HEMOPTYSIS

Allen Widysanto

DEFINITION
Hemoptysis

is defined as the spitting of

blood derived from the lungs or bronchial
tubes as a result of pulmonary or
bronchial hemorrhage

CLASSIFICATION
HEMOPTYSIS

MASSIVE

NONMASSIVE

Blood loss 200-1000 ml/24 hours

Blood loss less than 200 ml

NO DEFINITE CRITERIA

Massive hemoptysis
Pulmonology and Respiratory Department
at FKUI /Persahabatan Hospital has own
criteria.
Blood loss 600 ml/24 hours and it doesnt stop on observation

Blood loss 250 ml but 600 ml/24 hours, Hb level 10 g%, hemoptysis
still occured
Blood loss > 250 ml but 600 ml/24 hours, hb level > 10 g%,
observation during 48 hours + conservative treatment , hemoptysis
still occured

Causes
idiopathic
PULMONARY

EXTRA PULMONARY

Upper Respir Tract

Tuberculosis
Ex Tuberculosis

Bronchitis
Bronchiectasis
Fungal infection

Lung cancer

GIT
Dental/gum
PH-MS

THE MOST IMPORTANT IS THE SOURCE

OF HEMOPTYSIS

Coagulopathy

PATHOPHYSIOLOGY
Aneurysme Rasmussen
TUBERCULOSIS

Lymphadenopathy
Bronchiectasis

Non specific
infection

bacterial

virus

Superficial mucosa inflammation may lead

Rupture of Superficial blood vessel

fungi

LUNG CANCER

Superficial mucosal invasion

Erosion into blood vessel
Angiogenesis
Secondary infection

CARDIAC

Left ventricular HF
Mitral Stenosis

IT IS DEPEND ON THE CAUSES

 Hemoptysis

in children

LOWER RESPIRATORY TRACT INFECTION

FOREIGN BODY ASPIRATION
BRONCHIECTASIS

PULMONARY TB .. Very rare

Hemoptysis vs Hematemesis
Absence of nausea and vomiting

Presence of nausea and vomiting

Lung disease

Gastric or hepatic disease

Asphyxia possible

Asphyxia unusual

Sputum examination
Frothy

Rarely frothy

Liquid or clotted appearance

Coffee ground appearance

Bright red or pink

Brown to black

Laboratory
Alkaline pH

Acidic pH

Mixed with macrophages and neutrophils

Mixed with food particles

DIAGNOSTIC
history taking
CLINICAL CLUES

SUGGESTED DIAGNOSIS

Anticoaulant use

Medication effect, coagulation disorder

Association with menses

Catamenial hemoptysis

Dyspnea on exertion, fatigue, orthopnea, paroxysmal

nocturnal dyspnea, frothy sputum

Mitral valve stenosis

Fever, productive cough

Upper Respiratory infection, acute sinusitis, bronchitis,

pneumonia, lung abscess

History of breast,colon or renal cancer

Metastatic disease of lungs

History of chronic lung disease, recurrent LRTI, cough with

copius sputum

Bronchiectasis

HV, immunosuppresion

Neoplasia, tuberculosis, Kaposis sarcoma

Nausea, vomiting, melena, alcoholism, chronic use of NSAID

Gastritis, gastric or peptic ulcer, esophageal varices

Pleuritic chest pain, calf tenderness

Pulmonary embolism or infarction

Tobacco use

Acute bronchitis, chronic bronchitis, lung cancer,

pneumonia

Travel history

Tuberculosis, parasites, biologic agents

Weight loss

Emphysema, lung cancer, tuberculosis,bronchiectasis,

lung abscess, HIV

DIAGNOSTIC
Physical Examination
Cachexia, clubbing, hoarseness, hyperpigmentation,
Horners syndrome

Lung cancer

Clubbing

Primary lung cancer, bronchiectasis, severe lung

metastasis

Dullness to percussion, fever, unilateral rales

Pneumonia

Facial tenderness, fever, mucopurulent nasal discharge,

postnasal drainage

Acute URTI, acute sinusitis

Fever, tachypnea, hypoxia, barrel chest, ICS retraction, pursed lip

breathing

AECB

Heart murmur, pectus excavatum

Mitral valve stenosis

Tahypnea, tachycardia, dyspnea, unilateral leg pain,

edema

Pulmonary thromboembolic disease

DIAGNOSTIC EVALUATION
History

taking
Physical examination
Supportive:

chest X ray
Sputum evaluation
Blood gas analysis
CT scan
Bronchoscopy

Harrison 15th,ed.

Management Nonmassive
Hemoptysis
Goal

BLEEDING CESSATION
ASPIRATION PREVENTION
TREATMENT UNDERLYING

AIRWAY

BREATHI
NG

CIRCULATI
ON

Depends on the underlying disease.

Sedatives: Fenobarbital 10-25 mg/4 hours or
Librium 10-25 mg/hours
Codein sulfat 15-30 mg/4jam
If bleeding 20-100 cc :
1.
IV line
2. Monitoring CVP
3. Complete blood count (platelet)
4. Electrolyte
5. PT-APTT

 ICU

setting if needed
Bronchoscopy
Surgical if bleeding > 150 ml/hour, use
double lumen ETT
Forgathy catheter
Pulmonary artery embolization

Management of massive
hemoptysis

Vital sign :
Oksigen

Deficit volume (colloid/cristaloid, blood transfusion

if hematocrit 25-30% or Hb 10 g%, bleeding
still occur)

Blood pressure ( vasopressor (dobutamin dan

dopamin)
2. Avoid airway obstruction

Trendelenberg position

ETT

Suction

Mechanical ventilator
1.

3. Stop bleeding
Bronchoscopy cito ( insert the Forgathy
catheter)
Bronchial artery catheterization,
embolization
Hemostatic agent is still unclear
Antitussive ( Codein 10-20 mg/4 hours)
Hemostatic physiology

4. Specific therapy
Through bronchoscope
Bronchial washing using cold Normal
Saline (NaCl 0.9%)
Vasoconstrictor agent : adrenalin
Endobronchial tamponade
Laser Neodynamium-aluminium-garnet
(Nd-YAG)

 Without

bronchoscope
Treat the underlying disease
IV vasopressin 0,2-0,4 unit/min
Antifibrinolitic
Radiasi --- vascular thrombosis
Artery embolization

MANAGEMENT OF MASSIVE
HAEMOPTYSIS
Airway

protection and resuscitation

Identifying the site and cause of
bleeding
Bronchoscopic treatment
Bronchial artery embolization (BAE)
Surgical treatment

SURGICAL MANAGEMENT

4 take home messages

Find

out the causes of hemoptysis

Remember the goal of management
Asphyxiation is the primary mechanism of
death due to hemotysis
Evaluation ABC is important