Jerpm.

com Original Research Article

TWO YEARS PROSPECTIVE OBSERVATIONAL STUDY OF HAEMOPTYSIS AT ONE OF THE TERTIARY

HEALTH CENTRES IN ANDHRA PRADESH
P. V. Kalyan Kumar1, Ramakrishna Gorantla2, Ramakrishna Rachakonda3, Jayakar Babu4, Venu M5

1Assistant Professor, Department of Pulmonary Medicine, Katuri Medical College, Guntur.

2Assistant Professor, Department of General Medicine, Katuri Medical College, Guntur.
3Professor, Department of Pulmonary Medicine, Katuri Medical College, Guntur.
4Professor and HOD, Department of Pulmonary Medicine, Katuri Medical College, Guntur.
5Assistant Professor, Department of Pulmonary Medicine, Katuri Medical College, Guntur.

ABSTRACT
BACKGROUND
Life-threatening haemoptysis is a common medical emergency in developing countries like India. This is an especially common cause
of morbidity and mortality. Untreated, life-threatening haemoptysis has a mortality that ranges from 50 to 80%. Haemoptysis can
be life-threatening as haemorrhage into the alveolar air spaces interferes with gas exchange and oxygen transfer into the blood. The
causes of haemoptysis as described in the literature are extensive; however, in India, patients with infectious aetiology complains of
haemoptysis.
Aim of this study is to investigate the causes of haemoptysis and imaging modalities in cohort of patients in our institution.

MATERIALS AND METHODS

Patients admitted for haemoptysis from 1st March 2014 to 1st March 2016 to the tertiary health centre included in this study. The
patients are included in the study if their haemoptysis were equal to or exceeded 50 mL over a 24-hour period immediately prior to
admission to hospital.

RESULTS
99 patients (59%) had a history of pulmonary tuberculosis; sixty eight (40%) patients were sputum positive for Acid-Fast Bacilli
(AFBs). Remaining 31 (19%) patients were sputum negative. Haemoptysis in these sputum negative cases are due to post-
tuberculosis sequelae. Among sputum positive cases, 11 patients (6.5%) were infected with multi-drug resistant TB. Pulmonary
tuberculosis remains the commonest cause for life-threatening haemoptysis. Bronchiectasis were seen in 35 patients and
aspergillomas were confirmed on CT in 12 patients; 11 neoplasms detected were bronchial carcinomas on histology and
consolidations were seen in 7 cases. Bronchial angiography showed a right Intercostobronchial (ICBT) was constant in 90% of
patients in this study. Anomalous bronchial arteries arising from the aortic arch were detected in 5 patients.

CONCLUSION
Timely management of haemoptysis in different clinical settings is critical, especially in case of massive bleeding, which is a life-
threatening condition. Tuberculosis remain the most important cause of haemoptysis. Imaging especially HRCT, MDCT has a major
role in this context, as it allows identification of a possible cause for the bleeding and guides eventual treatment by providing a
comprehensive and accurate assessment of the lung parenchyma, airways and thoracic vessels.

KEYWORDS
Haemoptysis, High Resolution Computer Tomography (HRCT), Multidetector CT (MDCT), Angiography (MDCTA), Tuberculosis (TB).
HOW TO CITE THIS ARTICLE: Kumar PVK, Gorantla R, Rachakonda R, et al. Two years prospective observational study of
haemoptysis at one of the tertiary health centres in Andhra Pradesh. Journal of Evolution of Research in Pulmonary Medicine 2016;
Vol. 2, Issue 2, July-December 2016; Page:1-5.
BACKGROUND in 24 hrs. is what most authors use in clinical reports to define
Haemoptysis or the expectoration of blood from the lower massive haemoptysis.5 It is estimated that 400 mL of blood in
respiratory tract1,2 can range from blood-streaking of sputum the alveolar space is sufficient to cause significant hindrance
to the presence of gross blood in the absence of any to the oxygen transfer,6 although only minor changes in the
accompanying sputum. The definition of massive haemoptysis vital signs will be noted for the same amount of blood loss.7
varies widely in the literature from 200 mL to 1000 mL/24 Haemoptysis of more than 200 mL within last 24 hrs.,
hrs.,3,4 but the expectoration of more than or equal to 600 mL bronchial bleeding causing haemodynamic instability,
respiratory impairment or drop of haematocrit level below
Financial or Other, Competing Interest: None. 30% was defined as life-threatening haemoptysis.
Submission 09-07-2016, Peer Review 15-11-2016, Furthermore, blood losses were sub-grouped into “severe” on
Acceptance 21-11-2016, Published 07-12-2016. a daily basis of 200 - 600 mL and “massive” on an amount over
Corresponding Author:
Dr. P. V. Kalyan Kumar, 600 mL/day. Massive haemoptysis is usually a sign of an
Plot No. 304, Brudavan Residence Apartment, underlying chronic disease.8 The most common causes
Brundavan Gardens, Opposite Teneega Restaurant, encountered in the developed world are pulmonary
Brundavan Gardens, Guntur-522007. Andhra Pradesh. tuberculosis, bronchiectasis, bronchogenic carcinoma, lung
E-mail: drpvkalyan@hotmail.com
abscess, cystic fibrosis and aspergilloma. 9,10 Haemoptysis has
been classified as single if there is one episode of bleeding

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lasting up to 7 days, but usually 1 - 2 days. It is called recurrent
when the bleeding continues for longer than 7 days or there is
a break in the continuity of at least 2 - 3 days.11 When pure
blood without sputum is expectorated, it is called frank
haemoptysis. Anuradha C12 defined recurrent haemoptysis as
a total of > 30 mL of bleeding in 24 hours.
Dual Blood Supply of the Lung
Two arterial vascular systems provide blood supply to the
lungs: the pulmonary arteries and the bronchial arteries. The
pulmonary arteries provide 99% of the arterial blood to the
lungs and are also involved in the exchange of gases. The
bronchial arteries supply nourishment to the extra- and
intrapulmonary airways and to the vasa vasorum of the
pulmonary arteries without being involved in the gas
exchange. Blood supply to the mediastinal lymph nodes
oesophagus, vasa vasorum of the aorta and pulmonary veins
and nerves, visceral pleura are provided by the bronchial
arteries.
Complex capillary anastomoses exist between the
pulmonary arteries and the bronchial arteries. Whenever the
pulmonary circulation is compromised as in thromboembolic
disease, vasculitis disorders and in hypoxic vasoconstriction,
the bronchial supply gradually increases causing a hyperflow
in the anastomotic blood vessels, which become hypertrophic
with thin walls and tend to break into the alveoli and bronchi,
giving rise to haemoptysis. Likewise, in chronic inflammatory
disorders such as bronchiectasis of lung, tuberculosis, mycotic
lung disorders and lung abscess, chronic bronchitis as well as
in neoplastic lung diseases, the release of angiogenic growth
factors promoting neovascularisation leading to haemoptysis.
In cases of severe haemoptysis requiring treatment, the source
of bleeding originates from bronchial and pulmonary arteries
in 90% and 5% of cases respectively and the remaining 5% of
cases haemoptysis may derive from non-bronchial systemic
arteries.13 Very rarely, haemoptysis has been reported
originating from both pulmonary and bronchial veins14,15 and
also capillaries.16
The bronchial arteries commonly originate from the upper
portion of the descending thoracic aorta. The origin is defined
orthotropic if the arteries arise from the descending aorta at
the level of the vertebral bodies of T5-T6 (or at the carina).
When the bronchial arteries originate at other levels
including aortic branches, they are referred to as ectopic.
Ectopic bronchial arteries commonly arise from the inferior
aspect of the aortic arch, thyrocervical trunk, internal
mammary artery, subclavian artery, brachiocephalic trunk,
costocervical trunk, pericardiophrenic artery, inferior phrenic
artery and also from abdominal aorta. Cauldwell et al 17
described the four most common origin of orthotopic
bronchial arteries (Figure 1).
Figure 1. Four Most Common Origin
of Orthotopic Bronchial Arteries
Journal of Evolution of Research in Pulmonary Medicine/ Vol. 2/ Issue 2/ July-December, 2016
Original Research Article
Type 1 (40.6%)
In this type, one right bronchial artery arising from an
Intercostobronchial Trunk (ICBT) and two left bronchial
arteries.
Type 2 (21.3%)
In this type, right bronchial artery arises from an
Intercostobronchial Trunk (ICBT) and has only one left.
Type 3 (20.6%)
In this type, two bronchial arteries from the right (one from an
ICBT) and two from the left.
Type 4 (9.7%)
In this type, two bronchial arteries from the right (one from an
ICBT) and one from the left, the most constant vessel is the
right ICBT present in 88.7%. Sometimes, the right and left
bronchial arteries can also arise from a common trunk.
Diagnostic Modalities
The diagnostic modalities for diagnosing the haemoptysis are
Chest radiograph (Chest x-ray), Bronchoscopy, High
Resolution Computed Tomography of the chest and lungs
(HRCT), Multidetector Computed Tomography (MDCT)
Angiography (MDCTA) and Digital Subtraction Angiography
(DSA).
MATERIALS AND METHODS
Study Population
Patients admitted for haemoptysis from 1st March 2014 to 1st
March 2016 to the tertiary health centre included in this study.
All patients are referred to the Department of Pulmonary
Medicine as an emergency from various hospitals in Guntur
are included. Patients are included in the study if their
haemoptysis were equal to or exceeded 50 mL over a 24-hour
period immediately prior to admission to hospital. Patients
were asked how much blood was coughed up in the previous
24 hours in terms of “tea cups” assuming the average tea cup
contained 100 mL of fluid. All patients were assessed by
pulmonologist and cardiothoracic surgeon.
The following Data was Recorded
a. Demographic information of the patient.
b. Total length of hospital stay.
c. Aetiology of pulmonary pathology.
d. Haemoglobin level and white cell count on admission.
e. Sputum analysis for acid fast bacilli.
f. HIV status and other serological tests.
g. Bronchoscopy findings.
Radiological Studies Assessed and Recorded Included
a. Chest radiograph.
b. High Resolution Computed Tomography (HRCT) chest.
c. Bronchial and systemic arteriography.
Imaging Assessment
Chest Radiograph
All patients well enough had a frontal chest radiograph
performed in the Radiology Department as an erect film
(PA view). If the patient was too ill, a bedside unit supine
radiograph was performed.
The following Radiological Signs were Recorded
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1. Presence of pulmonary cavities. 99 patients (59%) had a history of pulmonary tuberculosis.
2. Masses within pulmonary cavities, such as mycetomas or The diagnosis of active or reactivated pulmonary tuberculosis
haematomas. was made on clinical criteria of cough, fever, loss of weight and
3. Fluid level in pulmonary cavities. night sweats, radiological findings as well as sputum positivity
4. Infiltrates. for Acid-Fast Bacilli (AFBs). Sixty-eight (40%) patients were
5. Pulmonary opacification. sputum positive for Acid-Fast Bacilli (AFBs). Remaining 31
6. Nodules. (19%) patients were sputum negative.
7. Masses. Haemoptysis in these sputum negative cases are due to
8. Lymphadenopathy. post tuberculosis sequelae. Among sputum positive cases, 11
9. Possible origin of bleeding. patients (6.5%) were infected with multi-drug resistant TB
(Table 2).
High Resolution CT Lungs (HRCT)
Pulmonary tuberculosis remains the commonest cause for
HRCT was performed on some of the patients who were well
life-threatening haemoptysis. Bronchiectasis were seen in 35
enough to cooperate in this study. This was performed on the
patients and aspergillomas (Table 2) were confirmed on CT in
helical CT.
12 patients; 11 neoplasms detected were bronchial
carcinomas on histology and consolidations were seen in 7
Analysis of Results and Statistical Analysis
Two years’ prospective study of patients admitted in the cases. Mitral stenosis is well known to present as haemoptysis
hospital with complaints of haemoptysis. Data analysed based and we had 2 cases of mitral stenosis, which presented as
on demographic data, aetiology and angiography findings. The massive haemoptysis. Two cases of carcinoid also presented as
results are further analysed using SPSS for Windows software massive haemoptysis.
version 24 (IBM SPSS incorporated).
Aetiology Number Percentage
Ethical Clearance Pulmonary tuberculosis 68 40.4%
All the patients are incorporated after Institutional Ethical Post tuberculosis sequelae 31 18.4%
Clearance. Bronchiectasis 35 20.8%
Aspergilloma 12 7.1%
RESULTS Neoplasms 11 6.5%
One hundred and sixty-eight (168) patients are included in Consolidation 07 4.1%
this study over a 24-month period from 1st March 2014 to 1st Others 04 2.3%
March 2016. There are 134 male and 34 female patients with
Table 2. Causes of Haemoptysis
a mean age of 28.9 years (Standard deviation SD 11.7 years).
Most of the patients are male and were smokers (Table 1).
HIV Status
Females have severe haemoptysis when compared to males;
All patients consented to be tested for HIV. Thirty-three
45 patients died (27%) during the study period. Of the 168
patients (19.6%) were sero-positive for HIV; all patients had
patients 51.7% (n = 87) of patients are non-smokers, 13.6% (n
= 23) are ex-smokers (Table 1) and 34.5% (n = 58) are current their CD4 lymphocyte counts estimated.
smokers. A total of 47.6% (n = 80) of patients are admitted for
the first episode of haemoptysis and 52.3% (n = 88) for Laboratory Parameters
recurrent haemoptysis. Of these 12.5% (n = 21) gave history The mean haemoglobin was 9.6 g/100 mL on admission
of mild haemoptysis, more patients 62% (n = 104) have (Range 4 to 14 g/100 mL SD 2.6 g/100 mLs). Twenty-one
moderate haemoptysis and 26.1% (n = 44) have massive (24%) patients required a blood transfusion. The mean white
haemoptysis. Duration of haemoptysis varied from a minimum cell count was 10,450 cells/mm3 (Range 3000 to 34,000
of 1 day to a maximum of 42 days (Mean 9.87 days); 41 cells/mm3, SD 6 270 cells/mm3). Sputum culture was positive
patients have history of pulmonary tuberculosis, the mean in only 3 patients for Klebsiella, Pseudomonas and Serratia
volume of the haemoptysis was 745 mL (Range 150 to 4000 bacterial species.
mL, SD 743 mL).
Total Males Females Bronchoscopy
Characteristics
n=168 n=134 n=34 Bronchoscopy was performed by the pulmonologist in all
Current Smokers 58 51 7 patients except fifty-two (52) patients, who refused the
Ex-Smokers 23 21 2 procedure. Bronchoscopy was normal in 44.6% (n = 75) and
Age > 65 years 43 32 12 abnormal in 24.4% (n = 41). The diagnostic yield of
Mild Haemoptysis 21 19 02 bronchoscopy was only in detecting endobronchial lesions.
Moderate The origin of the haemorrhage was correctly identified in 20
104 81 23
Haemoptysis patients when compared to the bronchial angiogram.
Severe Haemoptysis 44 12 32 Bronchoscopy was able to detect two endobronchial
Past Tuberculosis carcinoids, two endobronchial masses, four signs of
41 23 18 inflammation, two endobronchial granulations. Tracheal and
Infection
HIV 33 21 12 epiglottis bleeding occurred in six patients. However,
Table 1. Demographics of the Patients bronchoscopy was done as an emergency in cases of massive
Table 1 Demographics of the included Patients haemoptysis and within 1 week in all other cases, but active
Pulmonary Aetiology of Haemoptysis bleeding was seen only in 48.1% of cases. Blood haemoglobin

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was estimated on the day of admission and repeated after
24 hrs.
CT of the Lungs
High resolution scans (HRCT) were done. CT detected the
bleeding source in 45 patients. The accuracy of CT in detecting
the source of the haemorrhage using bronchial angiography as
the gold standard was 56%.
Bronchial and Systemic Angiography
The following are the bronchial angiography findings as
shown in the Table 3.
Findings Number % malignancy of the lung, breast and liver.
Enlarged Bronchial A 94 56%
Normal Bronchial A 34 20%
Bleeding source 121 72%
Bronchopleural shunts 25 15%
Bronchial aneurysms 15 9%
Contrast leak extravasation 0 destruction of the muscle and elastic components of the
Anomalous Bronchial A 15 9%
Table 3. Angiographic Findings
The bronchial arteries are (Tablet 3) enlarged in 94 (56%)
patients and normal in calibre in 34 (20%) patients. As an
indicator of a bleeding source, parenchymal hypervascularity
and neovascularity was detected in 121 (72%) of patients. No
active contrast extravasation was detected in any arteriogram.
Bronchial artery aneurysms were present in 15 patients.
Broncho-pulmonary shunts were present in 15 patients.
The commonest bronchial artery pattern seen in this study
are a right intercostobronchial trunk with two separate left
bronchial arteries in 56% of patients followed by a right
intercostobronchial trunk and one left bronchial artery in 20%
of patients followed by an ICBT and separate bronchial on the
right and two left bronchial in 20%, a single trunk dividing into
left and right bronchial arteries in 2% of patients and a right
ICBT and separate right bronchial and separate single left
bronchial in 2% of patients.
A right ICBT was constant in 90% of patients in this study.
Anomalous bronchial arteries arising from the aortic arch
were detected in 5 patients.
DISCUSSION
The incidence of haemoptysis is influenced by several factors
including the geographic area of study and the institution
where the research is conducted that is in general hospital or
tertiary hospital. In our study, most cases of haemoptysis was
caused by infection. So most common cause of haemoptysis
was tuberculosis. As mentioned above, of the 168 cases of
haemoptysis evaluated 41% were directly related to active
pulmonary tuberculosis and 21% were related to
bronchiectasis. Tuberculosis (TB) continues to be the most
common reason of haemoptysis. It is estimated that one-third
of the world population is infected with TB and 5% to 10% of
these patients will develop the disease. It is important to keep
parasitic infections examples paragonimiasis, schistosomiasis
infestations in the differential for a patient returning from
Asia, South America and the Middle East countries. In the
United States and other developed countries, bronchitis,
bronchiectasis and bronchogenic carcinoma constitutes 2% to
30% of cases of haemoptysis. In our study, bronchogenic
Journal of Evolution of Research in Pulmonary Medicine/ Vol. 2/ Issue 2/ July-December, 2016
Original Research Article
carcinoma constitutes 6.5% of all the cases. Bronchiectasis
contributes to 21% of these cases. In a study by Ong and Eng,18
the most common cause of haemoptysis in an ICU based in
Singapore was bronchiectasis (66%) followed by mycetoma
(14%), active TB (10%), tumour (7%) and diffuse alveolar
haemorrhage (3%). In a cohort of Austrian19 patients admitted
to an ICU with life-threatening haemoptysis, lung cancer
(35%) was identified more commonly than TB (23%),
metastatic disease (10.5%), bronchiectasis (8.5%) and
vascular malformation (7%). Bronchogenic carcinoma20
contributes to majority of cases in patients with malignancy-
related haemoptysis. Other malignant aetiologies include
bronchial carcinoid and pulmonary metastasis from
In addition, invasive pulmonary aspergillosis and chronic
necrotising aspergillosis in immunocompromised patients,
mainly HIV patients can also cause fatal pulmonary
haemorrhage. It is known that bronchiectasis consists of
irreversible bronchial dilatation and occurs due to the
bronchial wall. Two elements are key to this destruction:
infectious disease and impaired clearance of bronchial
secretions. Infection with Mycobacterium tuberculosis is still
quite common in India and can cause bronchiectasis, either
due to the active infectious process in the bronchi or to lung
scarring caused by a previous infection or even due to
bronchial compression caused by hilar adenopathy.
Preference of Investigations in Order are
Blood Investigations
Type and cross-matching of a blood specimen, complete blood
count (White blood cell count, haemoglobin level, haematocrit
and platelet count) and white blood cell differential,
prothrombin time (or International Normalised Ratio) and
partial thromboplastin time, electrolytes, blood urea nitrogen
and creatinine, arterial blood gas, liver function tests and
urinalysis.
Bronchoscopy
Bronchoscopic interventions used to control acute bleeding
(Eg., balloon tamponade, iced saline lavage, topical
medication) and also can be used as diagnostic modality.
Arteriography
Arteriography is generally performed if there is persistent
bleeding following bronchoscopy. The preceding
bronchoscopy may be helpful in identifying the side or area of
bleeding, thereby assisting the radiologist in locating the
precise bleeding site. Therapeutic embolisation is possible
during the diagnostic arteriography procedure.
Computed Tomography
Early Computed Tomography (CT) of the chest has been
increasingly advocated to help localise the bleeding site and to
diagnose the cause of the haemoptysis. It is generally
performed in patients whose bronchoscopy was non-
diagnostic and in whom arteriography is not necessary,
because the bleeding has ceased. The major advantage of CT is
that it may identify abnormalities that are difficult to detect by
bronchoscopy and arteriography such as bronchiectasis, lung
abscess, pulmonary artery (Rasmussen’s) aneurysm and mass
lesions (Eg., cancer, aspergilloma, arteriovenous
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malformations). In addition, CT scans may identify a systemic
arterial supply to a lesion. Features suggestive of a systemic
blood supply include increased pleural thickness (> 3 mm)
adjacent to a parenchymal lesion and/or enhanced vascular
structures in a nearby extrapleural fat layer.
The primary disadvantages of chest CT are that it requires
movement of the patient away from the intensive care unit and
occasionally it may provide misleading results. As an example,
a clot in an airway or bleeding into a cavity may be mistaken
as a tumour mass on CT scan.
CONCLUSION
Timely management of haemoptysis in different clinical
settings is critical, especially in case of massive bleeding which
is a life-threatening condition. Moderate haemoptysis was the
commonest type of presentation. Tuberculosis remain the
most important cause of haemoptysis. Imaging, especially
HRCT, MDCT has a major role in this context as it allows
identification of a possible cause for the bleeding and guides
eventual treatment by providing a comprehensive and
accurate assessment of the lung parenchyma, airways and
thoracic vessels. Systemic bronchial and non-bronchial
arteries are identifiable on MDCT angiography and play a
major role in massive bleeding. A thorough knowledge of
normal and variant anatomy of these arteries is crucial for the
planning of endovascular embolisation.
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