK

2. Bleeding diathesis/anticoagulants

3. Missed endobronchial lesion

4. Bronchiectasis sicca

5. Pulmonary infarct,? oral contraceptive intake

6. Factitious haemoptysis

7. Idiopathic, 1-2 episodes per year

8. Thoracic endometriosis

Further investigation

ENT examination

Coagulation profile, monitor anticoagulant levels

Bronchoscopy

Bronchoscopy, CT, Bronchography

History, underlying cause, Ventilation/perfusion scan

History, circumstantial evidence

Repeat bronchoscopy, ?Bronchogram

Repeat chest radiograph, thoracic CT

FIG I. Diagnostic approach to a patient with haemoptyses and a normal chest X-ray.

DIAGNOSISThe initial diagnostic work up of a patient with haemoptysisshould include a detailed clinical history, meticulousphysical examination and exclusion of clinical conditionsmimicking haemoptysis, such as pseudohaemoptysis,haematemesis and other extrapulmonary sources ofbleeding.Good quality postero-anterior and lateral chest X-rays

together with a detailed clinical history, physical examina-tion, and bacteriological and cytological evaluation ofthe sputum are often sufficient to identify the cause of .bleeding. Patients with haemoptysis can be consideredunder two categories.

1. those with a normal or non-localizing chest X-ray, and2. those with a definite abnormality on chest X-rayFigures 1 and 2 provide an approach to such patients.

BronchoscopyThough both fibreoptic and rigid bronchoscopes can beused, the rigid instrument is preferred in a patient withmassive haemoptysis. The advantage of a fibreopticbronchoscope is its extended range of vision which allowsexamination of the lobar bronchi. It is preferred in patients

. with minimal bleeding or in whom haemoptysis hasceased. While there is a need for bronchoscopic localiza-tion of the bleeding site in a patient with massivehaemoptysis, especially when surgery or angiographicintervention is contemplated, the ideal timing for bron-choscopy is debatable.

BronchographyThe only role of bronchography is to define the extent ofbronchiectasis when definitive surgical resection is beingplanned. Some workers have advocated performingbronchography and fibreoptic bronchoscopy at the sametime.as it is safe and provides excellent access to the wholebronchial tree. The importance of bronchography inthe evaluation of haemoptysis is highlighted in Figs. 3aand 3b.

AngiographyAngiography helps in localizing the site of bleeding andthe nature of pulmonary abnormality. Both bronchial andpulmonary artery angiography may be useful. Selectivecatheterization of the bronchial artery should be donefirst in patients with chronic inflammatory conditions suchas tuberculosis, aspergillosis, cystic fibrosis and bron-

178 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 5, NO.4

Abnormal chest radiograph ICavitary lesions

1. Bronchogenic carcinoma

2. Pulmonary tuberculosis

Smoking and occupational history, sputum cytology, bronchoscopyand washings, brush cytology, biopsy

Contact history, sputum microscopy and culture, bronchoscopy ifsmear negative

History of aspiration, blood and sputum culture, haemogram,bronchoscopy

3. Lung abscess

Intracavitary mass

1. Aspergilloma

2. Blood clot

3. Rasmussen aneurysm

4. Hydatid cyst

Fungal culture, serum precipitins, bronchoscopy

Resolves spontaneously, repeat chest radiograph afterhaemoptysis-free interval

Predominantly upper zones, pulmonary/bronchial artery angiogram

Endemicity, contact with domestic animals, skin and complementfixation tests, sputum examination for scolices, ultrasonography

Mu/tip/e nodular/cavitary lesions

1. Wegener's granulomatosis X-ray paranasal sinuses, evaluation of renal function,anti-neutrophil cytoplasm antibody (ANCA)

Identification of the primary site by appropriate studies

Serum studies, biopsy, X-ray joints

2. Metastases

3. Rheumatoid

Non-cavitary lesions

1. Solitary pulmonary nodule

5. Chronic bronchitis

Smoking history, assessment of radiological stability, skintests, CT and CT guided needle aspiration biopsy, angiography

History of tuberculosis/fungal disease, lithoptysis, changingposition/disappearance of calcific focus, bronchoscopy,repeat chest X-ray

Onset from childhood, recurrent bronchopneumonia, sweat studies,tests of pancreatic function, microbiological studies on sputum

X-ray paranasalsinuses, ENT examination, bronchoscopy, CT,bronchography, respiratory ciliary/semen studies, immunoglobulinstudies

Smoking and occupational history, dirty chest pattern onX-ray, pulmonary function tests, EKG

Postural change in symptoms/signs, recurrent unifocal. collapse/consolidation, bronchoscopy, CT

History, ventilation/perfusion scans, EKG, serum enzymes,.pulmonary angiogram

2. Broncholithiasis

3. Cystic fibrosis

4. Bronchiectasis

6. Bronchial adenoma

7. Pulmonary infarct

Cardiac causes

Episodes of orthopnoea, paroxysmal nocturnal dyspnoea, historyof rheumatic fever, hypertension or ischaemic heart disease,corresponding changes in the cardiac shadow, EKG, 'Echocardiography

FIG 2. Diagnostic approach to a patient with haemoptyses and an abnormality on chest X- ray.

SEETHARAMAN, ARORA : HAEMOPTYSIS

A: Chest X-ray (PA view) showing an ill-defined haziness inthe right upper zone.

179

B: Bronchogram showing tubular bronchiectasis of theapical and posterior segments of the right upper lobe.

FIG 3. Fifty-year-old male with quiescent pulmonary tuberculosis and recurrent haemoptysis.

chiectasis. Initial pulmonary artery studies should beperformed in those with pulmonary embolism, pulmonaryarteriovenous fistulae and neoplastic pulmonary arteryinvolvement. A suspected Rasmussen aneurysm needsevaluation by both bronchial and pulmonary arteryangiograms.Bronchial arteriography helps in localizing the bleeding

site when bronchoscopy cannot be done, is contra-indicated or is inconclusive. It is not a substitute forbronchoscopy.

Radionuclide studiesTechnetium sulphur colloid lung scans can be done tolocate the bleeding site, particularly in patients withnon-diagnostic chest X-rays. It may also complement the

A: Chest X-ray (PA view) shows noabnormality.

X-ray, bronchoscopicor angiographic studies. It has theadvantage of being a non-invasive technique. However,the diagnostic efficacy and cost-effectiveness need to beevaluated.

Computed tomographyIt has a limited role in the evaluation and management ofpatients with haemoptysis. It supplements the otherinvestigative techniques. In an evaluation of 32 patientswith haemoptysis, the additional information obtainedfrom CT altered the management decisions in only6 patients. I Serial CT scans have been employed todiagnose bronchopulmonary endometriosis in patientswith haemoptysis and normal chest X-rays. However, it isoccasionally of considerable benefit (Figs. 4a, 4b and 5).

B: CT scan of the thorax showing asolitary cavity with a fluid interfacein the medial basal segment of theright lower lobe.

FIG 4. Twenty-five year old female with recurrent haemoptyses.

FIG 5. CT scan of the thorax in a youngadult with bronchial asthma andrecurrent haemoptyses. It showsbronchial dilatations at the sub-carinallevel. A bronchogram confirmedcentral bronchiectasis,

180 THE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 5, NO.4

Management - Indications

I NormalABG

Medical management ISurgical approach I FEV1 >2L

and/or embolotherapy I MW >50% precf

teral disease Recurrent bleeding in a~

ase course progressive strictly localized disease

r cardiopulmonary reserve 1. Bleeding site identified

ctious pulmonary tuberculosis 2. No bleeding diathesis

moptysis as a manifestation 3. Reasonable long term survivalystemic disease 4. Quiescent pulmonary tuberculosisperative stabilization -II 5. Surgically fit candidate

ure of endobronchial occlusionerapy s I Iiple bleeding sites * Elective I IEmergency I

I

1. Bila

2. Dise

3. Poo

4.lnfe

5. Haeof s

6. Preo

7. Failth

8. Mult

*Embolotherapy can be employed with varying degrees of success

icted

Recurrent haemoptysis

FIG 6. Management flow chart.

MANAGEMENTThis can be considered under three broad categories-medical, interventional and surgical. The indications ofthe various modes of treatment are outlined in Fig. 6.

MedicalMedical management constitutes the initial modality oftreatment for all patients and its basic principles remainthe same irrespective of the aetiology and the severity ofbleeding. These include

1. Attention to airway and postural management2. Absolute bed rest3. Establishment of a large bore intravenous line4. Accurate recording of blood volume lost and the rateof haemoptysis, judicious transfusion and fluidtherapy by careful haemodynamic monitoring

5. Sedation to allay anxiety (without abolishing thecough relex)

6. Stool softeners (to avoid straining)7. Estimation of arterial blood gases and correction ofcoagulation abnormalities

8. Attention to oxygenation9. Antituberculous chemotherapy when indicated10. Broad spectrum antibiotics11. Bronchoscopy and localization of the bleeding site

Even though haemoptysis can be controlled by theabove measures, in the vast majority of patients, medicaltreatment alone is not a definitive form of therapy. This isparticularly so in patients with unremittent or recurrentbleeding. In these patients, embolization or surgery maybe needed.

Interventional approachMassive haemoptysis is one area in pulmonology whichcalls for a joint strategy from the physician and thesurgeon. Two issues that are crucial in the management ofsuch bleeding are airway control and pulmonary separa-tion. Unremittent bleeding warrants intubation witha large endotracheal tube which permits subsequentbronchoscopic examination.Endobronchial control measures such as balloon

tamponade; bronchial infusion therapy using thrombin,fibrinogen or batroxobin; and endobronchial ice coldsaline lavage using the rigid or fibreoptic bronchoscope,can be used. In patients with massive haemoptysis thesemay be life-saving. They can also be used in patientsawaiting surgery, to control bleeding following biopsy andin patients with bilateral disease, terminal malignancy andbronchovascular fistulae.

Embolization: Deliberate transcatheter arterialembolization of either the bronchial or pulmonaryarteries is a helpful technique. Particulate material suchas gelfoam is most commonly used and is very effective incontrolling bleeding.

SurgerySurgical resection offers the most definitive form oftherapy for massive haemoptysis and is indicated for theresection of diseased and damaged portions of the lungwhich are the sites of bleeding. The outcome dependsupon the extent of surgical resection, the volume of bloodlost in the 24 hours preceding the surgical procedure andcontralateral aspiration of blood during resection.

SEETHARAMAN, ARORA : HAEMOPTYSIS 181

Pulmonary aspergilloma

1. Embolotherapy

2. Instillation of antifungalsa. Intracavitaryb. Endobronchial

3. Local radiotherapy

Massive haemoptysis

t-----L.-----t Uneventful

Complex aspergilloma Simple aspergilloma

FIG 7. Management of pulmonary aspergilloma.

CRYPTOGENIC HAEMOPTYSISThere remains a group of patients with apparently normallooking chest radiographs in whom, despite detailedclinical examination and investigation, the cause ofhaemoptysis remains elusive. This condition is calledidiopathic, essential or cryptogenic haemoptysis. It occursin about 15% of patients (range 2% to 18%).Cryptogenic haemoptysis indicates a benign prognosis.

Suri et al.? found that in this condition fibreoptic broncho-scopy is useful only in elderly male smokers. Theydiscovered an underlying malignancy in only 3 of 79patients so investigated and in more than half of theothers, haemoptysis subsided during a two-year follow up.

PULMONARY ASPERGILLOMACavitary pulmonary tuberculosis, in both the active andthe quiescent stages, is a well known predisposing factorfor the development of pulmonary aspergilloma. Though

both the situations are common in our country, there isvery little data available on the management of thiscomplication. The exact mode of therapy is controversial.However, a schematic approach to manage such patientsis outlined in Fig. 7.

CONCLUSIONThere cannot be a uniform therapeutic policy for thetreatment of patients with haemoptysis. It needs to beindividualized, based on the nature of the underlyingdisease, the general condition of the patient and theavailability of specialized services. We have provided onlyguidelines which may help in the management.

REFERENCES1 Haponik EF, Britt EJ, Smith PL, et al. Computed chest tomographyin the evaluation of haemoptysis. Chest 1987;91:80--5.

2 Suri JC, Goel A, Singla R. Cryptogenic haemoptysis: Role offibreopticbronchoscopy. Indian J Chest Dis Allied Sci 1990;32:149-52.