Hemoptysis is defined as blood admixture in the sputum. With massive coughing up bright red blood is called hemoptysis. (NB. The Übers .: In the German-speaking countries is a distinction between hemoptysis and hemoptysis usual, so the difference is briefly outlined here. In the text below, this differentiation is maintained as much as possible.) Massive hemoptysis corresponds to the expectoration of ? 600 ml of blood (about a full kidney dish) h in 24th Pathophysiology The bulk of the blood in the lung (95%) is circulated through the low-pressure system of the pulmonary arteries and thus enters into the pulmonary capillary bed, where gas exchange takes place. Approximately 5% of the blood flow through the high-pressure system of the bronchial arteries, which arise from the aorta and supply the large airways and adjacent structures. When hemoptysis the blood comes in most cases from the bronchial circulation, unless the pulmonary arteries are injured by trauma, erosion granulomatous or calcified lymph nodes or tumors or, rarely pulmonary artery catheter or inflammation of the Pulmonalkapillaren. Etiology bloody sputum tingiertes often occurs in banal diseases such as infections of the upper respiratory tract and viral bronchitis. The differential diagnoses are numerous (see Table: Causes of hemoptysis). In adults, 70-90% of cases are caused by bronchitis bronchiectasis Necrotizing pneumonia TB Primary lung cancer is an important cause in smokers ? 40 years, but metastatic cancer rarely causes coughing up blood. A cavernous Aspergillus infection is increasingly recognized as a cause, but is not as common as cancer. In children, common causes include infection of the lower respiratory tract foreign body aspiration Massive hemoptysis The most common causes have edged over time and vary according to geographic location, but following these include: bronchial bronchiectasis TB and other pneumonia causes of hemoptysis cause suspicious findings diagnostic approach * Tracheobronchial cause tumor (carcinoma, bronchial metastasized, K aposi sarcoma) night sweats weight loss in the past smoked heavily risk factors for Kaposi’s sarcoma (for example HIV) chest X-ray CT bronchoscopy bronchitis (acute or chronic) Acute: productive or non-productive cough Chronic: coughing on most days of the month or for 3 months per year in two consecutive years in patients with known COPD or smoking history acute: Chronic Clinical evaluation: chest X-ray bronchiectasis Chronic cough and mucus in patients with a history of recurrent infections High-resolution chest CT bronchoscopy Broncholithiasis Calcified lymph nodes in patients with previous granulomatosis chest CT bronchoscopy foreign body (chronic and not usually diagnosed) Chronic cough (usually in an infant or child) without symptoms of infections of the upper respiratory tract Sometimes fever Chest x-ray Sometimes bronchoscopy Pulmonary parenchymal cause lung abscess Subacute Fi boar cough night sweats anorexia weight loss chest x-ray or CT show irregularly shaped cavity with “air-fluid levels” pneumonia fever, productive cough, dyspnea, pleuritic chest pain Decreased breath sounds or Ägophonie Increased leukocyte count Chest x-ray of blood and sputum cultures in hospitalized patients Active granulomatosis (tuberculosis, fungal conditions, parasitic, syphilitic) or mycetoma (fungus ball) fever, cough, night sweats and weight loss in patients with known exposures often former immunosuppression chest X-ray CT thorax Mikrobiolo cal examination of sputum samples or “bronchoscopy washings” Goodpasture’s syndrome fatigue weight loss Often hematuria Sometimes edema urinalysis creatinine renal biopsy antiglomerular cANCA tests granulomatosis with polyangiitis often chronic, bloody nasal discharge and nasal ulcerations often joint pain and skin involvement (nodules, purpura) gum thickening and ” mulberries “- gingivitis Saddle nose and perforation of the nasal septum Sometimes renal biopsy of an affected area (eg. B. kidney, skin) with cANCA test and evidence of vasculitis in small to medium-sized arteries bronchoscopy lupus pneumonitis fever, cough, dyspnea and pleuritic chest pain in patients with a history of SLE chest CT (showing alveolitis) Sometimes “bronchoscopy washings” (show lymphocytosis or granulocytosis) primary vascular causes arteriovenous malformations Mucocutaneous telangiectasia or peripheral cyanosis chest CT angiography pulmonary angiography Pulmonary embolism sudden onset of severe pain in the chest, increased respiratory and heart rate, especially in patients with known risk factors for a pulmonary embolism CT angiography or V / Q scan Doppler or duplex studies of the extremities show results of DVT Increased pulmonalvenöser pressure (particularly mitral , left-sided heart failure) humidity RG signs of central or peripheral volume overload (eg. As increased neck veins, peripheral edema) dyspnea (while lying flat orthopnea) or 1-2 h after falling asleep (paroxysmal nocturnal dyspnea) ECG BNP measurement echocardiography aortic aneurysm with leakage in the lung parenchyma back pain chest x-ray showing widened mediastinum thoracic CT angiography rupture of pulmonary artery Current placement or manipulation of a pulmonary artery catheter emergency chest CT angiography or emergency pulmonary angiography tracheo-arterial Anonymafistel Placement of the tracheostomy tube within the last 3 days to 6 weeks Clinical examination (eg. B. Determination of bleeding by endotracheal tube in clinical environment) Other Pulmonary endometriosis (catamenial hemoptysis) Recurrent hemoptysis during menstruation Clinical evaluation Sometimes therapeutic trial with oral contraceptives Systemic coagulation disorder or use of anticoagulants or thrombolytics patients systemic anticoagulants for the treatment of pulmonary embolism, DVT or atrial fibrillation patients receiving thrombolytic agents for the treatment of stroke or myocardial infarction receive Sometimes family history PT / PTT or to ti-factor Xa plasma levels off of hemoptysis by correcting the coagulation deficit * All patients with hemoptysis should perform chest X-ray and pulse oximetry. BNP = brain (B-type) natriuretic peptide; cANCA = antineutrophil cytoplasmic antibody; DVT = deep vein thrombosis, V / Q = ventilation / perfusion. Assessment of medical history, the history of present illness should the duration and temporal patterns (z. B. sudden onset, cyclic recurrence) releasing factors (z. B. allergen exposure, cold, effort, supine), and approximate volume of hemoptysis (eg. B . banding, teaspoon, cup) cover. Patients require a specific statement to between true hemoptysis, Pseudohemoptyse (d. E. Bleeding coming from the nose and throat and later coughed up) and Hematemesis to distinguish. A feeling of postnasal drip or bleeding from the nose, without coughing indicates Pseudohemoptyse. Simultaneous nausea and vomiting with black, brown or coffee ground colored blood is characteristic of a hematemesis. Frothy sputum, bright red blood, and (if solid) are a feeling of choking characteristic of a true hemoptysis. In reviewing the body systems should for symptoms that indicate the possible causes are sought. These include fever and sputum (pneumonia); Night sweats, weight loss and fatigue (cancer, TB); Chest pain and dyspnea (pneumonia, pulmonary embolism); Pain in the legs and leg swelling (pulmonary embolism); Hematuria (Goodpasture’s syndrome) and bloody nasal discharge (granulomatosis with polyangiitis). Patients should be asked about risk factors for these causes. These risk factors include HIV infection, the use of immunosuppressive drugs (TB, fungal infection); Exposure to TB; long history of smoking (cancer) and recent immobilization or surgery, known cancer, previous or familial occurrence of clotting disorders, pregnancy, use of estrogen-containing medications and recent long-distance travel (pulmonary embolism). The medical history should cover known disorders that can cause hemoptysis; including chronic lung disease (eg. as COPD, bronchiectasis, TB, cystic fibrosis), cancer, bleeding disorders, heart failure, thoracic aortic and pulmonary-renal syndromes (z. B. Goodpasture’s syndrome, granulomatosis with polyangiitis). The exposure to TB is important, especially in patients with HIV infection or other immune-compromised state. Frequent nosebleeds in the past, rapid bruising or liver disease suggest a possible clotting disorder. The medication profile should regarding the use of anticoagulants and antiplatelet agents checked werden.Körperliche examination Vital signs are checked for fever, tachycardia, tachypnea and low oxygen saturation. Constitutional characters (eg. As cachexia) and the degree of patient discomfort (eg. As use of the respiratory muscles, breathing with pursed lip, agitation, decreased consciousness) should also be considered. It is carried out a complete examination of the lungs, and in particular the scope of the inhaled and exhaled air; Symmetry of breath sounds and whether wet RG, wheezing, stridor and wheezing are present. It should be looked for signs of consolidation (z. B. Ägophonie, dull sound head). The cervical and supraclavicular areas should be inspected and palpated on lymphadenopathy (reference to cancer or TB). The neck veins were inspected for distension and legs and presacral area dented edema (indication of heart failure) can be palpated. The heart sounds were bugged and all occurring additional heart sounds or sounds that indicate a heart failure and increased pulmonary pressure are observed. The abdominal examination should focus on signs of liver congestion or lesions that may indicate either cancer or Hematemesis of potential esophageal varices. Skin and mucous membranes should be examined for ecchymosis, petechiae, telangiectasia, gingivitis or evidence of bleeding from the oral or nasal mucosa. If the patient can reproduce hemoptysis during the investigation, the color and amount of blood was found werden.Warnzeichen The following results are of particular importance: Massive hemoptysis back pain The presence of a pulmonary artery catheter or tracheostomy malaise, weight loss or fatigue Heavy smoking in the past dyspnea in rest during the examination or no or diminished breath sounds interpretation of results the history and physical examination often leave suggests a diagnosis and diagnosis are at the forefront of further investigation (see table: causes of hemoptysis). Despite the many ways it can be considered by some generalities. A previously healthy person with unremarkable findings without risk factors (eg. As for TB, pulmonary embolism), which begins at a time of acute cough with fever, most likely has a hemoptysis due to acute respiratory disease. Chronic diseases are much further down the list of possibilities. However, it must if risk factors are present, are strongly expected from these specific diseases. A clinical prediction rule (see Table: Clinical Prädiktionsregel for the diagnosis of pulmonary embolism) can help assess the risk of pulmonary embolism. A normal oxygen saturation does not rule out a pulmonary embolism. Patients with hemoptysis due to pulmonary disease (z. B. COPD, cystic fibrosis, bronchiectasis) or heart disease (eg. As heart failure) have a clear history of these diseases generally. Hemoptysis are no initial presentation. In patients with known TB immune deficiency or a fungal infection should be suspected. In patients with symptoms or complaints of a chronic disease, but with no known disorder cancer or tuberculosis should be suspected, although it can act in a patient with hemoptysis to the onset of lung cancer, which is otherwise asymptomatic. Several specific findings are remarkable. Known renal failure and hematuria suggest a pulmo-renal syndrome through (z. B. Goodpasture’s syndrome, granulomatosis with polyangiitis). Patients with granulomatosis with polyangiitis may have nasal mucosa lesions. Visible telangiectasia can infer arteriovenous malformations. Patients with hemoptysis due to a bleeding disorder have usually taken skin findings (petechiae, purpura, or both) or earlier anticoagulants or antiplatelet agents. Recurrent hemoptysis coinciding with the menstrual strongly suggest a pulmonary endometriosis hin.Tests patients with massive hemoptysis should be treated before a detailed diagnosis and stabilized, usually in an intensive care unit. In patients with mild hemoptysis diagnosis can be performed on an outpatient basis. Imaging techniques are always used. A chest x-ray absorption is obligatory. In patients with normal radiological findings and bronchitis matching a history of empirical treatment is the same reasonable. In patients with pathological findings and an empty bronchitis medical history, CT and bronchoscopy should be made. In CT lung lesions can be displayed, which are not visible in the conventional X-ray exposure, and lesions are located in view of the following bronchoscopy and biopsy. CT angiography or, less commonly, ventilation / perfusion scintigraphy with or without arteriography can confirm the diagnosis of pulmonary embolism. By CT and pulmonary angiography and pulmonary arteriovenous fistulas can be detected. To distinguish a hemoptysis from a Hematemesis and nasopharyngeal or oropharyngeal bleeding, a fiber optic inspection of the pharynx, larynx and respiratory tract can be done along with a gastro-endoscopy if the etiology is unclear. Laboratory tests are also carried out. The patient is usually a blood count should create the platelet count checked and measurements of PT and PTT are performed. Anti-Factor Xa tests a supra therapeutic anticoagulation reveals in patients receiving heparin with low molecular weight. In a urinalysis (hematuria, proteinuria, cylinder) should be looked for signs of glomerulonephritis. To test for active TB, should first be carried out skin tests and sputum culture. But even with negative results mucus has dissolved or endoscopic bronchoscopy are performed to obtain samples for acid bacilli tests if an alternative diagnosis can not be found wird.Kryptogene hemoptysis The cause of hemoptysis remains unclear at 30-40% of patients however, patients with cryptogenic hemoptysis have a favorable prognosis in general, they usually suspend within the diagnosis following 6 months. Therapy Massive hemoptysis The initial therapy of massive hemoptysis has two goals: preventing the aspiration of blood in the uninvolved lung (can suffocation cause) prevention of blood loss due to ongoing bleeding, it may be difficult to protect uninvolved lung because it is often initially unclear is, which side is bleeding. If the bleeding site is recognized therapeutic options exist u. a. is to position the patient with the lower bleeding lung portion and selective intubation of the uninvolved lung and / or closure of the bronchus to which the bleeding lung portion is connected downstream to perform. The prevention of blood loss involves the treatment of hemorrhagic diathesis and direct hemostasis tests. Coagulation disorders can be treated with FFP, selective administration of coagulation factors and platelet concentrates. Bronchoscopic hemostasis occurs (n. D. Ed .: or argon) by means of laser plasma coagulation, electrocautery or injections with epinephrine or vasopressin. Massive hemoptysis is one of the few indications for the use of a rigid bronchoscope (as opposed to a flexible). Thus the examined bronchus can be controlled; einzusehende the cutout is larger than in a flexible device, the suction is effective, and it is for therapeutic procedures such as laser treatment is more suitable. The now preferred method for staunching massive pulmonary bleeding with a success rate up to 90% is the embolization a angiography of the bronchial artery (1). Can not be brought to a standstill with a rigid bronchoscope or by embolization massive hemoptysis, is indicated as a last choice an emergency operation. Once a diagnosis is made, a further treatment is directed to the reason (2, 3) .Leichte hemoptysis The treatment of mild hemoptysis is focused on eliminating the causes. When bronchial adenoma or -karzinom a Frühresektion may be indicated. In a Broncholithiasis (erosion of a calcified lymph node in the adjacent bronchus) a pneumonectomy may be indicated when the stone can not be removed through a rigid bronchoscope. If the bleeding is a result of a cardiac decompensation or mitral stenosis, they usually suspended with appropriate cardiac therapy. In mitral valve stenosis even life-threatening bleeding may occur in rare cases that require emergency even valvulotomy. Hemorrhage in pulmonary embolism are rarely pronounced and almost always suspend spontaneously. In recurrent embolism and persistent bleeding, anticoagulation can be contraindicated and the introduction of a vena cava filter therapy of choice. Since bleeding in bronchiectasis are usually the result of infections, they are with appropriate antibiotics and postural drainage behandelt.Behandlungshinweis 1.Mal H, Rullon I Mellot F, et al: Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 150 (4): 996-1001.1999. 2. Lordan JL, Gascoigne A, Corris PA. The lung specialist in intensive medicine. Illustrative Case 7: evaluation and treatment of massive hemoptysis. Thorax 58: 814-819, 2003. 3. Jean-Baptiste E. Clinical evaluation and treatment of massive hemoptysis. Critical Care Medicine 28 (5): 1642-1647, 2000. Conclusion A hemoptysis must be distinguished from haematemesis and bleeding from the nasopharynx and Oropharyngealbereich. Bronchitis, bronchiectasis, tuberculosis and necrotizing pneumonia or lung abscesses are the main causes in adults. Infection of the lower respiratory tract and foreign body are the most common causes in children. Patients with massive hemoptysis should be treated before a detailed diagnosis and stabilized. With a massive hemoptysis patients should – when the side of bleeding is known – are stored in a lower position with the affected lung side. A massive hemoptysis is preferably treated by embolization of bronchial arteries.

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