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Haemoptysis: Diagnosis and Treatment

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Haemoptysis: Diagnosis and Treatment Acute Medicine 2012; 11(1): 39-45 39 Trainee Section Haemoptysis: Diagnosis and Treatment K Hurt & D Bilton Abstract There are no consensus guidelines available for Haemoptysis is a common symptom in clinical practice, the management of haemoptysis and its treatment which requires further investigation. Fortunately, massive can be challenging, even for experienced physicians. haemoptysis only accounts for a small proportion of these episodes. It is a medical emergency that carries a high Pathophysiology mortality rate. There are no agreed management guidelines. The lungs have a double arterial supply. The This review discusses proposed methods of resuscitation as pulmonary arteries carry deoxygenated blood under well as outlining a diagnostic algorithm and discusses low pressure to the lungs for the purpose of gas treatments including bronchial artery embolization, exchange. The bronchial arteries account for <1% of endobronchial therapy, surgery and medical therapies. the circulation to the lungs and supply oxygenated blood to the lung parenchyma. They are under Keywords systemic pressure, originating from the descending Haemoptysis, bronchoscopy, bronchial artery embolization, aorta, usually between 3rd and 8th thoracic vertebral CT thorax, lung cancer, bronchiectasis, cystic fibrosis. level, most commonly between the 5th and 6th. 6 There is a wide anatomical variation in bronchial Introduction artery anatomy. In around 5-10% of people the Haemoptysis can be defined as the expectoration of anterior medullary artery that supplies the anterior blood from the lower respiratory tract. The amount spinal artery arises from the intercostal bronchial of blood can vary widely, from streaking of the trunk. However a recent report of bronchial artery sputum to rapidly fatal massive haemoptysis. Whilst embolizations suggests that this figure is somewhat haemoptysis in general is a relatively common lower. 7 clinical problem, massive haemoptysis remains Around 90% of haemoptysis will originate from fortunately very rare. The exact incidence is the bronchial arteries and around 5% from the unknown because there is no agreed definition in pulmonary arterial circulation. 8 Mechanisms of bleeding are multi-factorial. In the literature as to what constitutes massive Katharine Hurt haemoptysis. Definitions range from a blood loss of the presence of chronic inflammation and infection MBBS MRCP 100 mls of blood expectorated in 24 hours 1 up to bronchial arteries hypertrophy and proliferate. There Clinical Research Fellow, 1000mls in 24 hours. 2 Most respiratory physicians is also enlargement of the usual systemic to Royal Brompton Hospital would use a definition somewhere between 200- pulmonary artery and pulmonary vein and Imperial College, 600mls/24 hours. It has been suggested that volume communications. These factors lead to increased London expectorated definitions are not useful in clinical blood flow and neovascularization. The resultant Diana Bilton practice and actually it is better to define thin walled vessels are at risk of rupturing into the FRCP MD functionally. 3,4 There are good reasons for this. airway causing haemoptysis. 7,9 Consultant Respiratory Haemoptysis is difficult to quantify, patients may Physician, over report amounts produced and the physiological Case History Royal Brompton Hospital and Imperial College, effects of haemoptysis will depend on the patient’s A 28 year old woman with cystic fibrosis (CF) and severe London clinical status. Death from massive haemoptysis is bronchiectasis presented to her local hospital after a single usually through a process of asphyxiation, rather than episode of haemoptysis. This was estimated, by the patient, Correspondence: exsanguination. 5 to have been around 200mls. She also described increased Katharine Hurt Haemoptysis is a serious symptom that requires shortness of breath, right sided chest pain and dizziness. Department of Cystic further investigation as it may be a sign of underlying Her CF was complicated by diabetes, for which she Fibrosis Royal Brompton Hospital required insulin, and chronic infection with Pseudomonas severe disease. The most common causes vary Sydney Street geographically with tuberculosis (TB) being the aeruginosa; she took a number of regular medications London most common underlying aetiology in the including pancreatic enzymes, vitamins, prophylactic SW3 6NP developing world and elsewhere bronchitis and lung nebulised antibiotics (colomycin) and a nebulised mucolytic. Email: k.hurt@imperial cancer. 2 She was not taking anticoagulant or anti-platelet drugs. .ac.uk © 2012 Rila Publications Ltd. 40 Acute Medicine 2012; 11(1): 39-45 Haemoptysis: Diagnosis and Treatment Neoplastic Airway Disease History of presenting complaint It is important to clarify that bleeding has arisen from the Bronchogenic carcinoma Bronchiectasis lower respiratory tract and to exclude haematemesis and Pulmonary metastatic Bronchitis epistaxis as alternative explanations. Attempts to quantify disease the amount of blood should also be made, although this Kaposi’s sarcoma Cystic Fibrosis can be very difficult. Infection Primary Vascular Disease Associated symptoms and risk factors Bacterial pneumonia Pulmonary AV malformations Any current or past diagnoses of respiratory disease should TB Pulmonary embolism be elicited and a detailed respiratory history should be taken to try and ascertain the underlying diagnosis. Mycetoma Pulmonary hypertension Symptoms of cough, sputum production, fever, chest pain Non tuberculous Congestive cardiac failure and weight loss could suggest acute infection, TB, chronic mycobacterial disease bronchitis, chronic suppurative lung disease or lung cancer Respiratory viral infection Mitral stenosis depending on time course. Risk factors for PE should be considered as well as symptoms of heart failure and valvular Parasitic disease Miscellaneous heart disease. In addition a smoking and travel history Systemic Disease Foreign body inhalation should be taken. Goodpasture’s syndrome Endometriosis A careful drug history, especially use of anticoagulant should be noted, any association with menses for female Wegener’s granulomatosis Amyloidosis patients should be considered and risk factors for HIV Microscopic polyarteritis Pulmonary sequestration infection should be identified. Concurrent systemic upset Systemic lupus Iatrogenic Lung Injury and rash may suggest an underlying vasculitis. erythematosus Clinical examination Coagulopathy In addition to a detailed respiratory examination, general Table 1. Important causes of haemoptysis. examination should involve assessment of nutritional status. Finger nails should be checked for signs of clubbing. What are the possible causes of her Lymph nodes should be examined in the neck, haemoptysis? supraclavicular and axilla regions. The skin and mucous Table 1 lists the most important causes of haemoptysis. membranes should be inspected for signs of bruising, Lung cancer accounts for around 20-30% of cases in pallor, rash, telangiectasia and gingivitis. recent series. Despite extensive investigation, the cause of Full cardiovascular examination should be performed, looking specifically for signs of congestive heart failure, haemoptysis remains unknown in 3-43% of patients. 10-12 In this case the presence of known bronchiectasis pulmonary hypertension, thromboembolic disease and makes this the most likely cause of her haemoptysis, valvular heart disease. although other causes in the list should be considered. How do you investigate and manage non On arrival in the emergency department she was apyrexial, massive haemoptysis? alert and orientated; her heart rate was 88/min with a blood Chest x-ray (CXR) is an important initial investigation. pressure of 100/64mmHg. Her respiratory rate was 18/min and Tumours, consolidation and mycetomas may be obvious. oxygen saturations 97% on air. Cardiovascular and abdominal Bilateral alveolar shadowing may suggest alveolar examination was unremarkable. Respiratory examination revealed haemorrhage and bronchiectasis may be seen. However, coarse crepitations throughout her right lung. CXR will fail to reveal the diagnosis in up to 46% of cases. 14 It is also important to remember that a normal What are the important features of history CXR does not mean that a diagnosis of lung cancer can be and examination when assessing a patient excluded. When investigating haemoptysis up to 24% of with haemoptysis? patients diagnosed with lung cancer had a normal CXR at For the purposes of management the patient needs to be the time of presentation. 15 Depending on the CXR there allocated into one of the following groups based on history are three main investigation routes. 16 and clinical findings. 1. If the CXR demonstrates a mass lesion, the patient should be referred to a respiratory specialist for 1. Minor haemoptysis (which may be investigated and further investigation and treatment, 17 which will treated as an outpatient) usually involve a staging CT scan, bronchoscopy (or 2. Major / massive haemoptysis with clinical stability. percutaneous lung biopsy) and cancer 3. Major / massive haemoptysis with clinical instability multidisciplinary team discussion. Initial assessment should use the ‘ABCDE’ approach in 2. If the CXR demonstrates parenchymal accordance with resuscitation council guidelines. 13 abnormalities referral to a respiratory specialist is recommended. A high resolution CT scan would © 2012 Rila Publications Ltd. Acute Medicine 2012; 11(1): 39-45 41 Haemoptysis: Diagnosis
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