1

What is haemoptysis?

Haemoptysis is defined as the coughing up of blood or blood-stained sputum.

The origin of the expectorated blood can be from the larynx, trachea, bronchi or lungs.

2

How is haemoptysis classified?

Haemoptysis is classified according to the volume of blood expectorated over a 24-hour period, as mild, moderate or severe (Table 1).

Severe haemoptysis is further subclassified as massive or exsanguinating. Whilst massive haemoptysis may be life-threatening as it puts the patient at risk of asphyxiation, exsanguinating haemoptysis may result in very large volumes of blood loss.

These are quantitative definitions and ultimately the condition of the patient will determine the management.

3

What is the aetiology of haemoptysis?

Infection. Massive haemoptysis occurs most frequently in relation to inflammatory lung disease (85%). Mycobacterium, particularly tuberculosis, is the most common, followed by aspergillosis, necrotising pneumonitis, lung abscess and cystic fibrosis.

Pulmonary. Bronchiectasis causes haemoptysis due to proliferation and enlargement of bronchial arteries and precapillary bronchopulmonary anastomoses. Patients often have many episodes associated with recurrent infectious exacerbations.

Neoplasia. Bronchogenic carcinoma usually causes small-volume haemoptysis as a result of airway mucosal ulceration. Rarely, it may result in massive haemoptysis due to bronchial artery proliferation related to tumour neovascularisation. Pulmonary metastases and bronchial adenoma may result in massive haemoptysis.

Vascular. Pulmonary embolus with infarction of lung parenchyma can result in bronchial artery bleeding and in these patients is often aggravated by the administration of anticoagulants. Arteriovenous malformations may occasionally be found.

Trauma. Trauma is an unusual cause of massive haemoptysis but may occur with tracheobronchial rupture and damage to the bronchial arteries.

Iatrogenic. Damage to the pulmonary artery from pulmonary artery (Swan-Ganz) catheters, bronchoscopy, endobronchial and transbronchial biopsy

Cardiac. Mitral valve stenosis may lead to the rupture of small pulmonary vessels due to pulmonary hypertension resulting in haemoptysis.

Coagulopathy. Haemophilia, von Willebrand disease, thrombocytopaenia, disseminated intravascular coagulation (DIC) and anticoagulant overdose can all present with haemoptysis.

4

What is the epidemiology of haemoptysis?

Although the majority of haemoptysis episodes are secondary to short-lived, self-limiting, upper and lower respiratory tract infection, it can be a sign of malignant pulmonary disease.

Haemoptysis has a 7.5% predictive value for lung cancer in men and 4.3% in women in the UK. In men aged over 75, this rises to 17%.

5

What is the source of the bleeding in haemoptysis?

Systemic arteries (90-95%) from:

a)

dilated, fragile bronchial vessels in the vicinity of a pathological lesion within the lung;

b)

non-bronchial systemic bleeding, originating from collateral vessels related to the internal thoracic, subclavian, axillary or intercostal arteries, which become ulcerated in the vicinity of pathological lesions.

Pulmonary arterial system (5-10%). The vast majority is secondary to Rasmussen aneurysms, which occur in the presence of chronic tuberculous lesions. The pulmonary artery becomes dilated and sometimes aneurysmal as a consequence of high-flow shunts developing between pulmonary and bronchial circulations. Occasionally, a lung cancer may erode into a neighbouring pulmonary artery leading to haemoptysis.

Major aortopulmonary collateral arteries (MAPCA) and arteriovenous malformations. In patients with single-ventricle circulation (especially a failing Fontan circulation), haemoptysis is thought to occur due to the loss of hepatic factor (which inhibits the neovascularisation process), when the inferior vena cava blood flow is redirected to the systemic circulation via intracardiac shunting.

6

What are the clinical features of a patient with haemoptysis?

The most obvious symptom and sign of haemoptysis is the coughing up of blood.

Other clinical features present may include fever, malaise, weight loss and clubbing, depending on the underlying cause.

7

What are the differential diagnoses of haemoptysis?

Haematemesis (vomiting of blood from the upper gastrointestinal tract) is common and is frequently confused with haemoptysis. The characteristics of the blood loss and a careful history from the patient can usually distinguish between the two (Table 2).

Pseudohaemoptysis represents a cough reflex stimulated by blood originating from neighbouring structures, including the nasopharynx and oropharynx (following an episode of epistaxis) or after aspiration of haematemesis.

8

What are the chest radiological (CXR) features of a patient with haemoptysis (Figure 1)?

In 20-40% of patients, the CXR will appear normal (Figure 1A).

In 60-80% of cases of haemoptysis, however, a plain CXR will demonstrate a cause, with common positive findings including pulmonary infiltration, cavitation or a mass (Figure 1B).

9

What are the computed tomography (CT) features of a patient with haemoptysis?

Contrast-enhanced CT images can identify and characterise all the lesions picked up on CXR and in addition can demonstrate bronchiectasis, AV malformations and aneurysms, and small intraparenchymal and endobronchial tumours (Figures 2, 3 and 4).

A CT scan should be performed before bronchoscopy, except in life-threatening situations.

10

What are the radiological features of haemoptysis on bronchial artery angiography (Figure 5)?

Using a catheter introduced retrogradely from the femoral artery into the bronchial arteries, contrast is injected to identify the source of bleeding.

A characteristic blush of extravasated contrast highlights the bleeding vessel.