Hemoptysis
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Transcript of Hemoptysis
HEMOPTYSIS
Dr. J. RoigPulmonary Division
Hospital N. Sra. de MeritxellAndorra
Life threatening hemoptysis (LTH)
LTH better than “massive” hemoptysis Value of clinical history Physical findings Laboratory data Chest X-ray Optionally other image techniques Bronchoscopy
Causes of hemoptysis Infections
Bronchitis Tuberculosis Fungus Pneumonia Lung abscess Bronchiectasis
Tumors Bronchial cancer Carcinoid
Cardiovascular Lung infarct Mitral stenosis
Trauma Other
Foreign body Hemorrhagic diatesis Goodpasture and
other immunological disorders
Orriols R et al. Aetiology of Life-threatening hemoptysis. Eur Resp J 1996;9(S23):315-16
Intubation: 7% (80 cases). Mortality rate 3.4% Causes: Active tuberculosis 14 (12.1%)
Sequels post TBC 22 (18.9%)Bronchiectasis 27 (23.3%)Unsure diagnosis 27 (23.3%)Bullous emphysema 10 (8.6%)Tumors 7 (6.1%)Aspergilloma 6 (5.2%)Mucoviscidosis 2 (1.9%)
Uncommon, sometimes neglected, causes of LTH: infections
Viral lung or bronchial infection (usually associated with disseminated iv coagulation and bleeding diathesis)
Necrotizing bronchial fungal infection Bacterial endocarditis Mycotic intrathoracic aneurisms Hirudo medicinalis (common leech)
S. aureus infection in healthy •Gillet Y. Association between S. aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients. Lancet 2002;359:753-59.•Boussaud V. Life-threatening hemoptysis in adults with CAP due to PV leukocidin-secreting S. aureus. Intensive Care Med 2003;29:1840-3.•Francis J. Severe Community-onset pneumonia in healthy adults caused by methicillin-resistant S. aureus carrying the PV leukocidin genes.CID2005
Tuberculosis - LTH
Active infection Rasmussen pulmonary artery aneurism Sequels post-tuberculosis:
BronchiectasisBroncholitiasisMycetoma in residual cavities
“Scar carcinoma”
Aspergillus - Hemoptysis
Aspergilloma Invasive aspergillosis Chronic necrotizing aspergillosis or semiinvasive Necrotizing pseudomembranous
tracheobronchitis Stump aspergillosis after lung resection Bronchocentric granulomatosis
Lung abscess and LTH Thomas NW. Life-threatening hemoptysis in
primary lung abscess. Ann Thorac Surg 1972;14:347
Sequential filling-emptying pattern is a warning sign of massive hemoptysis in lung abscess: urgent surgery must be considered
Philpott NJ. Lung abscess: a neglected cause of
life-threatening hemoptysis. Thorax 1993;48:674 Recommends surgery if LTH in chronic abscess
Uncommon, sometimes neglected, causes of LTH: cardiovascular
Eisenmenger syndrome Mitral stenosis Left ventricle pseudoaneurysm Aortobronchial fistulas Vascular pulmonary abnormalities
associated with liver disease
Vascular diseaseBRONCHIAL CIRCULATION Angiomes and aneurisms of bronchial arteries Varicosities in chronic liver disease Vasculitides Arterial hypervascularization secondary to:
Inflammatory process Tumors Congenital heart disease Chronic stenosis of pulmonary artery
Vascular diseaseSYSTEMIC CIRCULATION Aortic dissection Systemic Hypervascularization
Intercostal arteriesOther as mamary artery
Vasculitides
Vascular diseasePULMONARY CIRCULATION Pulmonary disease Arteriovenous fistula Tumors (angiosarcoma) Aneurysms (micotic or not) Primary pulmonary hypertension Varicosities in chronic liver disease Vasculitides
Vascular abnormalities in chronic liver disease Man KM et al. Pulmonary varices presenting as
a solitary lung mass in a patient with end-stage liver disease. Chest 1994;106:294-6.
Schnader J et al. Hemoptysis, hepatopulmonary syndrome and respiratory failure. Clinical conference on management dilemmas. Chest 1997;111:1724-32.
Youssef A et al. Hemoptysis secondary to bronchial varices associated with alcoholic liver cirrhosis and portal hypertension. Am J Gastroenterol 1994;89:1562-3.
Uncommon, sometimes neglected, causes of LTH: vasculitis
Tracheobronchial form of Wegener Behçet vasculitis Hughes-Stovin syndrome Takayasu arteritis
Uncommon, sometimes neglected, causes of LTH: congenital abnormalities
Agenesis of pulmonary artery Congenital anomalies of large mediastinal
vessels, such as hemitruncus Cystic disease with/without laryngeal
papylomatosis Pulmonary sequestration Accessory cardiac bronchus
Uncommon, sometimes neglected, causes of LTH: tumors
Some pulmonary metastasis (angiosarcoma and hepatocellular carcinoma)
Some endobronchial metastasis (thyroid papillar carcinoma)
Cystic mediastinal mass Inflammatory pseudotumor Pulmonary cavernous hemangiomatosis
Uncommon, sometimes neglected, causes of LTH: other bronchial abnormalities
Broncholithiasis Tracheopatia osteochondroplastica Aspiration of foreign body
Causes of Diffuse Alveolar Hemorrhage (DAH) - 1 Bone marrow transplantation, especially
autologous Drug-induced pulmonary hemorrhage Isolated pulmonary capillaritis with negative
antineutrophil cytoplasmic antibodies Pulmonary arterial fibromuscular dysplasia DAH associated with high altitude edema DAH with positive antiglomerular basement
membrane antibodies without renal involvement Idiopathic pulmonary hemosiderosis
Causes of Diffuse Alveolar Hemorrhage (DAH) - 2 Systemic vasculitides, collagen vascular diseases Negative pressure alveolar hemorrhage Serious group A streptococcal infections Ehlers-Danlos syndrome Crack-cocaine inhalation Severe bleeding diathesis (DIC) Trimellitic anhydride inhalation Primary antiphospholipid syndrome Lung transplant rejection Pulmonary-renal syndrome Pulmonary infection in immunocompromised Pulmonary veno-occlusive disease
Keypoints in DAH DAH may be the initial form of
presentation There is no correlation between the
amount of expectorated blood and the real volume of alveolar bleeding
If glomerular involvement, deterioration of renal function may be very quick
Value of progressively hemorrhagic BAL Value of sequential DLCO in non-acute
setting
Uncommon, sometimes neglected, causes of LTH: miscellaneaous Lymphangioleimyomatosis Uremia Exogenous lipid pneumonia Intrathoracic Recklinghausen disease Extreme breath-hold diving Bullous emphysema Broncholitis obliterans organizing pneumonia Sarcoidosis Respiratory bronchiolitis associated interstitial
lung disease Subphrenic abscess penetrating the diaphragm
LTH –Miscellaneous (1)
Thoracic trauma Broncholitiasis Foreign body Hemorrhagic diathesis Vasculitis – alveolar hemorrhage Old, chronic scars (sequels):
Middle lobe syndromeEmphysema (bullae)
LTH - Miscellaneous (2)
Fibrosing mediastinitis Mediastinal tumors: teratoma Esophageal cancer Sarcoidosis Septal diffuse amiloidosis Fictitious hemoptysis
General measures in LTH Immediate intubation and mechanical ventilation if
Asphyxia Hypovolemic shock
Evaluate admission to the respiratory and ICU Nothing by mouth Ipsilateral decubitus lying on the alleged bleeding site Intravenous line Evaluate local applicability of the general algorithmic
approach Provision to allow rapid blood replacement Control of bleeding speed and volume of expectorated
blood Chest radiograph Routine blood tests: consider specialized tests if indicated Consider specialized diagnostic procedures if indicated
Hemoptysis, X-ray and FOB
Misdiagnoses if classical criteria are followed Hemoptysis > 7 days Age > 40 Smoking habit
FOB in any hemoptysis without diagnosis: Increasing incidence of tumor even in age < 40 Overall % of cancer on long-term follow-up: 4% A variety of other non-tumor diagnoses by FOB LTH is unpredictable Low morbidity (0.08%) and mortality (0.01) of FOB
LTH: technical aspects of FOB
ENT evaluation is mandatory Aspiration channel > 2.6 mm of Ø Avoid FOB-related bleeding iatrogenia:
BronchiectasisCarcinoid tumorBronchial angiomasAneurysms of pulmonary arteryRemoval of old foreign body
Iatrogenic causes of LTH - 1 Surgical corrections of congenital heart disease Endobronchial brachytherapy Self-expanding, indwelling airway and esophageal stent-
related fistulas Bronchoscopy-related bleeding complications Migration to lung of vascular and heart (cardioverter
defribillator) patches Aortobronchial fistula after vascular aortic thoracic graft Coronary angiography with abciximab infusion Late bleeding after anticoagulation therapy in pulmonary
embolism Bronchial artery infusion of cytostatic therapy to treat
pulmonary metastasis
Iatrogenic causes of LTH - 2 Pulmonary irradiation Lymphoma and other mediastinal tumors
irradiation Catheter-induced pulmonary artery lesion Transtracheal aspiration Percutaneous lung aspiration Long-standing tracheostomy with
tracheoinnominate artery fistula Thrombolytic therapy, especially with
unsuspected cavitary lung disease Retained intrathoracic old gauze (“gauzeoma”) or
sponge
Iatrogenic causes of LTH - 3 Bronchovascular fistula after lung transplantation Drug-induced bleeding diathesis: DAH Intravascular migration of fractured sternal wire
after median sternotomy Positive pressure ventilation in patients with
cavitary tuberculosis Bronchovascular fistula after lung transplantation Bronchial stump aspergillosis in old
endobronchial silk thread sutures Hemoptysis secondary to veno-occlusive
pulmonary disease (VOPD) after Glen operation Pulmonary venous stenosis after catheter
radiofrequency ablation
Hellical CT in LTH
Great blood vessels disease Usually X-ray, FOB and BAE are first options Often confusing “mass-like” images in lung
parenchima Frequent accumulation of blood at the bottom of
both lungs. Relevance of accurate technique: thin section,
“helical CT”,…
General measures in LTH Immediate intubation and mechanical ventilation if
Asphyxia Hypovolemic shock
Evaluate admission to the respiratory and ICU Nothing by mouth Ipsilateral decubitus lying on the alleged bleeding site Intravenous line Evaluate local applicability of the general algorithmic
approach Provision to allow rapid blood replacement Control of bleeding speed and volume of expectorated
blood Chest radiograph Routine blood tests: consider specialized tests if indicated Consider specialized diagnostic procedures if indicated
LTH
General measures
Transitory measures to stop bleeding
Angiography with embolization
Identification of the anatomical origin of bleeding
Bronchoscopic measures
+
Is the patient stable and is resection technically feasible?
Is surgery 1st ? Appropriate medical treatment
Surgery
YES NO
YES
NO
Bronchial artery embolization (BAE) Anatomic variability both in number and localization Direct visualization of site of bleeding is very
difficult Sometimes hypervascularized areas are extensive
and bilateral Sometimes origin of bleeding is in collateral
systemic circulation Percentage of origin of bleeding in pulmonary
circulation is very low Risk if anterior spinal artery from bronchial artery
(<5%)
Complications of BAE Spinal complication (paraplegia) Chest pain Dysphagia Main-stem bronchus infarction Bronchial stenosis Splenic or other systemic infarct Bronchial-esophageal fistula Paradoxic embolization or migration of coil Pulmonary hypertension (if left-to-right shunt) Referres pain to the ipsilateral forehead and orbit
Drugs reported to be potentially effective in some causes of LTH Tranexamix acid, especially in mucoviscidosis* Vasopressin* Immunosupressive drugs and steroids in some
cases of DAH and vasculitis Recombinant activated factor VII (rFVIIa) Percutaneous intracavitary treatment in lung
fungal infection Cidofovir in juvenile laryngeal papillomatosis-
related multicystic disease Anticoagulant therapy in embolism Hormone: LAM; thoracic endometriosis Corrective therapy of coaguloptahies
* Anecdotal reports and uncontrolled studies