Chapter 66

Hemoptysis is coughing of blood that originates from the respiratory tract below the level of the larynx. The causes of hemoptysis vary from simple bronchitis to life-threatening pulmonary embolism. Most causes are not life-threatening, but the symptoms are quite frightening to patients. Hemoptysis is an “alarm” symptom for possible lung cancer and requires investigation in older smokers in whom the PPV for cancer is highest.1 Even with careful evaluation, a cause is not identified in up to 25% of cases.

Priorities in the evaluation of hemoptysis are:

• Ensuring adequate oxygenation and ventilation
• Confirming a pulmonary source of bleeding
• Attempting to identify the cause of hemoptysis through appropriate diagnostic evaluation
• Appropriate disposition

The true incidence of hemoptysis is unknown because many cases are unreported. Causes of hemoptysis vary with when the data were collected, types of investigations performed, and geographic demographics of the population studied.2 Before the 1960s, most cases of hemoptysis were caused by active tuberculosis (followed by bronchiectasis, often from tuberculosis) and lung neoplasia. In Western countries, bronchitis, pneumonia, and lung neoplasia are now common causes of hemoptysis.3 In underdeveloped countries, tuberculosis and bronchiectasis predominate.

Table 66-1 lists disorders associated with hemoptysis. Unusual causes of note for the ED include crack cocaine inhalation–induced pulmonary hemorrhage,4 warfarin (Coumadin) and glycoprotein IIb/IIIa inhibitor–induced bleeding,5 hemoptysis from thrombolytics,6 catamenial hemoptysis associated with menses (which can also cause pneumothorax),7 and postprocedure complications of pulmonary artery catheterization,8 bronchoscopy, or lung biopsy. Cardiovascular causes, such as congestive heart failure and mitral stenosis, account for about 3% of cases. Hemoptysis from trauma can be due to pulmonary contusion, airway injury, or coagulopathy.9 When no cause for hemoptysis is identified, a small number of patients may eventually develop malignancy.10

Table 66-1 Disorders Associated with Hemoptysis

Hemoptysis has a 60:40 male predominance and occurs in all age groups. Male gender, age >40 years old, and history of smoking are risk factors for a neoplastic cause of hemoptysis.11 Hemoptysis in children is rare and most often due to cystic fibrosis, foreign body aspiration, congenital heart disease, infection (pneumonia, tracheobronchitis), pulmonary-renal syndromes, child abuse (accidental and deliberate suffocation), and tracheostomy complications.12

The lung ...

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