Hemoptysis pathophysiology
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]
Overview
Lung has two main vascular systems that include pulmonary circulation and bronchial circulation. There are multiple anastomoses between pulmonary and bronchial arteries which create physiologic right to left shunts. Blood in the hemoptysis is mostly originated from the Lung. However, it could be from the gastrointestinal system as well. Primary origin of the blood comes from bronchial arteries. However, other sources of bleeding might be pulmonary vessels, aorta, intercostal, coronary, thoracic, and phrenic arteries. Hemoptysis is an important symptom that has different etiologies and pathogenesis mechanisms. Hemoptysis may happen following infarction and ischemia of pulmonary parenchyma as seen in pulmonary embolism, vasculitis, and infections. Another mechanism of hemoptysis is vascular engorgement with erosion as seen in bronchitis, bronchiectasis, and toxic exposure to cigarette and other irritants. In some cases underlying cause can not be identified and they are considered as idiopathic. However, they might present with massive hemoptysis. There are multiple conditions that are associated with hemoptysis which include granulomatosis with polyangiitis, sarcoidosis, immunodeficiency, and indoor ice hockey play.
Pathophysiology
Physiology
- Lung has two main vascular systems that include pulmonary circulation and bronchial circulation.
- There are multiple anastomoses between pulmonary and bronchial arteries which create physiologic right to left shunts.
- Pulmonary circulation
- It provides gas exchange where deoxygenated blood enters the lungs through pulmonary arteries and oxygenated blood returns to circulation through pulmonary veins.
- Pulmonary arteries
- Pulmonary veins
- Pulmonary circulation
-
- Bronchial vessels provide blood and nutrients to the bronchi and connective tissue of the lungs. They supply blood to the respiratory bronchioles and the visceral pleura of the lung.
- Bronchial arteries carry oxygenated blood to the lung tissues. They are arised from the thoracic aorta. There are usually two branches to the left lung and one to the right lung.
- Bronchial veins return the deoxygenated blood from the lung tissues to the systemic circulation. The right side drains into the azygos vein and the left side drains into the left superior intercostal vein or the accessory hemiazygos vein.
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Pathogenesis
- Hemoptysis is an important symptom that has different etiologies and pathogenesis mechanisms.[3]
- Blood in the hemoptysis is mostly originated from the Lung. However, it could be from the gastrointestinal system as well.[4]
- Primary origin of the blood comes from bronchial arteries.[5][6]
- Other sources of bleeding might be:[7][8][6]
- Aorta
- Intercostal arteries
- Coronary arteries
- Thoracic arteries
- The upper and inferior phrenic arteries
- Pulmonary vessels
- Hemoptysis may happen following infarction and ischemia of pulmonary parenchyma. It is seen in following conditions:[9][10]
- Pulmonary emboli
- Vasculitis including:
- Infections including:
- Staphylococcus aureus
- Pseudomonas aeruginosa
- Aspergillus fumigatus
- The phycomycetes
- Another mechanism of hemoptysis is vascular engorgement with erosion. It is seen in following conditions:[11][12]
- Acute infection such as:
- Viral bronchitis
- Bacterial bronchitis
- Chronic infection such as:
- Toxic exposure
- Acute infection such as:
- In some cases underlying cause can not be identified and they are considered as idiopathic. However, they might present with massive hemoptysis.[13][14]
Associated Conditions
- There are multiple conditions that are associated with hemoptysis which include:
- Granulomatosis with polyangiitis
- Sarcoidosis
- Immunodeficiency
- Indoor ice hockey play[15][16]
References
- ↑ "File:2119 Pulmonary Circuit.jpg - Wikimedia Commons".
- ↑ "File:Pulmonary Blood Circulation.png - Wikimedia Commons".
- ↑ "Hemoptysis - Clinical Methods - NCBI Bookshelf".
- ↑ Andersen, P. E. (2016). "Imaging and interventional radiological treatment of hemoptysis". Acta Radiologica. 47 (8): 780–792. doi:10.1080/02841850600827577. ISSN 0284-1851.
- ↑ Ittrich, H.; Klose, H.; Adam, G. (2014). "Radiologic Management of Haemoptysis: Diagnostic and Interventional Bronchial Arterial Embolisation". RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren. 187 (04): 248–259. doi:10.1055/s-0034-1385457. ISSN 1438-9029.
- ↑ 6.0 6.1 Noë, G.D.; Jaffé, S.M.; Molan, M.P. (2011). "CT and CT angiography in massive haemoptysis with emphasis on pre-embolization assessment". Clinical Radiology. 66 (9): 869–875. doi:10.1016/j.crad.2011.03.001. ISSN 0009-9260.
- ↑ Sakr, L.; Dutau, H. (2010). "Massive Hemoptysis: An Update on the Role of Bronchoscopy in Diagnosis and Management". Respiration. 80 (1): 38–58. doi:10.1159/000274492. ISSN 1423-0356.
- ↑ Gupta, Mudit; Srivastava, Deep Narayan; Seith, Ashu; Sharma, Sanjay; Thulkar, Sanjay; Gupta, Rashmi (2013). "Clinical Impact of Multidetector Row Computed Tomography Before Bronchial Artery Embolization in Patients With Hemoptysis: A Prospective Study". Canadian Association of Radiologists Journal. 64 (1): 61–73. doi:10.1016/j.carj.2011.08.002. ISSN 0846-5371.
- ↑ Shigemura, Norihisa; Wan, Innes Y.; Yu, Simon C.H.; Wong, Randolph H.; Hsin, Michael K.Y.; Thung, Hoi K.; Lee, Tak-Wai; Wan, Song; Underwood, Malcolm J.; Yim, Anthony P.C. (2009). "Multidisciplinary Management of Life-Threatening Massive Hemoptysis: A 10-Year Experience". The Annals of Thoracic Surgery. 87 (3): 849–853. doi:10.1016/j.athoracsur.2008.11.010. ISSN 0003-4975.
- ↑ Chun, Joo-Young; Morgan, Robert; Belli, Anna-Maria (2010). "Radiological Management of Hemoptysis: A Comprehensive Review of Diagnostic Imaging and Bronchial Arterial Embolization". CardioVascular and Interventional Radiology. 33 (2): 240–250. doi:10.1007/s00270-009-9788-z. ISSN 0174-1551.
- ↑ Tom, Lisa M.; Palevsky, Harold I.; Holsclaw, Douglas S.; Trerotola, Scott O.; Dagli, Mandeep; Mondschein, Jeffrey I.; Stavropoulos, S. William; Soulen, Michael C.; Clark, Timothy W.I. (2015). "Recurrent Bleeding, Survival, and Longitudinal Pulmonary Function following Bronchial Artery Embolization for Hemoptysis in a U.S. Adult Population". Journal of Vascular and Interventional Radiology. 26 (12): 1806–1813.e1. doi:10.1016/j.jvir.2015.08.019. ISSN 1051-0443.
- ↑ Zhao, Tian; Wang, Sini; Zheng, Lili; Jia, Zhongzhi; Yang, Yunjun; Wang, Weiping; Sun, Houzhang (2017). "The Value of 320-Row Multidetector CT Bronchial Arteriography in Recurrent Hemoptysis after Failed Transcatheter Arterial Embolization". Journal of Vascular and Interventional Radiology. 28 (4): 533–541.e1. doi:10.1016/j.jvir.2017.01.006. ISSN 1051-0443.
- ↑ Savale L, Parrot A, Khalil A, Antoine M, Théodore J, Carette MF, Mayaud C, Fartoukh M (June 2007). "Cryptogenic hemoptysis: from a benign to a life-threatening pathologic vascular condition". Am. J. Respir. Crit. Care Med. 175 (11): 1181–5. doi:10.1164/rccm.200609-1362OC. PMID 17332480.
- ↑ Herth F, Ernst A, Becker HD (November 2001). "Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin". Chest. 120 (5): 1592–4. PMID 11713139.
- ↑ Karlson-Stiber C, Höjer J, Sjöholm A, Bluhm G, Salmonson H (May 1996). "Nitrogen dioxide pneumonitis in ice hockey players". J. Intern. Med. 239 (5): 451–6. PMID 8642238.
- ↑ "Exposure to nitrogen dioxide in an indoor ice arena - New Hampshire, 2011". MMWR Morb. Mortal. Wkly. Rep. 61 (8): 139–42. March 2012. PMID 22377844.