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Hemoptysis

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by Noah Lechtzin, MD, MHS

Hemoptysis is coughing up of blood from the respiratory tract. Massive hemoptysis is production of 600 mL of blood (about a full kidney basin’s worth) within 24 h.

Pathophysiology

Most of the lung’s blood (95%) circulates through low-pressure pulmonary arteries and ends up in the pulmonary capillary bed, where gas is exchanged. About 5% of the blood supply circulates through high-pressure bronchial arteries, which originate at the aorta and supply major airways and supporting structures. In hemoptysis, the blood generally arises from this bronchial circulation, except when pulmonary arteries are damaged by trauma, by erosion of a granulomatous or calcified lymph node or tumor, or, rarely, by pulmonary arterial catheterization or when pulmonary capillaries are affected by inflammation.

Etiology

Blood-streaked sputum is common in many minor respiratory illnesses, such as URI and viral bronchitis.

The differential diagnosis is broad (see Table: Some Causes of Hemoptysis).

In adults, 70 to 90% of cases are caused by

  • Bronchitis

  • Bronchiectasis

  • Necrotizing pneumonia

  • TB

Primary lung cancer is an important cause in smokers 40 yr, but metastatic cancer rarely causes hemoptysis. Cavitary Aspergillus infection is increasingly recognized as a cause but is not as common as cancer.

In children, common causes are

  • Lower respiratory tract infection

  • Foreign body aspiration

Massive hemoptysis

The most common causes have changed over time and vary by geographic region but include the following:

  • Bronchogenic carcinoma

  • Bronchiectasis

  • TB and other pneumonias

Some Causes of Hemoptysis

Cause

Suggestive Findings

Diagnostic Approach*

Tracheobronchial source

Tumor (bronchogenic, bronchial metastatic, Kaposi sarcoma)

Night sweats

Weight loss

History of heavy smoking

Risk factors for Kaposi sarcoma (eg, HIV)

Chest x-ray

CT

Bronchoscopy

Bronchitis (acute or chronic)

Acute: Productive or nonproductive cough

Chronic: Cough on most days of the month or for 3 mo per year for 2 successive years in patients with known COPD or smoking history

Acute: Clinical evaluation

Chronic: Chest x-ray

Bronchiectasis

Chronic cough and mucus production in patients with a history of recurrent infections

High-resolution chest CT

Bronchoscopy

Broncholithiasis

Calcified lymph nodes in patients with history of prior granulomatous disease

Chest CT

Bronchoscopy

Foreign body (typically chronic and undiagnosed)

Chronic cough (typically in an infant or young child) without URI symptoms

Sometimes fever

Chest x-ray

Sometimes bronchoscopy

Pulmonary parenchymal source

Lung abscess

Subacute fever

Cough

Night sweats

Anorexia

Weight loss

Chest x-ray or CT showing irregularly shaped cavity with air-fluid levels

Pneumonia

Fever, productive cough, dyspnea, pleuritic chest pain

Decreased breath sounds or egophony

Elevated WBC count

Chest x-ray

Blood and sputum cultures in hospitalized patients

Active granulomatous disease (tuberculous, fungal, parasitic, syphilitic) or mycetoma (fungus ball)

Fever, cough, night sweats, and weight loss in patients with known exposures

Often history of immunosuppression

Chest x-ray

Chest CT

Microbiologic testing of sputum samples or bronchoscopy washings

Goodpasture syndrome

Fatigue

Weight loss

Often hematuria

Sometimes edema

Urinalysis

Creatinine levels

Renal biopsy

Antiglomerular basement membrane testing

cANCA testing

Granulomatosis with polyangiitis (Wegener granulomatosis)

Often chronic, bloody nasal discharge and nasal ulcerations

Often joint pain and skin manifestations (nodules, purpura)

Gingival thickening and mulberry gingivitis

Saddle nose and nasal septum perforation

Sometimes renal insufficiency

Biopsy of any affected area (eg, kidney, skin) with cANCA testing and demonstration of vasculitis in small to medium-sized arteries

Bronchoscopy

Lupus pneumonitis

Fever, cough, dyspnea, and pleuritic chest pain in patients with a history of SLE

Chest CT (showing alveolitis)

Sometimes bronchoscopy washings (showing lymphocytosis or granulocytosis)

Primary vascular source

Arteriovenous malformation

Presence of mucocutaneous telangiectasia or peripheral cyanosis

Chest CT angiography

Pulmonary angiography

Pulmonary embolism

Abrupt onset of sharp chest pain, increased respiratory rate and heart rate, particularly in patients with known risk factors for pulmonary embolism (see History)

CT angiography or V/Q scanning

Doppler or duplex studies of extremities showing findings of DVT

Elevated pulmonary venous pressure (especially mitral stenosis, left-sided heart failure)

Crackles

Signs of central or peripheral volume overload (eg, elevated neck veins, peripheral edema)

Dyspnea while lying flat (orthopnea) or appearing 1–2 h after falling asleep (paroxysmal nocturnal dyspnea)

ECG

BNP measurement

Echocardiography

Aortic aneurysm with leakage into the pulmonary parenchyma

Back pain

Chest x-ray showing widened mediastinum

Chest CT angiography

Pulmonary artery rupture

Recent placement or manipulation of a pulmonary artery catheter

Emergency chest CT angiography or emergency pulmonary angiography

Tracheal-innominate artery fistula

Placement of tracheostomy tube within the previous 3 days to 6 wk

Clinical evaluation (eg, identifying hemorrhage from endotracheal tube in compatible clinical setting)

Miscellaneous

Pulmonary endometriosis (catamenial hemoptysis)

Recurrent hemoptysis during menstruation

Clinical evaluation

Sometimes therapeutic trial of oral contraceptives

Systemic coagulopathy or use of anticoagulants or thrombolytics

Patients receiving systemic anticoagulants for treatment of pulmonary embolism, DVT, or atrial fibrillation

Patients receiving thrombolytics for treatment of stroke or MI

Sometimes a family history

PT/PTT or anti-factor Xa levels

Cessation of hemoptysis with correction of coagulation deficit

*All patients with hemoptysis should have chest x-ray and pulse oximetry.

BNP = brain (B-type) natriuretic peptide; cANCA =antineutrophil cytoplasmic antibody; DVT = deep venous thrombosis; V/Q = ventilation/perfusion.

Evaluation

History

History of present illness should cover the duration and temporal patterns (eg, abrupt onset, cyclical recurrence), provoking factors (eg, allergen exposure, cold, exertion, supine position), and approximate volume of hemoptysis (eg, streaking, teaspoon, cup). Patients may need specific prompting to differentiate between true hemoptysis, pseudohemoptysis (ie, bleeding originating in the nasopharynx that is subsequently coughed up), and hematemesis. A sensation of postnasal drip or any bleeding from the nares without coughing is suggestive of pseudohemoptysis. Concomitant nausea and vomiting with black, brown, or coffee-ground–colored blood is characteristic of hematemesis. Frothy sputum, bright red blood, and (if massive) a sensation of choking are characteristic of true hemoptysis.

Review of systems should seek symptoms suggesting possible causes, including fever and sputum production (pneumonia); night sweats, weight loss, and fatigue (cancer, TB); chest pain and dyspnea (pneumonia, pulmonary embolism); leg pain and leg swelling (pulmonary embolism); hematuria (Goodpasture syndrome); and bloody nasal discharge (granulomatosis with polyangiitis [Wegener granulomatosis]).

Patients should be asked about risk factors for causes. These risk factors include HIV infection, use of immunosuppressants (TB, fungal infection); exposure to TB; long smoking history (cancer); and recent immobilization or surgery, known cancer, prior or family history of clotting, pregnancy, use of estrogen -containing drugs, and recent long-distance travel (pulmonary embolism).

Past medical history should cover known conditions that can cause hemoptysis, including chronic lung disease (eg, COPD, bronchiectasis, TB, cystic fibrosis), cancer, bleeding disorders, heart failure, thoracic aortic aneurysm, and pulmonary-renal syndromes (eg, Goodpasture syndrome, granulomatosis with polyangiitis ). Exposure to TB is important, particularly in patients with HIV infection or another immunocompromised state.

A history of frequent nosebleeds, easy bruising, or liver disease suggests possible coagulopathy. The drug profile should be reviewed for use of anticoagulants and antiplatelet drugs.

Physical examination

Vital signs are reviewed for fever, tachycardia, tachypnea, and low O 2 saturation. Constitutional signs (eg, cachexia) and level of patient distress (eg, accessory muscle use, pursed lip breathing, agitation, decreased level of consciousness) should also be noted.

A full lung examination is done, particularly including adequacy of air entry and exit, symmetry of breath sounds, and presence of crackles, rhonchi, stridor, and wheezing. Signs of consolidation (eg, egophony, dullness to percussion) should be sought. The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy (suggesting cancer or TB).

Neck veins should be inspected for distention, and the legs and presacral area should be palpated for pitting edema (suggesting heart failure). Heart sounds should be auscultated with notation of any extra heart sounds or murmur that might support a diagnosis of heart failure and elevated pulmonary pressure.

The abdominal examination should focus on signs of hepatic congestion or masses, which could suggest either cancer or hematemesis from potential esophageal varices.

The skin and mucous membranes should be examined for ecchymoses, petechiae, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa.

If the patient can reproduce hemoptysis during examination, the color and amount of blood should be noted.

Red flags

The following findings are of particular concern:

  • Massive hemoptysis

  • Back pain

  • Presence of a pulmonary artery catheter or tracheostomy

  • Malaise, weight loss, or fatigue

  • Extensive smoking history

  • Dyspnea at rest during examination or absent or decreased breath sounds

Interpretation of findings

The history and physical examination often suggest a diagnosis and guide further testing (see Table: Some Causes of Hemoptysis).

Despite the many possibilities, some generalities can be made. A previously healthy person with a normal examination and no risk factors (eg, for TB, pulmonary embolism) who presents with acute-onset cough and fever most likely has hemoptysis due to an acute respiratory illness; chronic disorders are much lower on the list of possibilities. However, if risk factors are present, those specific disorders must be strongly suspected. A clinical prediction rule (see Table: Clinical Prediction Rule for Diagnosing Pulmonary Embolism) can help estimate the risk of pulmonary embolism. A normal O 2 saturation does not exclude pulmonary embolism.

Patients whose hemoptysis is due to a lung disorder (eg, COPD, cystic fibrosis, bronchiectasis) or heart disease (eg, heart failure) typically have a clear history of those disorders. Hemoptysis is not an initial manifestation.

Patients with known immunocompromise should be suspected of having TB or a fungal infection.

Patients with symptoms or signs of chronic illness but no known disorders should be suspected of having cancer or TB, although hemoptysis can be the initial manifestation of lung cancer in a patient who is otherwise asymptomatic.

Several specific findings are of note. Known renal failure or hematuria suggests a pulmonary-renal syndrome (eg, Goodpasture syndrome, granulomatosis with polyangiitis). Patients with granulomatosis with polyangiitis may have nasal mucosal lesions. Visible telangiectasias suggest arteriovenous malformations. Patients with hemoptysis due to a bleeding disorder usually have cutaneous findings (petechiae, purpura, or both) or a history of anticoagulant or antiplatelet drug use. Recurrent hemoptysis coinciding with menses strongly suggests pulmonary endometriosis.

Testing

Patients with massive hemoptysis require treatment and stabilization, usually in an ICU, before testing. Patients with minor hemoptysis can undergo outpatient testing.

Imaging is always done. A chest x-ray is mandatory. Patients with normal results, a consistent history, and nonmassive hemoptysis can undergo empiric treatment for bronchitis. Patients with abnormal results and patients without a supporting history should undergo CT and bronchoscopy. CT may reveal pulmonary lesions that are not apparent on the chest x-ray and can help locate lesions in anticipation of bronchoscopy and biopsy. CT angiography or, less commonly, ventilation/perfusion scanning with or without pulmonary arteriography can confirm the diagnosis of pulmonary embolism. CT and pulmonary angiography can also detect pulmonary arteriovenous fistulas.

Fiberoptic inspection of the pharynx, larynx, and airways may be indicated along with esophagogastric endoscopy when the etiology is obscure to distinguish hemoptysis from hematemesis and from nasopharyngeal or oropharyngeal bleeding.

Laboratory testing is also done. Patients usually should have a CBC, a platelet count, and measurement of PT and PTT. Anti-factor Xa testing can be used to detect supratherapeutic anticoagulation in patients receiving low molecular weight heparin. Urinalysis should be done to look for signs of glomerulonephritis (hematuria, proteinuria, casts). TB skin testing and sputum culture should be done as the initial tests for active TB, but negative results do not preclude the need to induce sputum or do fiberoptic bronchoscopy to obtain samples for further acid-fast bacillus testing if an alternative diagnosis is not found.

Cryptogenic hemoptysis

The cause of hemoptysis remains unknown in 30 to 40% of patients, but the prognosis for patients with cryptogenic hemoptysis is generally favorable, usually with resolution of bleeding within 6 mo of evaluation.

Treatment

Massive hemoptysis

Initial treatment of massive hemoptysis has two objectives:

  • Prevent aspiration of blood into the uninvolved lung (which can cause asphyxiation)

  • Prevent exsanguination from ongoing bleeding

It can be difficult to protect the uninvolved lung because it is often initially unclear which side is bleeding. Once the bleeding side is identified, strategies include positioning the patient with the bleeding lung in a dependent position and selectively intubating the uninvolved lung and/or obstructing the bronchus going to the bleeding lung.

Prevention of exsanguination involves reversal of any bleeding diathesis and direct efforts to stop the bleeding. Clotting deficiencies can be reversed with fresh frozen plasma and factor-specific or platelet transfusions. Laser therapy, cauterization, or direct injection with epinephrine or vasopressin can be done bronchoscopically.

Massive hemoptysis is one of the few indications for rigid (as opposed to flexible) bronchoscopy, which provides control of the airway, allows for a larger field of view than flexible bronchoscopy, allows better suctioning, and is more suited to therapeutic interventions, such as laser therapy.

Embolization via bronchial artery angiography is becoming the preferred method with which to stop massive hemoptysis, with reported success rates of up to 90%. Emergency surgery is indicated for massive hemoptysis not controlled by rigid bronchoscopy or embolization and is generally considered a last resort.

Once a diagnosis is made, further treatment is directed at the cause.

Minor hemoptysis

Treatment of minor hemoptysis is directed at the cause.

Early resection may be indicated for bronchial adenoma or carcinoma. Broncholithiasis (erosion of a calcified lymph node into an adjacent bronchus) may require pulmonary resection if the stone cannot be removed via rigid bronchoscopy. Bleeding secondary to heart failure or mitral stenosis usually responds to specific therapy for heart failure. In rare cases, emergency mitral valvulotomy is necessary for life-threatening hemoptysis due to mitral stenosis.

Bleeding from a pulmonary embolism is rarely massive and almost always stops spontaneously. If emboli recur and bleeding persists, anticoagulation may be contraindicated, and placement of an inferior vena cava filter is the treatment of choice.

Because bleeding from bronchiectatic areas usually results from infection, treatment of the infection with appropriate antibiotics and postural drainage is essential.

Key Points

  • Hemoptysis needs to be distinguished from hematemesis and nasopharyngeal or oropharyngeal bleeding.

  • Bronchitis, bronchiectasis, TB, and necrotizing pneumonia or lung abscess are the most common causes in adults.

  • Lower respiratory tract infection and foreign body aspiration are the most common causes in children.

  • Patients with massive hemoptysis require treatment and stabilization before testing.

  • With massive hemoptysis, if the side of bleeding is known, patients should be positioned with the affected lung in the dependent position.

  • Bronchial artery embolization is the preferred treatment for massive hemoptysis.

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  • PANHEPRIN
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  • VASOSTRICT

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