What Is the Source of This Man’s Hemoptysis?

Answer: A. Bronchial artery dilatation

The computed tomography scan showed prominent tortuous mediastinal vessels, probably attributable to bronchial artery dilatation (Figure, arrows).

Figure. A contrast-enhanced computed tomography scan of the chest.

The patient was given broad-spectrum antibiotics for aspiration pneumonia. After the patient underwent endotracheal intubation for airway protection, an esophagogastroduodenoscopy was performed, results of which did not reveal active bleeding sites, varices, or ulcers. However, a fiberoptic bronchoscopy revealed blood in the left main bronchus, but no active bleeding.

Later that evening, a repeat bronchoscopy was performed because of suspected bleeding. Clots were noted at the main carina, in both mainstem bronchi, and in the left lower lobe and lingular bronchi. Interventional radiology was consulted for the possibility of performing fluoroscopically guided embolization of the left bronchial artery. Results of serologic studies ruled out the possibility of vasculitides. Various infectious causes of hemoptysis—including tuberculosis, aspergillosis, and lung abscess—were also ruled out. Bronchial artery embolization was not performed because the bleeding had stopped, and the risk-benefit ratio was deemed to be adverse.

The patient was followed up at regular intervals for 2 years, and his last computed tomography scan showed resolution of consolidative changes with fibrotic scarring in right middle lobe.

Discussion. Hemoptysis is the expectoration of blood from the lower respiratory tract. Expectoration can range from blood-streaked sputum to large volumes of blood, termed “life-threatening hemoptysis.”¹ Blood loss resulting in hemodynamic instability can be considered to be massive hemoptysis requiring urgent, lifesaving intervention.¹ However, there is no consensus as to the volume of blood that constitutes “massive hemoptysis,” with various studies suggesting 100 mL to 1000 mL over a 24-hour period.¹ Instead of defining by the amount or rate of blood loss, a practical approach would be to define “life-threatening hemoptysis” as any hemoptysis that can be life threatening either by aspiration or exsanguination.^1,2 The other serious concern in the setting of massive hemoptysis is the aspiration of blood throughout the ipsilateral and contralateral lung, resulting in respiratory insufficiency.³

Tuberculosis and bronchiectasis are leading causes of massive hemoptysis.⁴ However, neoplasia of the lung, clotting disorders, other bronchopulmonary infections (eg, aspergillosis), and less-frequent etiologies such as Goodpasture syndrome or aortobronchial fistulas can also cause significant bleeding in the respiratory tract.³

It is important to note that the lungs have dual blood supply, and hemoptysis can originate from either (or both) circuits.⁶ The pulmonary arteries carry the entire output of deoxygenated blood from the right ventricle to the pulmonary capillaries and alveoli facilitate gas exchange.⁶ The bronchial arteries originate from the aorta and supply a small amount of oxygenated blood to the tracheobronchial tree.⁶ The bronchial artery circuit can occasionally be the source of massive hemoptysis. The bleeding can occur either in the setting of inflammation or blockage of downstream vessels, which can in turn predispose to pseudoaneurysms, especially at the site of anastomoses between the bronchial and pulmonary arterial circuits.^7,8 This predisposition to bleeding, coupled with exposure to higher pressures of the systemic circulation, is believed to be the mechanism for significant bleeding.⁷

The diagnostic evaluation of patients with hemoptysis begins with routine chest radiography scanning. Chest radiography scanning can sometimes reveal the etiology of the bleeding—for example, in the case of tuberculosis, consolidation or a neoplastic process. However, the sensitivity of chest radiography scanning is low. Computed tomography scanning was found to be about 67% sensitive in a retrospective study of 208 patients who had presented with massive hemoptysis.⁹ The researchers demonstrated that computed tomography scanning was the most sensitive single modality to identify the source of bleeding.

In our patient, computed tomography scans demonstrated consolidative changes involving the right middle lobe and the lingular segment of the left upper lobe, as well as dilated tortuous mediastinal vessels, likely bronchial artery branches.⁵ While increased vessel diameter does not usually increase the risk of bleeding, a diameter of more than 2 mm most likely represents underlying inflammatory or obstructive pathology and the concomitant predisposition to aneurysm formation.^10,11

Bronchial artery dilatation can be caused by congenital or acquired diseases. The congenital causes include pulmonary agenesis, Tetralogy of Fallot, and anomalous left coronary artery arising from the pulmonary artery.¹¹ Acquired causes include bronchiectasis, cystic fibrosis, tuberculosis, lung abscess, chronic thromboembolic disease, pulmonary hypertension, Takayasu arteritis, fibrosing mediastinitis, and malignancy.¹¹ In our patient, serology tests were negative for vasculitides, and a contrast study ruled out thromboembolic phenomena. No evidence of malignancy was noted in the results of the imaging studies. However, computed tomography scans showed consolidation of the right middle lobe and lingular segment of left upper lobe. Although bronchoalveolar lavage was negative for culture of bacteria, including acid-fast bacilli and fungal elements, the cause of bronchial artery dilatation seems to be a chronic inflammatory event that could not be determined.

Bronchoscopy is an essential tool in the management of patients with massive hemoptysis. However, the choice of a flexible versus rigid bronchoscope remains controversial. Bronchoscopy is utilized for clot retrieval and the application of topical vasoconstrictors to promote the cessation of bleeding, as well as to secure the airway.¹² A bronchoscopy that is performed soon after presentation can reveal the site of the bleed. In the case of life-threatening bleeding, bronchial balloon catheters can be introduced via flexible bronchoscopy while the patient awaits surgical intervention.

Ultimately, if bronchoscopic maneuvers fail to control the bleeding, bronchial artery embolization and occasionally surgical resection of the lung are performed. Since a majority of the bleeds originate from the bronchial arteries, embolization usually results in cessation of bleeding. However, an untoward complication of bronchial artery embolization is spinal cord ischemia.¹³ Since our patient remained hemodynamically stable and the bleeding stopped with bronchoscopic clot retrieval and suctioning, the patient was managed conservatively, and he was discharged home with outpatient follow-up.

Conclusion. Massive hemoptysis is a life-threatening condition requiring emergent intervention. Hemoptysis from the bronchial circuit usually results in massive hemoptysis because of higher pressures of systemic circulation. Bronchial artery dilation is a rare yet important differential for hemoptysis, which requires prompt treatment with bronchoscopic maneuvers or bronchial artery embolization.

References

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6. Blood flow to the lung. In: Levitzky MG, ed. Pulmonary Physiology. 9th ed. McGraw-Hill Education; 2018.

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