Hemoptysis
Daniel R. Crouch
Tonya D. Russell
General Principles
Definition
Hemoptysis refers to the expectoration of blood originating from the lower airway or lung.
Massive hemoptysis is defined as the expectoration of large amounts of blood.
There is no consensus on the volume of blood needed to be classified as massive but definitions range from 100 to > 600 mL over a 24-hour period.
Massive hemoptysis can be life threatening and should be considered a medical emergency. Death is usually from asphyxiation or exsanguination with flooding of the alveoli resulting in refractory hypoxemia.
Massive hemoptysis accounts for about 1–5% of all patients presenting with hemoptysis.
The most common causes of hemoptysis in the United States are bronchitis, bronchiectasis, bronchogenic carcinoma, TB, and pneumonia.
The pulmonary circulation consists of dual blood supplies: the pulmonary and bronchial artery systems.
The pulmonary artery system is a low-pressure system with pressures of 15–20/5–10 mm Hg. It delivers blood from the right ventricle to the pulmonary capillary beds for oxygenation and returns it to the left atrium via the pulmonary veins.
The bronchial arteries arise from the aorta and thus exhibit systemic pressures. There are one or two bronchial arteries per lung and these arteries are the main source of nutrients and oxygenation of the lung tissue and hilar lymph nodes.
In patients with normal pulmonary artery pressures, bleeding from the pulmonary arterial system only accounts for ∼5% of massive hemoptysis cases.
Mortality risk factors identified for in-hospital mortality include mechanical ventilation, pulmonary artery bleeding, cancer, aspergillosis, chronic alcoholism, and an admission CXR with infiltrates in more than two quadrants.1
Diagnosis
A thorough history, physical examination, and laboratory evaluation can help determine the correct etiology of the hemoptysis and clarify the best diagnostic procedure.
Processes that could be confused with hemoptysis, such as hematemesis or bleeding from the upper airway, must first be eliminated.
Clinical Presentation
Important historical points to cover include prior lung, cardiac, or renal disease, history of smoking cigarettes, prior hemoptysis, pulmonary symptoms, infectious symptoms, family history of hemoptysis or brain aneurysms (hereditary hemorrhagic telangiectasia), chemical exposures (asbestos, organic chemicals), travel history, TB exposures, bleeding disorders, use of anticoagulants or antiplatelet agents, and gastrointestinal or upper airway complaints.
Signs that may aid in diagnosis include telangiectasias (hereditary hemorrhagic telangiectasia), skin rashes (vasculitis, rheumatologic diseases, infective endocarditis), splinter hemorrhages (endocarditis, vasculitis), clubbing (chronic lung disease, carcinoma), bruits that increase with inspiration (large arteriovenous [AV] malformations), cardiac murmurs (endocarditis, mitral stenosis, congenital heart disease), and lower extremity edema (deep vein thrombosis).
Differential Diagnosis
The differential diagnosis of hemoptysis is presented in Table 18-1 (also see Chapter 19).
Diagnostic Testing
Laboratories
Complete blood count: to assess the magnitude and acuity of bleeding and for thrombocytopenia.
Renal function and urinalysis: to look for evidence of pulmonary-renal syndromes.
TABLE 18-1 CAUSES OF HEMOPTYSIS
Infection
Bronchitis
Endocarditis
Lung abscess
Mycetoma
Pneumonia (viral, tuberculous, fungal, necrotizing)
Malignancy
Primary bronchogenic carcinoma
Kaposi sarcoma
Lung metastases
Pulmonary
Bronchiectasis
Bullous emphysema
Cystic fibrosis
Trauma/foreign body
Broncholithiasis
Direct lung trauma
Foreign body
Tracheovascular fistula
Cardiac/pulmonary vascular
Arteriovenous malformation
Endocarditis
Mitral stenosis
Pulmonary artery rupture
Pulmonary embolism/infarction
Miscellaneous
Amyloidosis
Cryptogenic
Endometriosis
Alveolar hemorrhage
Vasculitis
Behçet syndrome
Goodpasture syndrome
Granulomatosis with polyangiitis (Wegener granulomatosis)
Henoch–Schönlein purpura
Microscopic polyangiitis
Rheumatologic
Rheumatoid arthritis
Systemic sclerosis
Systemic lupus erythematosus
Hematologic
Antiphospholipid antibody syndrome
Autologous or allogeneic stem cell transplant
Coagulopathy
Medication/drugs/toxin exposure (penicillamine, cytotoxics, nitrofurantoin, amiodarone, retinoic acid, crack cocaine, solvents)
Idiopathic pulmonary hemosiderosis
Coagulation profile: to assess for the presence of a coagulopathy.
Pulse oximetry and an arterial blood gas: to assess oxygenation.
Imaging
The three traditional methods of evaluating the etiology of hemoptysis include CXR, CT scan, and bronchoscopy.
Performing a CXR first is reasonable for the majority of patients. Findings may lead to at least localization of the site of bleeding.
A negative CXR may not be very helpful, depending on the clinical picture. For example, a nonsmoking young patient with a relatively small amount of transient hemoptysis in the setting of acute bronchitis and a normal CXR likely does not require further evaluation.
In other patients a normal CXR does not eliminate the possibility of a serious cause, including malignancy.2
Further imaging (usually CT scan) is appropriate in patients with hemoptysis >30 mL or >40 years old and >30 pack-years of smoking, persistent/recurrent hemoptysis <30 mL and >40 years old or >30 pack-years of smoking, and in patients with massive hemoptysis (>300–400 mL).2,3,4,5,6
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