It is Controversial as to Whether Acute Bronchitis is Associated with Life-Threatening Hemoptysis (with Older Case Series Reporting an Incidence of 5-37%) (Chest, 1994) [MEDLINE], Although it is Generally Believed to Be Rare in Patients Who Have Structurally Normal Lungs by Chest CT Scan
Due to Vascular Nature of Bronchial Carcinoid and Risk of Bleeding, Many Providers Avoid Bronchoscopic Biopsy (Although the Risk of Bleeding is Considered Low) (Lung, 2016) [MEDLINE]
Non-Life-Threatening Hemoptysis Occurs in 7-10% of Lung Cancer Patients at the Time of Presentation and in 20% of Lung Cancer Patients at Some Time During Their Course of Illness (Clin Chest Med, 1994) [MEDLINE]
Lung Cancer Accounts for Between 5-30% of Massive Hemoptysis Cases (Ann Thorac Surg, 2009) (J Vasc Interv Radiol, 2015) [MEDLINE] [MEDLINE] (Cardiovasc Intervent Radiol, 2018) [MEDLINE]
Broncho-Vascular Fistula Cases Have Been Reported with the Use of Self-Expanding Metallic Airway Stents (Ann Thorac Med, 2013) [MEDLINE]
Aortic Aneurysm with Erosion into Airway (Tex Heart Inst J, 2009) [MEDLINE]
Aortic Infection with Erosion into Airway
Aortic Surgery with Stent with Erosion into Airway
Indwelling Vascular Device with Erosion into Airway
Tracheoinnominate Artery Fistula (see Tracheal-Innominate Artery Fistula): typically associated with low tracheostomy placement (tracheostomy tube can eroide through the tracheal wall into the innominate artery, since the innominate artery crosses the anterolateral surface of the trachea at the level of the upper sternum)
Cases Have Been Reported in Association with Tracheostomy Placement (Ann Thorac Cardiovasc Surg, 2013) [MEDLINE]
Tracheo-Subclavian Artery Fistula: typically associated with low tracheostomy placement
Cases Have Been Reported in Association with Tracheostomy Placement (Eur J Cardiothorac Surg, 2007), [MEDLINE]
Clinical
Hemoptysis May Be Heralded by Small Episodes of Hemoptysis and May Be Massive
Hemoptysis May Be Due to Diffuse Alveolar Hemorrhage (as an Early Complication of HSCT)
Hemoptysis May Be Due to Idiopathic Pneumonia Syndrome (as a Late Complication of HSCT): idiopathic pneumonia syndrome is due to diffuse lung injury (from a combination of drugs, radiation, and/or thrombocytopenia) (Am J Respir Crit Care Med, 2011) [MEDLINE]
Underlying Viral/Fungal Infection Can Also Contribute to Diffuse Alveolar Hemorrhage or Idiopathic Pneumonia Syndrome
Usually Results in Diffuse Alveolar Hemorrhage in Association with an Underlying Pulmonary Disease, Such as Lung Cancer/Bronchiectasis/Infection, or with Combination of Anticoagulants
Acquired Vitamin K Deficiency (see Vitamin K) (Respiration, 2000) [MEDLINE]
Hemoptysis (and Diffuse Alveolar Hemorrhage) Has Been Described in 6% of Habitual Free-Base (Crack) Cocaine Smokers
Levamisole-Contaminated Cocaine Has Been Associated with Pulmonary Hemorrhage in Several Case Reports
Electronic Cigarrettes/Vaping (see xxxx) (NEJM, 2020) [MEDLINE]
Clinical
E-Cigarette Use/Vaping Has Been Associated with ARDS/Diffuse Alveolar Damage, with Hemoptysis Present in 11% of Cases at Time of Presentation (NEJM, 2020) [MEDLINE
Vaping Has Also Been Associated with Acute Eosinophilic Pneumonia, Organizing Pneumonia, Lipoid Pneumonia, Hypersensitivity Pneumonitis, and Giant Cell Interstitial Pneumonitis
Fludarabine (Fludara) (see Fludarabine): DAH may occur (Haematologica, 2000) [MEDLINE], as well as diffuse alveolar damage (Chest, 2002) [MEDLINE]
Pulmonary Venous Hypertension with Reversal of Blood Flow from the Pulmonary Capillaries into the Bronchial Veins
Clinical
Hemoptysis is Often Minor, But Sudden, Life-Threatening Hemoptysis Can Occur with Rupture of a Bronchial Varix (“Pulmonary Apoplexy”): this may occur during a period of increased pulmonary blood flow and/or increased blood volume (during pregnancy, exercise, hypervolemia, etc)
Approximately 30% of Patients with Hemoptysis Have No Identifiable Etiology After Careful Evaluation (Chest, 2001) [MEDLINE] (Am J Respir Crit Care Med, 2007) [MEDLINE] (Respiration, 2010) [MEDLINE]
In Long-Term Follow-Up (5 Years) of Patients with Cryptogenic Hemoptysis, <2% of Patients Developed Lung Cancer (Eur Clin Respir J, 2019) [MEDLINE]
Diagnosis
Bronchial Arteriogram Studies Identify Areas of Hypervascularity or Aneurysm (Suggestive of Bronchial Dieulafoy Lesion) in >80% of Cryptogenic Hemoptysis Cases (Chest, 2017) [MEDLINE] (J Vasc Interv Radiol, 2017) [MEDLINE]
Pseudohemoptysis
Aspirated Blood from Upper Airway or Gastrointestinal Source
Lungs Have a Dual Arterial Blood Supply (Insights Imaging, 2020) [MEDLINE]
Pulmonary Arteries
Function
Pulmonary Arteries Predominantly Supply the Lung Parenchyma –Size/Pressure
Pulmonary Arteries Have a Larger Caliber than the Bronchial Arteries
Pulmonary Arteries are a Low-Pressure System
Consequently, Most Episodes of Hemoptysis Originate from the Pulmonary Arterial Circulation and are Not Life-Threatening
Anatomy
Pulmonary Arteries Originate from the Right Ventricle
Source of Hemoptysis
The Bronchial Arterial System is the Predominant Source of Hemoptysis in 90% of Cases of Massive Hemoptysis (Crit Care Med, 2000) [MEDLINE]
Other Sources Include
Pulmonary Arteries (5% of Cases)
Non-Bronchial Systemic Arteries (5% of Cases)
Bronchial Arteries
Function
Bronchial Arteries Predominantly Supply the Tracheobronchial Tree, Large Blood Vessels, Lymph Nodes, Esophagus, and Pleura (Radiographics, 2006) [MEDLINE]
The Bronchial Arterial Circulation Accounts for Only 2% of the Total Vascular Supply to the Lung
Bronchial Arteries are Very Plastic, Potentially Increasing Their Blood Flow from 1% to 30% of the Cardiac Output in Response to a Pulmonary Insult
Consequently, Bronchial Artery Hypertrophy and Dilatation of Thin-Walled Distal Bronchial-to-Pulmonary Artery Anastomoses May Occur
Size/Pressure
Bronchial Arteries Have a Smaller Caliber than the Pulmonary Arteries
On Contrast-Enhanced CT, They are Very Thin and Difficult to Detect
Normal Caliber of the Bronchial Arteries is <1.5 mm Near the Origin and <0.5 mm Distally, as They Branch in the Pulmonary Hila
When Bronchial Artery Hypertrophy Occurs, Their Diameter Can Exceed 2 mm, and They Tend to Have a More Tortuous Course
Bronchial Arteries are a High-Pressure System (Under Systemic Arterial Pressure)
Anatomy
Orthotopic Origin
The Bronchial Arteries Most Commonly Originate from the Descending Thoracic Aorta, Usually at the T5-T6 Vertebral Plane, 1–2 cm Above or Below the Level of the Carina
The Orthotopic Right Bronchial Artery Originates Preferentially from the Posteromedial Aortic Wall (Directly or or More Commonly from a Short Intercostal-Bronchial Trunk), Running Retrotracheally Towards the Hilum
The Orthotopic Left Bronchial Artery Originates Preferentially from the Anterior or Lateral Aortic Wall, Running Retrotracheally Towards the Hilum
Most Patients Have 1-2 Bronchial Arteries on Each Side and a Total of 3-4 Bronchial Arteries
Ectopic Origin
In Up to 36% of Cases, the Bronchial Arteries Ectopically Originate from Aortic Arch, Subclavian Artery, Thyrocervical Trunk, Internal Mammary Artery, or Coronary Arteries (J Thorac Imaging, 2003) [MEDLINE] (Eur Radiol, 2007) [MEDLINE]
Ectopic Bronchial Arteries are Recognized Due to Their Adjacent Course with the Associated Bronchi
Bronchial Arteries Have Distal Microvascular Anastomoses Connecting to the Pulmonary Arterial System (Chest, 1972) [MEDLINE]
Source of Hemoptysis
Despite the Bronchial Arteries Accounting for Only 2% of the Total Vascular Supply to the Lung, the Bronchial Arteries are the Predominant Source of Hemoptysis in 90% of Cases of Massive Hemoptysis (Crit Care Med, 2000) [MEDLINE]
Other Sources Include
Pulmonary Arteries (5% of Cases)
Non-Bronchial Systemic Arteries (5% of Cases)
Other Arteries
The Non-Bronchial Arterial Circulation (Aorta, Intercostal Arteries, Coronary Arteries, Thoracic Arteries, Axillary Arteries, Subclavian Arteries, Upper and Lower Inferior Phrenic Arteries) Can Supply the Lungs in <5% of Cases (Chest, 2008) [MEDLINE] (Respiration, 2010) [MEDLINE]
Many Chronic Inflammatory Lung Lesions are Jointly Supplied by Hypertrophied Bronchial Arteries, as Well as by Collateral Systemic Arteries
Pulmonary Venous Drainage
Venous bronchial drainage is mainly through the pulmonary veins, with a smaller contribution of drainage through the superior vena cava, azygos, and hemyazigos systems
Quantification of Hemoptysis (Eur Respir J, 2008) [MEDLINE]
Massive/Life-Threatening Hemoptysis: hemoptysis of 150 mL/day (around 1/2 cup blood/day) or at a rate ≥100 mL/hr
Life-Threatening Hemoptysis is Defined as Hemoptysis Which Results in Airway Obstruction, Significantly Gas Exchange Abnormalities, or Hemodynamic Instability
Quantification of Hemoptysis (Diagn Interv Radiol, 2017) [MEDLINE]
Mild Hemoptysis
Hemoptysis <100 mL/Day or <50 mL/Episode
Moderate Hemoptysis
Hemoptysis ≥100–300 mL/Day or >3 Episodes of >100 mL/Day in a One Week Period
Severe/Massive/Life-Threatening Hemoptysis
Hemoptysis >300 mL/Day
Hemoptysis of Any Volume Resulting in a Decrease in Hemoglobin (Decrease >1g/dL), Hematocrit (Decrease >5%), Respiratory Failure (SpO2 <60%), or Hypotension (Systolic Blood Pressure <90 mm Hg)
Treatment
Antitussives
xxx
Correction of Coagulopathy (If Present) (see Coagulopathy)
Bronchial Artery Embolization for the Control of Hemoptysis was First Described by Remy in 1974 (Ann Radiol-Paris, 1974) [MEDLINE] (Diagn Interv Radiol, 2017) [MEDLINE]
Bronchial Artery Embolization Has Bee Used to Control of Hemoptysis Resulting from Both Benign and Malignant Etiologies, as Well as for All Grades of Hemoptysis
Bronchial Artery Embolization is Generally Indicated for Persistent, Life-Threatening Hemoptysis Despite Initial Diagnostic/Therapeutic Measures, Such as Bronchoscopy and Chest CT Scan (Radiographics, 2002) [MEDLINE]
Rationale for Studying the Bronchial, Pulmonary, and Systemic Arterial Circulations
Bronchial Artery Angiogram
The Large Majority of Hemoptysis Cases Arise from the Bronchial Circulation and, Therefore, Bronchial Arterial Embolization is the Initial Procedure of Choice
Despite the Fact that the Bronchial Arteries Account for Only 2% of the Total Vascular Supply to the Lung, They are the Predominant Source of Hemoptysis in 90% of Cases of Massive/Life-Threatening Hemoptysis (Crit Care Med, 2000) [MEDLINE]
Pulmonary Artery Angiogram
Specific Reasons to Initially Perform a Pulmonary Artery Angiogram, Instead of Bronchial Artery Angiogram
Suspected Pulmonary Embolism (with Infarction) with Associated Coagulopathy
Systemic Artery Angiogram
The Systemic Circulation is Generally Studied When the Bronchial Arterial Angiogram and Pulmonary Artery Angiogram is Unrevealing and Life-Threatening Hemoptysis Persists (or Recurs After Bronchial Artery Embolization)
Some Centers Routinely Perform a Thoracic Aortogram After Bronchial Artery Embolization to Improve the Detection of Bleeding from the Systemic Circulation (AJR Am J Roentgenol. 2003) [MEDLINE]
Technique
Pre-Procedure Bronchoscopy and Chest CT are Used to Preliminarily Localize the Site of Hemorrhage
Procedure is Performed in an Interventional Radiology Suite
Almost All Operators Perform a Prior Flush Aortogram to Identify Abnormal Bronchial and Non-Bronchial Systemic Collaterals (Diagn Interv Radiol, 2017) [MEDLINE]
However, Observation of Contrast Extravasation from a Specific Vessel into the Airway is Very Rare, Since the Rate of Bleeding rate is Rarely Sufficient (ie, >1 mL/min) for Detection by Angiogram
Bronchopulmonary Shunting
Artery-Artery or Artery-Vein Shunting
Embolization is Achieved Using Occlusive Material (Spheres, Coils, etc) into the Suspected Bleeding Vessel or the Proximal Vessels Which Supply the Bleeding Vessel
No Embolization is Performed if a Culprit Vessel Cannot Be Identified
In This Systematic Review, Superselective Catheterization of abnormal arteries using microcatheters was almost routinely performed by all authors after 2010
In This Systematic Review, Superselective catheterization enabled Bypassing Anterior Spinal arteries and catheterization of smaller, more distal, and torturous arteries; thereby providing better overall hemoptysis control and lesser risk of complications
Rate of Success
Success Rate of Bronchial Artery Embolization is Approximately 60-90% (Chest, 2002) [MEDLINE] (Radiology, 2013) [MEDLINE] (Am J Med Sci, 2014) [MEDLINE] (Asian Cardiovasc Thorac Ann, 2015) [MEDLINE]
In Systematic Reviews, the Technical Success Rate was 81-100% (Diagn Interv Radiol, 2017) [MEDLINE]
Causes of Technical Failure Include an Uncooperative Patient, Patient Condition Not Permitting Bronchial Artery Embolization, Artery Tortuosity, Arterial Dissection/Vasospasm, Arterial Ostial Narrowing, Arterial Acute or Multiple Branching
Success Rate is Enhanced When the Bronchial, Pulmonary, and/or Systemic Arterial Circulations are Well-Defined During the Procedure
Early Technical Failures Occur in 5-10% of Cases
Inability to Cannulate the Bronchial Artery
Failure to Identify and/or Embolize All of the Collateral Systemic Feeder Vessels (Arising from the Gastric, Intercostal, Internal Mammary, Renal, or Hepatic Arteries)
Rate of Rebleeding is 10-20% Over the Next 6-12 mos (Diagn Interv Radiol, 2017) [MEDLINE]
Rebleeding May Be Due to Incomplete Embolization, Revascularization, or Recanalization
Risk Factors for Rebleeding After Bronchial Artery Embolization
Bleeding from Aspergilloma
Bleeding from Tuberculosis
Bleeding from Bronchiectasis
Presence of Non-Bronchial Systemic Collateral Arteries
In Systematic Reviews, the Rate of Complicating Spinal Cord Ischemia was 0.6-4.4% (Diagn Interv Radiol, 2017) [MEDLINE]
Due to the Fact that the Anterior Spinal Arteries Arises from a Bronchial Artery in 5% of the Population
Cannulation or Embolization of the Bronchial Artery May Compromise Blood Flow to the Anterior Spinal Cord, Resulting in Cord Ischemia/Infarction
Risk
Risk of Spinal Cord Infarction Has Been Reported to Be <5% ( Semin Intervent Radiol, 2004) [MEDLINE] and <1% with an Experienced Interventional Radiologist
Mitigation of Risk
Meticulous Technique, the Use of Microcatheters in a Coaxial System and Distal Positioning to the Expected Location of the Spinal Artery Feeders Can Minimize the Risk of Spinal Artery Embolization
Small Particles (<200 μm) Should Be Avoided Due to an Increased Risk of Spinal Artery Embolization, as Compared with Larger Particles (>300 μm)
Non-Target Embolization of the Brain (Resulting in Cortical Blindness), Esophagus, and Pulmonary Circulation
In Systematic Reviews, the Rate of Complicating Transient Ischemic Attack and Cortical Blindness was 0.6-2% (Diagn Interv Radiol, 2017) [MEDLINE]
This was Attributed to Manipulation of the Subclavian Arteries or Due to Embolization Agents Crossing Bronchopulmonary Anastomoses
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Drug/Toxin
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Outbreak investigation of epidemic dropsy in Addis Ababa, Ethiopia. Ethiop Med J. 2013;Suppl 2:9 [MEDLINE]
Riociguat for the treatment of pulmonary arterial hypertension. N Engl J Med. 2013 Jul;369(4):330-40 [MEDLINE]
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Cryptogenic Hemoptysis
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A clinicopathologic study of 34 cases of diffuse pulmonary hemorrhage with lung biopsy confirmation. Am J Surg Pathol 1990; 14: 1112-1125 [MEDLINE]
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A case of aggressive atypical anti-GBM disease complicated by CMV pneumonitis. BMC Nephrol. 2019;20(1):2 [MEDLINE]
Malignant Triton Tumor
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Tracheovascular/Bronchovascular Fistula
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Trauma
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Anatomy and Physiology
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Diagnosis
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Robot-assisted ligation of bronchial artery could be an alternative to embolization. Eur J Cardiothorac Surg. 2018 Mar 1;53(3):686-688. doi: 10.1093/ejcts/ezx336 [MEDLINE]
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