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Key Features

Essentials of Diagnosis

  • Inquire about

    • Fever

    • Cough, and other symptoms of lower respiratory tract infection

    • Smoking history

    • Nasopharyngeal or gastrointestinal bleeding

    • Chest radiography and complete blood count (and, in some cases, prothrombin time (PT)/international normalized ratio (INR)

General Considerations

  • Massive hemoptysis

    • > 200–600 mL (about 1–2 cups) of blood/24 hours

    • Hemodynamic or airway compromise

  • Causes can be classified anatomically

    • Airway (bronchitis, bronchiectasis, malignancy)

    • Pulmonary vasculature (left ventricular failure, mitral stenosis, pulmonary embolism, pulmonary arterial hypertension, arteriovenous malformation [AVM])

    • Parenchymal (pneumonia, inhalation of crack cocaine, or autoimmune diseases)

  • Diffuse alveolar hemorrhage is due to small vessel bleeding usually due to autoimmune or hematologic disorders or rarely precipitated by warfarin

Demographics

  • Up to 20% of cases among the elderly are due to lung cancer

  • Less than 10% of cases are due to pulmonary venous hypertension (eg, mitral stenosis, pulmonary embolism)

  • Most cases that have no visible cause on CT scan or bronchoscopy resolve within 6 months without treatment

  • Iatrogenic hemorrhage may follow transbronchial lung biopsies, anticoagulation, or pulmonary artery rupture due to distal placement of a balloon-tipped catheter

  • No cause is identified in 15–30% of cases

Clinical Findings

Symptoms and Signs

  • Blood-tinged sputum to frank blood

  • Dyspnea may be mild or severe

  • Hypoxemia may be present

  • Elevated pulse, hypotension, and decreased oxygen saturation suggest large volume hemorrhage

  • The nares and oropharynx should be carefully inspected to identify a potential upper airway source of bleeding

  • Chest and cardiac examination may reveal evidence of heart failure or mitral stenosis

Diagnosis

Laboratory Tests

  • Complete blood count

  • Coagulation studies (platelet count, PT/INR, activated partial thromboplastin time)

  • Kidney function tests, urinalysis

Imaging Studies

  • Chest radiograph may demonstrate the cause; alveolar infiltrates seen in diffuse alveolar hemorrhage

  • High-resolution CT of the chest can diagnose bronchiectasis and AVM as well as many malignancies and other disorders

  • Bronchoscopy is indicated when there is a suspicion of malignancy or a normal chest radiograph

  • Echocardiography may reveal evidence of heart failure or mitral stenosis

Treatment

  • Antifibrinolytics may reduce the duration of bleeding, but evidence is limited

Therapeutic Procedures

  • In massive hemoptysis, airway protection and circulatory support are first steps

  • Patients should be placed in a decubitus position with the affected lung down

  • Rigid bronchoscopy and surgical consultation are necessary in uncontrollable hemorrhage

  • Bronchoscopy and angiography can localize lesions

  • Angiographic embolization is initially effective in 85% of cases, although 20% rebleed in 1 year

Outcome

When to Refer

  • Refer to pulmonologist when bronchoscopy of lower respiratory tract is needed

  • Refer to otolaryngologist for evaluation of upper respiratory tract bleeding source

  • Refer to hematologist ...

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