An Interactive: Case Presentation

Hemoptysis

Night Float team

Danish Ejaz Bhatti
Khouroush Hudsony
Lalit Kalra
 Brain Storming


Differential Diagnosis
− Tracheo-bronchial source
− Pulmonary Parenchymal source
− Primary Vascular Source
− Source other than lower respiratory tract
− Rare Causes
 Presenting Complaint

A 76 year old lady presented to ER with an

episode of massive hemoptysis.
(massive >2ooml in a day)
 Brain Storming

Is it hemoptysis or hematemesis ?

How to differentiate!!!
 Past Medical History


Diabetes Mellitus Type II
− Since 1984
− Used Insulin for 10 years later on started on pills
− Not taking medications for about 1 year
− Home Blood sugar is around 120

Hypertension
− Since 5 years
− Takes lisinopril
 History of Present Illness

Loosing weight
− Started around a year back
− More noticeable since 4-5 months (skin going loose)
− 48 lbs in 2-3 months (was 165 lbs few months back and now
117 lbs when last weighed)

Pain in Right Shoulder
− Started 4-5 months back
− Is relieved by keeping her arm up under her head as pillow
− Was consulting at Howard university and was told it is probably
arthritits
− Had some imaging done but unaware of the results

Blood in sputum
− Had a cough since 4-5 months
− Noticed few streaks of blood initially (first time around 4
months back)
− Scant blood, infrequently, last time was one month back
− This morning had hemoptysis, around one cup-full in amount,
came with cough, with no chest pain, fresh and clotted blood
− No asphyxiation, no nausea/vomitting
− Spitting up blood frequently in small amount since then.

Other complaints
− Has been constipated for around one month
− Some complaints of swelling of lips a few times especially in the
morning
 Review of Systems

Pertinent Negative
− No history of fever, rigors, chills
− No complaints of being dizzy on standing up
− No complaints of hoarseness of voice (my voice has always
been a bit heavy)
− No complaints of epi-gastric pain, water brash or acid brash in
mouth
− She is post menopausal since age of 33yrs
− No history of anticoagulant use.
− No complaints of PND, chest pain, heart disease
− No history of chronic lung disease, copious purulent sputum
− No history of travel
− Never been tested for HIV, no risk factors of HIV
− Never had a TB skin test

Operations:
− Hysterectomy at the age of 33 yrs for fibroids
− Para-umbilical hernia repair around 1979

Preventive Health:
− Immunization: had them last year, not sure about this year
− Mammography: 5 years ago
− Colonoscopy: 5 years ago

Home medications:
− Lipitor 20 mg PO Q Day
− Lisinopril 20 mg PO Q Day
− Naproxen 375 mg PO Q Day

Family History:
− Mother alive, have some heart problems
− Father alive, has DM
− Brother alive, has arthritis

Social History:
− Lives by herself and can take care of herself
− Alcohol: drinks once a week and last use was 4 days ago
− Smoking: Current smoker, >20 pack-years smoking
 Brain Storming

Diagnostic Clues in History !!!

 Physical Examination

Vital Signs
− Pulse: 122/min B.P: 128/92 R.R: 22/min Temp: 97.3 O2 Sat:
98% on RA

General
− AAO x 3, emaciated looking with loose skin, puffy looking face

HEENT
− PERRLA, EOMI, Nasal septum normal, Normal Gingiva

Neck
− Supple, JVP not elevated but distended superficial veins, No
lymphadenopathy in neck

Lungs
− Decreased excursion with slight dullness to percussion in right
upper chest
− Bronchial breathing in Right upper lobe with occasional crept
 Physical Examination

Breast:
− No palpable nodules, No axillary lymphadenopathy

Heart:
− S1 + S2 , some irregular beats occasionally, No rales, murmur
or gallop

Abdomen:
− Mid-line scar, soft, NT, No visceromegaly, BS +ive

Extremities:
− No clubbing, No peripheral edema, Pulses palpable,

Neurologic:
− Power 5/5 in all limbs, Sensations intact. CN II-XII intact

Rectal:
− Guaiac -ive, normal sphincter tone, no stool palpable in rectal
 Brain Storming

Diagnostic Clues on Physical Examination !!!

 Brain Storming

Next Best Step in Management !!!

 Admission Studies

Hematology:
− WBC: 6.1 − GRAN AUTO: 60.6
− HGB: 10.4 − LYMPHOS AUTO: 21.2
− HCT: 31.5 − MONO AUTO: 10.2
− PLAT: 415
− MCV: 79 − PT: 13.3
− MCH: 26 − INR: 1.1
− RDW: 15.6 − PTT: 27
− MPV: 8.0
 Admission Studies

Chemistry: 
LFT's:
− Ca+: 9.6 − Alb: 3.8
− Na+: 141 − Tot. Pr: 7.2
− K+: 4.2 − Bili D: 0.04
− CL-: 107 − Bili T: 0.2
− HCO3: 26 − AST: 14
− BUN: 19 − ALT: 6
− Cr: 1.2 − Alk Phos: 119
− Glu: 84
− A.G: 8
 Admission Studies

Cardiac Enzymes: 
Lipid Profile:
− CK/MB 3.2 − Chol: 150
− CPK: 63 − Trigly: 128
− Trop T: <0.010 − HDL-Chol: 51

Iron Studies: − LDL-Chol: 78
− Iron: 22
− TIBC: 271
 Brain Storming

Diagnostic Clues in Laboratory Tests !!!

 Admission EKG


Sinus Rhythm with premature atrial complexes

T wave abnormality, consider lateral ischemia
 Brain Storming

Diagnosing Hemoptysis, Next Best Step !!!

 Brain Storming

Diagnostic Clues in Chest Xray!!!

 Chest X Ray

A large homogenous right hilar mass with atelectasis of the

anterior segment of the right upper lobe.
Hilar mass measured more than 4 cm in size with
consolidation of the right upper lobe.
 Chest CT Scan with contrast

Large mass in the right lung apex extending to the right

hilum, 11 cm in craniocaudal dimension, 6.5 x 5 cm in
axial dimension consistent with the large malignancy.
Superior vena cava is compressed but not obstructed.
Moderate elevation of right diaphragm may be due to right
phrenic nerve compression by the mass.
Bilateral old rib fractures.
Treatment Goals in Hemoptysis Management

1.Aspiration Prevention

2.Bleeding Cessation

3.Treating Underlying Cause

 Non Massive Hemoptysis

The most common presentation is mild hemoptysis in

Acute Bronchitis.
In low risk patients (<40 years of age, <40 Pack years of
smoking) with Normal Chest X ray conservative
management can be used. (correction of tissue perfusion,
hypoxemia and coagulopathy if present)
 Massive Hemoptysis

Mortality less than 9% with blood loss less than
1000ml/24 hours but rises to 59% if more blood loss,
with causes other than Lung CA.

Mortality for Cancer associated bleeding is 59% but
rises to 80% with blood loss more than
1000ml/24hours.

Necrotizing pneumonitis, lung abcess, bronchiectasis
has less than 1% mortality and can be managed
conservatively.
 Interventions for Massive Hemoptysis


Bronchoscopy rigid vs flexible

Double lumen endo-bronchial intubation

Endo-bronchial tamponade

Bronchial artery embolization

Surgery (lobectomy vs pneumectomy)
 Bronchoscopy

Rigid Bronchoscopy
− Better airway patency
− Greater suctioning
− Needs to be done in OR with general anesthesia
− Only visualize major airways

Flexible Bronchoscopy
− Can be used in ER
− Visualize upto 5th or 6th bronchial division

Instillation of Epinephrine
− After bleeding localization
− 1:20,000 solution into bronchial tree
− Variable success depending on bleeding severity
 Double lumen Endo-bronchial Intubation


Allows proper ventilation of
non bleeding lung while
suctioning bleeding lung (as
temporary measure)

Flexible bronchoscopy can
still be performed via lumen

Main disadvantage is tube
misplacement (upto 50 %)

Flexible bronchoscopy can
be performed to look for
tube placement

Alternative is to place single
lumen endo-bronchial tube
deep down into right or left
main stem bronchus
 Endo-bronchial tamponade


To occlude bleeding
bronchus by using a balloon
catheter.

Foleys catheter (14 Fr) are
too big and will not protect
normal segments from
bleeding segments.

Fogarthy Catheter (4 Fr) is a
better option, however has
a proximal balloon that
needs to be removed.

Freitage Catheter, similar to
Fogarthy but without
proximal balloon.
 Bronchial artery embolization

Should only be
performed in ICU

Selective
angiographic study of
bronchial arteries

Polyvinyl alcohol
foam, absorbable
gelatin, pledgets of
Gianturco steel coils
 Abstract

Six patients with hemoptysis were treated by

endobronchial sealing, with n-butyl cyanoacrylate, of the
bleeding segment or subsegment. There was an
immediate arrest of bleeding without any recurrence for a
mean follow-up period of 127 (± 67.17) days.
Endobronchial sealing appears to be an effective method
of managing hemoptysis.
 Discussion

Hemoptysis poses serious problems, especially when the
conservative treatment fails.

Cold saline lavage with 50-mL aliquots of iced saline at 4°C
(total of 500 mL) showed good results when instilled through
a rigid bronchoscope in 23 patients; recurrence of
hemoptysis was observed in two cases.

Wedging of the bleeding segment with the flexible
bronchoscope tip is effective in controlling bleeding after
transbronchial lung biopsy. Local administration of
adrenaline solution (1:20,000), thrombin , and fibrinogen-
thrombin have been attempted in a small number of cases.

The ND-Yag laser used bronchoscopically can effectively
stop bleeding from endobronchial pathology and can also
allow more definite therapy at the same sitting.

Balloon tamponading of the bleeding bronchial segment
is also helpful, with variable success rates.
 Discussion

Bronchial artery embolization effectively stops bleeding
from a bronchial arterial source, although failures and
complications occur. There is also occasional difficulty
− cannulating the vessel,
− vessel perforation, intimal tears, and
− inadvertent ectopic embolism

Surgery is currently recommended when
− Bronchial artery embolization not available or technically
impossible or unsuccessful;
− when the bleeding is so massive that any delay in
arranging the embolization is very risky;
− when the underlying cause is unlikely to be controlled by
embolization, as in a case of suspected rupture of
pulmonary artery or a mycetoma with profuse collateral
 Discussion

We have adopted sealing of the bleeding segment or
subsegment with n-butyl cyanoacrylate.
− It is a biocompatible adhesive that solidifies quickly on
exposure to humidity with antibacterial effects.
− Cyanoacrylate glues are already in use. They have been
used to prevent postoperative air leak from the bronchial
stamp after lung resectional surgery.
− The cyanoacrylate glues have prothrombotic properties
such as increased platelet aggregation and possible
enhancement of local thromboxane production.
− Although cyanoacrylates are significantly safe, they are
volatile and chemically active materials reported to cause
eczema, rhinitis, and asthma in occupational exposure.
Occupational contact dermatitis has also been reported.
 Conclusion

In using cyanoacrylate for endobronchial sealing for

hemoptysis, we have not found any significant side
effects. Moreover, the glue is expectorated gradually
over the next few days. In conclusion, it appears that
endobronchial sealing with n-butyl cyanoacrylate glue
is a simple, less invasive, and safe procedure to
control hemoptysis.