Hemoptysis

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

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

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

• 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

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