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A 35-year-old man with history of chronic cough comes to your office and is very concerned after having 2 episodes of prolonged coughing that produced blood-streaked sputum. He also reports subjective fever for 4 days and cough productive of yellow sputum. This is the first time he has experienced this constellation of symptoms.

  • What additional questions would you ask to learn more about his hemoptysis?
  • How would you classify his hemoptysis in terms of quantity?
  • Can you make a definite diagnosis through an open-ended history followed by focused questions?
  • What are the alarm features when evaluating a patient with hemoptysis?

Hemoptysis is the expectoration of blood or blood-stained sputum. It implies that the blood originates from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage.1 The blood supply to the lungs is derived from the pulmonary and bronchial arterial systems. The low-pressure pulmonary arterial system tends to produce small-volume hemoptysis, whereas bleeding from the bronchial arterial system, which is more common, tends to be profuse. However, it may be difficult to differentiate hemoptysis from bleeding from the upper gastrointestinal tract or upper airway. Based on the amount of blood expectorated, hemoptysis can be classified as scant or mild, submassive or moderate, and massive or severe.2–4

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Scant (mild) hemoptysisLess than 20 mL (less than a tablespoon) in 24 hours. Blood streaks usually noted with expectorated phlegm.
Submassive (moderate) hemoptysisBetween 20 and 250 mL (less than a cup) in 24 hours.
Massive (severe) hemoptysisMore than 250 mL (more than a cup) in 24 hours.
Cryptogenic or idiopathic hemoptysisNo cause is found after extensive diagnostic evaluation.

See References 1–4

There are more than 100 causes of hemoptysis. In the primary care setting, the most common causes of hemoptysis are acute and chronic bronchitis, pneumonia, tuberculosis, and lung cancer.4 Other important causes include bronchiectasis, pulmonary embolism, trauma, fungal infections, foreign bodies, and rheumatologic diseases such as systemic lupus erythematosus, Goodpasture's syndrome, and antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis. Bronchitis is still considered the most common cause of hemoptysis, but it rarely causes massive hemoptysis. Although massive hemoptysis accounts for only 5% to 15% of episodes, it is a true medical emergency that requires intensive care with immediate evaluation for the underlying cause.5

Differential Diagnosis1–4

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Lung cancer15%–30%

  • To determine the likely etiology of hemoptysis, consider the amount of blood expectorated, duration of symptoms, and the patient's age, smoking history, and past medical history.
  • Differentiate between true hemoptysis versus bleeding from the upper airway or gastrointestinal tract.
  • Review medications known to cause or exacerbate bleeding including aspirin and nonsteroidal anti-inflammatory drugs, anticoagulants (warfarin and heparin), and chemotherapeutic agents (which may cause thrombocytopenia).
  • ...

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