Definition and EtiologyTop
Hemoptysis refers to expectoration of frank blood or blood-tinged sputum.
Massive hemoptysis refers to bleeding from the respiratory tract, usually >200 mL over 24 hours, which may be life-threatening and lead to respiratory failure.
Bleeding can originate from two sources: bronchial arteries or the pulmonary vasculature. Nearly the entire cardiac output traverses through the low-pressure pulmonary arteries, while the bronchial arteries are under much higher pressure but carry only a small fraction of the total cardiac output. Bleeding from high-pressure bronchial vessels is the cause, particularly in the setting of massive hemoptysis, as the bronchial arteries are the vascular supply of the large airways. Mechanisms of bleeding include:
1) Inflammation and proliferation of vessels prone to bleeding (bronchiectasis, tuberculosis).
2) Infiltration and angiogenesis in pulmonary malignancies.
3) Pulmonary vascular disorders: Increased left atrial pressure (mitral stenosis, left ventricular failure), pulmonary hypertension, pulmonary embolism.
4) Bleeding diathesis that is either congenital, acquired, or iatrogenic.
5) Parenchymal disorders including infection and inflammatory conditions including capillaritis (see Vasculitis Syndromes).
6) Neoplasm with direct invasion into bronchial arteries or pulmonary arteries.
Causes of hemoptysis:
1) Frequent causes: Bronchitis, bronchiectasis, lung cancer, bacterial pneumonia, tuberculosis (in some geographic locations).
2) Moderately frequent causes: Pulmonary embolism (thrombotic, less commonly septic and fat), left ventricular failure, aspergillosis, vasculitis including granulomatosis with polyangiitis [formerly Wegener granulomatosis], connective tissue disease (anti–glomerular basement membrane disease [formerly Goodpasture syndrome], systemic lupus erythematosus), lung trauma (including iatrogenic trauma caused by bronchoscopy, lung biopsy, chest tubes or central line insertions, and thoracotomy).
3) Rare causes: Bleeding disorder, mitral stenosis, parasitic infestations, pulmonary artery pseudoaneurysm (Rasmussen aneurysm), drugs (anticoagulant agents, fibrinolytic agents, acetylsalicylic acid, cocaine), foreign body aspiration, hemosiderosis, amyloidosis, trauma related to performing right heart catheterization.
The most frequent causes of massive hemoptysis: Malignancy, bronchiectasis, tuberculosis (TB), trauma, bleeding disorder.
1. History and physical examination: Establish the cause on the basis of:
1) Characteristics of hemoptysis and accompanying signs and symptoms:
a) Massive expectoration of blood-stained sputum is suggestive of bronchiectasis.
b) Purulent and bloody sputum: Bronchitis, bronchiectasis; if accompanied by fever, pneumonia or pulmonary abscess.
c) Pink frothy sputum: Left ventricular failure, mitral stenosis.
d) Expectoration of pure blood: Lung cancer, tuberculosis, arteriovenous malformations, pulmonary embolism.
a) Smoking, recurrent hemoptysis: Suggestive of lung cancer.
b) Sudden-onset hemoptysis with severe chest pain and dyspnea: Pulmonary embolism.
c) Chest trauma, invasive diagnostic procedures: Trauma-induced hemoptysis.
d) Vasculitis or connective tissue disease: Hemoptysis and manifestations of the underlying systemic condition.
e) Considerable weight loss: Lung cancer, tuberculosis, systemic inflammatory condition.
f) Paroxysmal nocturnal dyspnea or exertional dyspnea: Left ventricular failure, mitral stenosis.
2. Diagnostic studies:
1) Chest radiography or computed tomography (CT) depending on the suspected cause (CT angiography if pulmonary embolism is suspected). CT imaging should be considered if the patient has risk factors for lung malignancy, presence of radiographic abnormalities on chest radiography, or concerning clinical course.
2) Complete blood count (CBC) and blood coagulation tests (international normalized ratio [INR], activated partial thromboplastin time [aPTT], and other).
3) Bronchoscopy for diagnostic purposes, particularly if lung cancer, diffuse alveolar hemorrhage, or infection is suspected; therapeutic bronchoscopy (see Treatment, below).
4) Ear, nose, and throat (ENT) examination if upper respiratory tract bleeding is suspected.
5) Other tests depending on the clinical suspicion (eg, testing for tuberculosis, antinuclear antibody, extractable nuclear antigen, antineutrophil cytoplasmic antibody, glomerular basement membrane antibody, urinalysis).
1. Maintain the airway and secure IV access. Transfer the patient to a monitored unit with frequent vital signs assessment. In patients with severe shortness of breath, poor gas exchange, hemodynamic instability, or rapid ongoing bleeding, resuscitation procedures should be initiated and the patient should be intubated with a large-bore endotracheal tube. Consider placing the tube in the main bronchus of the opposite lung, allowing separate ventilation and isolation of the affected lung. Placement of a double-lumen tube is an alternative solution.
2. Start oxygen therapy. Maintain oxygen saturation (SaO2) >90%.
3. Identify which side is bleeding. If the bleeding site has been identified, place the patient in a recumbent position on the side of the affected lung.
4. Collect blood samples for blood type, cross-matching, complete blood count (CBC), and blood coagulation parameters. Perform portable chest radiography.
5. Correct any coagulation abnormalities, anemia, and hypovolemia.
6. Exclude bleeding from the upper respiratory and gastrointestinal tracts.
7. Bronchoscopy can serve both diagnostic and therapeutic purposes in the management of massive hemoptysis. First, it can identify the source of bleeding. Second, bronchoscopy techniques may assist in controlling pulmonary hemorrhage through balloon tamponade, iced saline lavage, application of topical vasoconstrictive agents, cryotherapy, and guiding double-lumen endotracheal tube positioning.
8. If bleeding persists, arteriography may be performed, which allows for diagnosis and therapeutic embolization. High-resolution CT of the chest with contrast can be performed if bronchoscopy is nondiagnostic and arteriography is not indicated (ie, bleeding has stopped).
9. Unilateral uncontrollable bleeding should warrant thoracic surgery consultation for consideration of resection of the affected lobe of the lung if the conventional measures outlined above are not successful.