Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 2-04: Hemoptysis + Key Features Download Section PDF Listen +++ +++ 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, including platelet count (and, in some cases, prothrombin time (PT)/international normalized ratio (INR) and activated partial thromboplastin time) +++ General Considerations ++ Massive hemoptysis > 200–600 mL (about 1–2 cups) of blood/24 hours Hemodynamic or airway compromise Causes can be classified anatomically Trachea (malignant invasion) Airway (COPD, bronchiectasis, bronchial Dieulafoy disease, and bronchogenic carcinoma) 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 Amyloidosis of the lung can cause hemoptysis No cause is identified in 15–30% of cases + Clinical Findings Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ ++ Compared to placebo (normal saline), inhaled tranexamic acid (an antifibrinolytic drug) Resolved mild hemoptysis within 5 days of hospital admission Shortened mean hospital length of stay Reduced the number of required invasive procedures (interventional bronchoscopy) +++ 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 Download Section PDF Listen +++ +++ 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 for severe coagulopathy complicating management +++ When to Admit ++ To stabilize bleeding process in patients at risk for or experiencing massive hemoptysis To correct disordered coagulation (using clotting factors or platelets, or both) To stabilize gas exchange + References Download Section PDF Listen +++ + +Davidson K et al. Managing massive hemoptysis. Chest. 2020 Jan;157(1):77–88. [PubMed: 31374211] + +Ittrich H et al. The diagnosis and treatment of hemoptysis. Dtsch Arztebl Int. 2017 Jun 5;114(21):371–81. [PubMed: 28625277] + +Jiménez-Zarazúa O et al. Alveolar hemorrhage associated with cocaine consumption. Heart Lung. 2018 Sep–Oct;47(5):525–30. [PubMed: 29958695] + +Nasser M et al. Alveolar hemorrhage in vasculitis (primary and secondary). Semin Respir Crit Care Med. 2018 Aug;39(4):482–93. [PubMed: 30404115] + +Torbiarczyk JM et al. Is bronchoscopy always justified in diagnosis of haemoptysis? Adv Respir Med. 2018;86(1):13–6. [PubMed: 29490417] + +Wand O et al. Inhaled tranexamic acid for hemoptysis treatment: a randomized controlled trial. Chest. 2018 Dec;154(6):1379–84. [PubMed: 30321510]