LUNG HEMORRHAGE AND HEMOPTYSIS

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LUNG HEMORRHAGE AND HEMOPTYSIS

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HEMOPTYSISDefinition

• Coughing up of blood
• Anywhere from blood-tinged sputum to massive
  bleeding
• Over 100 reported causes

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OTHER POSSIBILITIES

• Blood from nose, throat, or larynx
• Blood from stomach
• Dark
• Acid pH
• May contain food particles
• Usually have GI complaints

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HEMOPTYSISCharacteristics

• Generally bright-red
• Alkaline pH
• Contains alveolar macrophages
• Frequently mixed with frothy or purulent sputum

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INITIAL EVALUATION

• Airway patency
• Vital signs
• Adequate oxygenation

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INITIAL MANEUVERS FOR MASSIVE BLEEDING

• Trendelenburg position
• Bleeding side down
• Volume resuscitation prn
• Intubation of the mainstem bronchus going to the
  non-bleeding lung (in extreme circumstances)
• Consider small doses of codeine or morphine to
  blunt the cough reflex, but keep in mind risk of
  aspiration from central depression
• CXR

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LABORATORY EVALUATION

• Platelet count, fibrinogen, thrombin time
  prothrombin time, partial thromboplastin time,
  and sometimes bleeding time
• Urinalysis, BUN, serum creatinine, antiglomerular
  basement antibodies (Goodpastures syndrome),
  antineutrophil cytoplasmic antibody (Wegeners
  granulomatosis), ANA, rheumatoid factor,
  complement, circulating immune complexes (SLE or
  other vasculitis), and cryoglobulin
  (cryoglobulinemia)

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SURGICAL VS MEDICALTHERAPY

• Immediate surgery considered for massive
  hemoptysis
• Definition of massive varies, from 200-900 cc
  in 4-24 hr
• No randomized, controlled study
• One widely cited non-randomized study by Crocco
  et al. reported higher survival rate for surgical
  group (81 vs 22) but study limited by small
  number of medical treatment group and higher
  degree of disease severity

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INITIATING THE SEARCH FOR A CAUSE

• A search for the bleeding site is rarely needed
  in patients with acute bronchitis, pneumonia, or
  bronchopulmonary suppuration
• Before middle age consider mitral stenosis,
  tuberculosis, pneumonia, or bronchiectasis
• After 40 to 45 years of age consider bronchogenic
  carcinoma and tuberculosis
• Consider pulmonary embolism in patients with a
  predisposing cause such as oral contraceptives or
  chronic heart failure

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NEOPLASMS (I)

• Hemoptysis very common in bronchogenic carcinoma
• Likeliest possibility in patients between 40 and
  60 years of age
• Likelihood greatly increased if there is a long
  history of cigarette smoking
• Usually cough and vague chest pain precede and
  accompany the hemoptysis

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NEOPLASMS (II)

• Can be from an ulceration, pneumonic process, or
  an abscess caused by the tumor
• Benign tumors can also cause hemoptysis, such as
  a bronchial carcinoid
• Metastatic tumors rarely cause hemoptysis until
  the pre-terminal stage

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INFECTIONS (I)

• Not uncommon in the pneumonia that complicates
  bronchogenic carcinoma or in the pneumonia caused
  by staphylococci, influenza virus, or Klebsiella
• Sputum rusty-looking or bloody in pneumococcal
  lobar pneumonia
• Sputum mixed with blood and pus in staphylococcal
  pneumonia

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INFECTIONS (II)

• Currant jelly-like sputum in Klebsiella pneumonia
• Brisk bleeding common in lung abscess, blood
  mixed with foul-smelling pus
• Bloody sputum associated with necrotic lung
  tissue in lung gangrene

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INFECTIONS (III)

• Hemoptysis common in bronchiectasis, bleeding
  often brisk and recurrent, but rarely
  life-threatening
• Most common fungal disorder associated with
  hemoptysis is a fungus ball in a cavity or
  cystic space
• Aspergillus is the usual fungal agent

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INFECTIONS (IV)

• Tuberculous pneumonia or cavity can cause
  persistent hemoptysis
• Right middle lobe syndrome is frequently
  associated with hemoptysis
• Sputum resembles anchovy sauce in amebic lung
  abscess

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CARDIOVASCULAR DISORDERS (I)

• Pulmonary congestion and alveolar edema
• Alveolar macrophages often laden with hemosiderin
  (heart failure cells)
• Sputum often pink and frothy
• Pulmonary embolism or thrombosis produce
  hemoptysis only when associated with infarction
• Pulmonary infarction is usually associated with
  pleuritic pain and a small pleural effusion

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CARDIOVASCULAR DISORDERS (II)

• Tight mitral stenosis is sometimes manifested by
  brisk, bright-red hemoptysis that is difficult to
  control
• Massive hemoptysis from mitral stenosis is an
  indication for surgical intervention
• Other rare cardiovascular causes include
  penetrating aortic aneurysm and AV fistula
  communicating with a small airway

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TRAUMA

• Lung puncture
• Lung contusion
• Necrosis of tracheobronchial lining by inhaled
  fumes or smoke

• Laceration or fracture of tracheobronchial tree
  from blunt trauma
• After pneumonectomy

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OTHERS (I)

• Foreign body
• Blood dyscrasias, such as thrombocytopenic
  purpura, hemophilia, or anticoagulant ingestion
• Vitamin C deficiency
• Goodpastures syndrome
• Vicarious menstruation

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• Catamenial Hemoptysis Diagnosis with High
  Resolution Computer Tomography
• Kun-Eng Lim, Chun-Hua Wang, Yon-Cheong Wong,
  Wen-Ching Hsu
• Pulmonary endometriosis manifesting as
  catamenial hemoptysis is a very rare condition.
  We describe two additional cases of pulmonary
  endometriosis with hemoptysis during menses and
  which was localized with high resolution lung CT.
  High resolution lung CT shows consolidation or
  ground glass opacity.

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OTHERS (II)

• Sarcoidosis
• Immune complex-induced systemic vasculitis
  (cryoglobulinemia, polyarteritis, Wegeners
  granulomatosis, Churg-Strauss syndromeetc.)
• Connective tissue diseases
• Idiopathic
• Hemosiderosis

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BRONCHOSCOPY

• Can often determine site of bleeding in
  hemoptysis
• Can sometimes determine cause of bleeding
• Early is better. Does not need to wait for
  bleeding to stop.
• Fiberoptic bronchoscopy allows optimal
  visualization of the bronchial tree
• Rigid bronchoscopy better in cases of brisk
  bleeding (ease of instrument passage)

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BRONCHOSCOPY

• Low yield in patients younger than 40 who are
  nonsmokers, have been bleeding for less than 1
  week, and have normal chest x-rays
• Of only limited help in patients with pulmonary
  hemorrhage

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OTHER DIAGNOSTIC APPROACHES

• Rarely indicated, but include
• Bronchography
• Computed tomography
• Pulmonary arteriography
• Red blood cell scanning

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CONSIDERATIONS FOR SURGERY (I)

• Sufficient pulmonary reserve?
• Cause of hemoptysis amenable to surgical
  correction?

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CONSIDERATIONS FOR SURGERY (II)

• Diffuse lung disease precludes surgery (e.g.,
  bronchiectasis attributable to cystic fibrosis,
  diffuse scarring from old tuberculosis, or lung
  cancer in a COPD patient with inadequate
  pulmonary function to tolerate resection)
• Consider bronchial arteriography and possible
  embolization in patients with diffuse lung
  disease and massive hemoptysis who can not
  undergo parenchymal resection

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PROGNOSIS FOR HEMOPTYSIS

• Excellent if
• CXR normal
• Bronchoscopy normal