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 hours.
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 upper respiratory infection and viral bronchitis.
The differential diagnosis is broad (see table Some Causes of Hemoptysis).
In adults, 70 to 90% of cases are caused by
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Necrotizing pneumonia
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Tuberculosis (TB)
Primary lung cancer is an important cause in smokers ≥ 40 years, 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
Massive hemoptysis
The most common causes of massive hemoptysis have changed over time and vary by geographic region but include the following:
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TB and other pneumonias
Some Causes of Hemoptysis
Cause |
Suggestive Findings |
Diagnostic Approach* |
Tracheobronchial source |
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Acute: Productive or nonproductive cough Chronic: Cough on most days of the month or for 3 months per year for 2 successive years in patients with known COPD or smoking history |
Acute: Clinical evaluation Chronic: Chest x-ray |
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Chronic cough and mucus production in patients with a history of recurrent infections |
High-resolution chest CT Bronchoscopy |
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Broncholithiasis |
Calcified lymph nodes in patients with history of prior granulomatous disease |
Chest CT Bronchoscopy |
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Foreign body (typically chronic and undiagnosed) |
Chronic cough (typically in an infant or young child) without symptoms of an upper respiratory infection Sometimes fever |
Chest x-ray Sometimes bronchoscopy |
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Tumor (bronchogenic, bronchial, metastatic, Kaposi sarcoma) |
Night sweats Weight loss History of heavy smoking Risk factors for Kaposi sarcoma (eg, HIV infection) |
Chest x-ray CT Bronchoscopy |
Pulmonary parenchymal source |
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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 |
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Fatigue Weight loss Often hematuria Sometimes edema |
Urinalysis Creatinine levels Renal biopsy Antiglomerular basement membrane testing cANCA testing |
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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 |
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Subacute fever Cough Night sweats Anorexia Weight loss |
Chest x-ray or CT showing irregularly shaped cavity with air-fluid levels |
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Lupus pneumonitis |
Fever, cough, dyspnea, and pleuritic chest pain in patients with a history of systemic lupus erythematosus |
Chest CT (showing alveolitis) Sometimes bronchoscopy washings (showing lymphocytosis or granulocytosis) |
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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 |
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Primary vascular source |
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Aortic aneurysm with leakage into the pulmonary parenchyma |
Back pain |
Chest x-ray showing widened mediastinum Chest CT angiography |
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Arteriovenous malformation |
Presence of mucocutaneous telangiectasia or peripheral cyanosis |
Chest CT angiography Pulmonary angiography |
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Elevated pulmonary venous pressure (especially in 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 hours after falling asleep (paroxysmal nocturnal dyspnea) |
ECG BNP measurement Echocardiography |
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Pulmonary artery rupture |
Recent placement or manipulation of a pulmonary artery catheter |
Emergency chest CT angiography or emergency pulmonary angiography |
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Pulmonary embolism, causing pulmonary infarction |
Abrupt onset of sharp chest pain, increased respiratory rate and heart rate, particularly in patients with known risk factors for pulmonary embolism |
CT angiography or V/Q scanning Doppler or duplex studies of extremities showing findings of DVT |
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Tracheal-innominate artery fistula |
Placement of tracheostomy tube within the previous 3 days to 6 weeks |
Identifying hemorrhage from endotracheal tube in compatible clinical setting) |
Miscellaneous |
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Pulmonary endometriosis (catamenial hemoptysis) |
Recurrent hemoptysis during menstruation |
Sometimes therapeutic trial of oral contraceptives |
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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 myocardial infarction Sometimes a family history |
PT/PTT or anti-factor Xa levels Cessation of hemoptysis with correction of coagulation deficit |
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* All patients with hemoptysis should have chest x-ray and pulse oximetry. |
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BNP = brain (B-type) natriuretic peptide; cANCA = antineutrophil cytoplasmic antibody; COPD = chronic obstructive pulmonary disease; DVT = deep venous thrombosis; PT = prothrombin time; PTT = partial thromboplastin time; V/Q = ventilation/perfusion; WBC = white blood cell. |
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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).
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 [chronic obstructive pulmonary disease], 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 oxygen 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
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. Clinical prediction can help estimate the risk of pulmonary embolism. A normal oxygen 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:
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Known renal failure or hematuria suggests a pulmonary-renal syndrome (eg, Goodpasture syndrome, granulomatosis with polyangiitis).
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Patients with granulomatosis with polyangiitis may have nasal mucosal lesions.
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Visible telangiectasias suggest arteriovenous malformations.
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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.
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Recurrent hemoptysis coinciding with menses strongly suggests pulmonary endometriosis.
Testing
Patients with massive hemoptysis require treatment and stabilization, usually in an intensive care unit, before testing. Patients with minor hemoptysis can undergo outpatient testing.
Imaging is always done, typically chest x-ray, although sometimes (eg, with known bronchiectasis) CT is the initial test. . 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 complete blood count, a platelet count, and measurement of PT (prothrombin time) and PTT (partial thromboplastin time). 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
Treatment
Massive hemoptysis
Initial treatment of massive hemoptysis has two objectives:
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. Desmopressin is used to reverse platelet dysfunction associated with uremia and kidney disease. Tranexamic acid is an antifibrinolytic drug being increasingly used to promote hemostasis. 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% (1). 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 (2, 3).
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.
Treatment references
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1.Mal H, Rullon I, Mellot F, et al: Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 150 (4): 996–1001,1999.
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2. Lordan JL, Gascoigne A, Corris PA: The pulmonary physician in critical care. Illustrative case 7: Assessment and management of massive haemoptysis. Thorax 58: 814–819, 2003.
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3. Jean-Baptiste E: Clinical assessment and management of massive hemoptysis. Critical Care Medicine 28(5): 1642–1647, 2000.
Key Points
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Hemoptysis needs to be distinguished from hematemesis and nasopharyngeal or oropharyngeal bleeding.
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Bronchitis, bronchiectasis, tuberculosis, and necrotizing pneumonia or lung abscess are the most common causes in adults.
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Lower respiratory tract infection and foreign body aspiration are the most common causes in children.
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Patients with massive hemoptysis require treatment and stabilization before testing.
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With massive hemoptysis, if the side of bleeding is known, patients should be positioned with the affected lung in the dependent position.
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Bronchial artery embolization is the preferred treatment for massive hemoptysis.
