Haemoptysis : Causes, Diagnosis Study, Treatment by Nurses Note

 Haemoptysis 

Definition of Haemoptysis 

• Haemoptysis is defined as the expectoration of blood or bloody sputum.

• "Potentially lethal" or "massive" haemoptysis is defined as greater than 600-800 mL blood in 24 hours. A more clinical and practical definition of massive haemoptysis is any bleeding that results in a threat to life because of airway or haemodynamic compromise by bleeding.

Pathophysiology of Haemoptysis 

• The lungs receive their blood supply via the pulmonary arterial circulation and the systemic bronchial arteries.

• More than 90% of cases of haemoptysis result from disruption of branches of bronchial arteries.

• Bronchial artery neovascularisation is the most common pathway for haemoptysis and generally results from diseases that cause pulmonary arteriole occlusion from hypoxic vasoconstriction, thrombosis or vasculitis.

• In bronchitis or fungal infections, acute or chronic inflammation creates tortuous ectatic vessels through neovascularisation that are prone to rupture.

• Pulmonary parenchymal necrosis from necrotising pneumonia or infarction of lung from pulmonary embolism, inflammatory and immunologic vasculitides can also lead to haemorrhage by exposing the capillary bed.

• Haemoptyisis in tuberculosis has been discussed elsewhere.

Causes of Haemoptysis 

Common causes of Haemoptysis

• Pulmonary tuberculosis

• Bronchial carcinoma

• Chronic bronchitis

• Bronchiectasis

• Lung abscess

• Pneumonia (particularly Klebsiella)

• Fungal infections (aspergilloma and invasive aspergillosis) 

• Pulmonary contusion/laceration (traumatic)

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Uncommon causes of Haemoptysis 

• Pulmonary thromboembolism

• Left ventricular failure

• Mitral stenosis

• Bronchial adenoma

• Pulmonary arteriovenous malformations

• Primary pulmonary hypertension

• Goodpasture's syndrome

• Wegener's granulomatosis

• Idiopathic pulmonary haemosiderosis

• Haemorrhagic diathesis

• One recently identified cause of massive haemoptysis is the use of bevacizumab, a vascular endothelial growth factor angiogenesis inhibitor that when used in the treatment of central squamous carcinomas of the lung may result in massive

haemoptysis.

Investigations of Haemoptysis 

• In massive haemoptysis, initial diagnostic tests must begin in concert with efforts to stabilise the patient and control the bleeding.

• Blood should be examined for haemoglobin level, total and differential leucocyte counts, erythrocyte sedimentation rate (ESR) and blood group. In addition, clotting screen including platelet count should be done if a haemorrhagic diathesis is suspected.

• Urine should be examined by microscopy for red cells and red cell casts in suspected haemorrhagic diathesis and Goodpasture's syndrome.

• Sputum should be examined in all cases by microscopy and culture.

• Ziehl-Neelsen staining may show acid-fast bacilli in pulmonary tuberculosis.

• Klebsiella pneumoniae may be isolated from the sputum in Klebsiella pneumonia.

• Cytological examination for malignant cells in suspected bronchial carcinoma.

• Sputum studies may be helpful in identifying the pathogenic organism in acute exacerbations of chronic bronchitis, bronchiectasis and Jung abscess.

• Chest radiographs, both posteroanterior and lateral views, can provide important diagnostic clues.

• Presence of cystic lesions, ring shadows, tram tracks and grape clusters favour the diagnosis of bronchiectasis.

• A distinct air-fluid level in a cavity is diagnostic of lung abscess.

• Fibrotic bands, bronchiectatic changes, cavity formation or fluffy shadows in the upper lobes suggest pulmonary tuberculosis.

• Rarely, an intracavitary aspergilloma is visible on chest radiograph as a cavity with a tumour-like opacity inside. A crescentic air shadow separates the fungal ball from the upper wall of cavity.

• Upper lobe consolidation with bulging interlobar fissure is characteristic of Klebsiella pneumonia.

• Bronchial carcinoma may manifest as central or peripheral pulmonary opacity, mediastinal widening, collapse of a lung or a lobe, or consolidation.

• Chest radiographs can be useful at times in pulmonary thromboembolism, mitral stenosis, primary pulmonary hypertension, pulmonary haemosiderosis and bronchial adenoma.

• Computed tomography of the chest is useful in delineating lesions that are not seen on a plain radiograph. It also better defines the lesions seen on radiograph.

• Electrocardiogram may be useful in unsuspected mitral stenosis, pulmonary thromboembolism and pulmonary hypertension.

• Bronchoscopy is the most important diagnostic procedure. Rigid bronchoscopy permits visualisation of the more central airways, whereas fibreoptic bronchoscopy permits visualisation of the more peripheral airways. In addition to localising the site of bleeding, bronchoscopy provides definitive visual, biopsy or cytologic information.

• Isotope lung scans are useful if pulmonary embolism is suspected in a patient with a normal chest radiograph.

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Treatment of Haemoptysis 

Minor Haemoptysis 

• Minor haemoptysis, which is scanty, will stop spontaneously without specific therapy. Treatment is aimed at the underlying cause.

• Substantial haemoptysis should be treated by keeping the patient calm, instituting complete bed rest and suppressing the cough. However, intubation and suction equipment should be ready at the bedside.

 Potentially Lethal or Massive Haemoptysis 

• Position the patient so that the side of the chest from which bleeding is arising is lowermost. This is to prevent asphyxiation due to aspiration of blood into the normal lung. If the location of bleeding is undetermined or the patient prefers, an upright position is also acceptable during this initial phase of management.

• Setup an intravenous infusion and collect blood for grouping and cross-matching. Maintain a chart of vital signs including blood pressure, pulse rate, respiratory rate and urine output.

• Administer oxygen.

• Blood transfusions are given according to the usual clinical guidelines of quantity of blood Jost, haematocrit, blood pressure, pulse rate and urine output.

• Strong sedatives should be avoided, but mild sedatives may be given to relieve anxiety.

• Distressing cough may be suppressed with linctus codeine 15 mL thrice daily.

• Consider endotracheal intubation if the patient has poor gas exchange, has rapid ongoing haemoptysis, is haemodynamically unstable or has severe shortness of breath.

• An alternative strategy is to place an endotracheal tube into either the right or left mainstem bronchus. This is easier to achieve with bleeding from the left lung when selective intubation of the right mainstem bronchus is required.

• Double-lumen endotracheal tube allows the two lungs to be isolated and ventilated separately.

• Role of tranexarnic acid, an antifibrinolytic agent, is controversial though most physicians would use it intravenously in massive haemoptysis.

• Consider emergency bronchoscopy if the bleeding is torrential.

    • The rigid bronchoscope is preferred as it enables blood to be aspirated more easily.

    • The fibreoptic bronchoscope may be used for cold saline lavage, which may sometimes arrest             bleeding. The iced saline is instilled in 50- to 100-mL aliquots followed by suctioning and repeated

 until there is noticeable improvement. Other techniques used to control bleeding include:

•  Topical thrombin or fibrinogen. 
• Topical coagulation with laser photocoagulation.
• Argon plasma coagulator. 
• Endobronchial brachytherapy in high doses (10-12 Gy/hour for a total of 500-4000 Gy). 
• Endobronchial cryotherapy. 

• A balloon catheter passed through the bronchoscope can be inflated proximally in the bleeding bronchus. This will isolate the source of bleeding from the rest of the lung and the contralateral lung, preventing asphyxiation by blood flooding.

• Bronchial arterial catheterisation and embolisation can at least temporarily arrest bleeding. Embolisation is performed using absorbable gelatin sponge or polyvinyl alcohol particles between 325 and 500 µm. The most important complication is spinal cord ischaemia.

• Surgical intervention is indicated in selected cases. Emergency resection of the lobe or lung, which is bleeding, may be necessary.