Hemoptysis

 Hemoptysis 

🔹 Introduction

Hemoptysis refers to expectoration of blood originating from the lower respiratory tract (below the glottis). It is a potentially life-threatening emergency when massive, as it can cause airway obstruction, asphyxiation, or hypoxemic respiratory failure, even before exsanguination occurs.

🔹 Classification

Clinical definition preferred:
➡️ Any hemoptysis that causes respiratory distress, airway obstruction, or hemodynamic instability should be treated as massive, irrespective of volume.

🔹 Pathophysiology

1. Vascular sources

• Bronchial circulation (90%) — systemic high-pressure system from thoracic aorta.
• Pulmonary circulation (10%) — low-pressure system, but involvement in vasculitis, AV malformations, or trauma.

2. Mechanisms

• Erosion or rupture of bronchial artery due to chronic inflammation or neoplasm.
• Neovascularization with fragile vessels (e.g., bronchiectasis, TB).
• Alveolar capillary leakage (e.g., diffuse alveolar hemorrhage).

🔹 Common Causes of Hemoptysis

1. Infectious

• Tuberculosis (active or sequelae) – cavitary lesions erode bronchial vessels.
• Bronchiectasis – chronic suppurative infection with fragile neovascularity.
• Lung abscess, necrotizing pneumonia, or fungal infections (Aspergilloma).

2. Inflammatory / Autoimmune

• Goodpasture’s syndrome (anti-GBM disease)
• Granulomatosis with polyangiitis (Wegener’s)
• Microscopic polyangiitis
• SLE, Behçet’s disease

3. Neoplastic

• Bronchogenic carcinoma – central tumors may erode vessels.
• Metastatic lesions – especially choriocarcinoma, renal cell carcinoma.

4. Cardiovascular

• Mitral stenosis – pulmonary venous hypertension → rupture of bronchial veins.
• Pulmonary embolism / infarction
• AV malformations, aneurysm of pulmonary artery (Rasmussen’s aneurysm)

5. Iatrogenic / Traumatic

• Bronchoscopy, biopsy, tracheostomy, catheter-induced injury, or mechanical ventilation.

6. Coagulopathy / Drugs

• Anticoagulants, antiplatelet therapy, DIC, thrombocytopenia.

7. Idiopathic

• Up to 30% of cases — particularly in smokers and chronic bronchitics.

🔹 Differential Diagnosis — “Pseudohemoptysis”

• Most common cause worldwide: Tuberculosis
• Most common cause in developed countries: Bronchiectasis
• Most common cause of death: Asphyxiation
• Definitive treatment for massive hemoptysis: Bronchial artery embolization
• DAH hallmark on BAL: Hemosiderin-laden macrophages
• Rasmussen’s aneurysm: Pulmonary artery aneurysm adjacent to TB cavity

🔹 Clinical Evaluation

1. History

• Onset: sudden (PE, bronchiectasis) vs gradual (malignancy).
• Associated symptoms: fever, weight loss, hematuria (vasculitis), chest pain.
• Risk factors: smoking, TB exposure, anticoagulants, recent procedures.

2. Physical Examination

• Vital signs, oxygenation, hemodynamic stability.
• Inspection for clubbing, cyanosis, signs of vasculitis, murmurs (mitral stenosis).
• Auscultation: crackles, bronchial breath sounds, wheeze, cavity signs.

🔹 Investigations

1. Initial

• CBC, renal and liver function, coagulation profile, ABG.
• Chest X-ray – localize lesion (cavity, mass, infiltrate, consolidation).
• Sputum for AFB, cytology, Gram/fungal stain.

2. Advanced

• CT chest (HRCT or CECT) —first line if patient is stable, best for localization, detecting bronchiectasis, malignancy, aspergilloma, PE.
• Bronchoscopy (Flexible or Rigid)
• Diagnostic & therapeutic.
• Allows localization, suctioning, tamponade, instillation of vasoconstrictors or iced saline.
• first line if patient is unstable

3. Specific

• Autoimmune panel: ANA, ANCA, anti-GBM.
• Urinalysis: red cells, casts (DAH).
• Echocardiography: evaluate mitral stenosis, cardiac causes.

🔹 Diffuse Alveolar Hemorrhage (DAH)

Definition: Bleeding into alveolar spaces due to capillaritis or non-inflammatory causes.

Causes:

• ANCA-associated vasculitis
• Anti-GBM disease
• SLE
• Drugs (amiodarone, cocaine, anticoagulants)

Clinical triad:

• Hemoptysis (may be absent in 30%)
• Anemia
• Diffuse pulmonary infiltrates

Bronchoalveolar lavage (BAL): sequentially more bloody aliquots, hemosiderin-laden macrophages.

🔹 Management Approach

1. Immediate Priorities (ABCDE)

• Airway protection – main cause of death is asphyxiation, not exsanguination.
• Intubate with large-bore single-lumen ETT (>8.5 mm) for bronchoscopy access.
• Selective mainstem intubation of non-bleeding lung if bleeding side known.
• Can use bronchial blocker
• Breathing: supplemental oxygen, mechanical ventilation if required.
• Circulation: IV access, fluids, transfusion for anemia/shock.

2. Localization of Bleeding

• CT chest followed by bronchoscopy — often both needed.
• If site identified, position patient bleeding side down (dependent position).

3. Specific Therapy

 a. Medical Measures

• Stop anticoagulants, correct coagulopathy (FFP, PCC, platelets).
• Tranexamic acid – 500–1000 mg IV or via nebulization; may reduce bleeding duration.
• Cold saline lavage, topical epinephrine (1:20,000) via bronchoscope.
• Treat underlying cause — antibiotics, antituberculars, immunosuppressants.

 b. Bronchoscopic Interventions

• Balloon tamponade, fibrin glue, topical hemostatics.
• Rigid bronchoscopy preferred in massive cases (better suction, airway control).

 c. Definitive Therapies

• Bronchial Artery Embolization (BAE):
• First-line definitive therapy for massive hemoptysis.
• Success: 70–90%, recurrence 10–30%.
• Embolic agents: PVA particles, coils, glue.
• Avoid spinal artery embolization (paraplegia risk).
• Surgical Resection:
• Indicated when embolization fails or if resectable localized lesion (aspergilloma, tumor, destroyed lobe).
• High mortality if done emergently; prefer elective once stabilized.

🔹 ICU and Critical Care Aspects

• Massive hemoptysis = Airway emergency → immediate airway control.
• Maintain PEEP cautiously to avoid dislodging clot.
• Prone positioning may aid dependent drainage.
• Blood conservation: monitor hemoglobin and coagulation closely.
• Multidisciplinary team: pulmonologist + interventional radiologist + thoracic surgeon.

🔹 Prognosis

• Depends on etiology and bleeding severity.
• Mortality in massive hemoptysis: >50% without intervention, <10% with early embolization.
• Recurrence common in bronchiectasis and TB sequelae.