Hemoptysis

The most common causes of massive hemoptysis vary by geographic region but include the following:

• Bronchogenic carcinoma

• Bronchiectasis

• TB and other pneumonias

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 medications, 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 medication profile should be reviewed for use of anticoagulants and antiplatelet drugs.

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.

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

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:

• 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.

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. Serologies for Goodpasture syndrome, granulomatosis with polyangiitis, and systemic lupus erythematosus should be obtained if these conditions are suspected. 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.

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 months of evaluation.

Initial treatment of massive hemoptysis has two objectives:

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

• Prevent exsanguination due to 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.

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 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).

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.

4).

1. 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. doi: 10.1378/chest.115.4.996

2. 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. doi: 10.1136/thorax.58.9.814

3. 3. Jean-Baptiste E: Clinical assessment and management of massive hemoptysis. Critical Care Medicine 28(5): 1642–1647, 2000. doi: 10.1097/00003246-200005000-00066

4. 4. Prutsky G, Domercq JP, Salazar CA, et al: Antifibrinolytic therapy to reduce haemoptysis from any cause. Cochrane Database Syst Rev 11(11):CD008711, 2016. doi: 10.1002/14651858.CD008711.pub3