Hemoptysis

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, including platelet count (and, in some cases, 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

  • Upper airway (bronchitis, bronchiectasis, malignancy)

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

  • Parenchymal (pneumonia, inhalation of crack cocaine, granulomatosis with polyangiitis, or Takayasu arteritis with pulmonary arteritis)

• Diffuse alveolar hemorrhage is due to small vessel bleeding usually due to autoimmune or hematologic disorders or rarely precipitated by hypertensive emergency or anticoagulant therapy

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 as can endometriosis

• 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

• Multidetector CTA is study of choice to determine location, etiology, and mechanism of the bleeding

• 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

• Inhaled tranexamic acid can be given to treat hemoptysis

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 ...