Hemoptysis

SALVA, WAILEA FAYE C.

Hemoptysis refers to expectoration of blood from the respiratory tract. Most commonly, it arises
from bronchi or medium-sized airways. Bleeding in the lungs are most likely due to the bronchial
arteries, since they are subjected under systemic pressure. They also have the ability to
neovascularize tumors, dilate airways of bronchiectasis, and cavitary lesions.

Causes of hemoptysis can be generalized as infectious, vascular and mechanical. Some of these
etiologies are discussed in the table below:

ETIOLOGY MECHANISM PERTINENT INFO

INFECTIONS
Chronic bronchitis Airway inflammation predisposes to bleeding Chronic cough
Bronchiectasis Airway inflammation predisposes to bleeding Blood-streaked sputum
Life-threatening bleeding may be due to a Chronic cough
ruptured blood vessel (i.e. bronchial artery) Industrialized countries
Tuberculosis Cavitary lesions, or less frequently, erosion of Fever, night sweats, chest pain,
pulmonary artery aneurysm into an existing chronic cough
cavity (i.e. Rasmussen aneurysm) Developing countries
Aspergillus infection Neovascularization in preexisting cavities Fatigue and weight loss
(usually in lung apices) Negative tests for TB
Most patients have prior lung damage/disease
Pulmonary abscess Devitalization of lung parenchyma, or rupture Indolent symptoms that evolve
Necrotizing pneumonia of hypertrophied vessels due to inflammation over a period of weeks or month
Paragonimiasis Invasion of lung parenchyma by the flukes Ingestion of crayfish
Endemic in SE Asia and China
VASCULAR
Pulmonary edema Increased LV end-diastolic pressure Pink frothy sputum
Pulmonary infarction Ischemic parenchymal necrosis in pulmonary (rarely presents with hemoptysis)
embolism
Diffuse alveolar Disruption of the alveolar-capillary basement Ask for SLE, cocaine use, stem cell
hemorrhage membrane, and eventual bleeding use, etc.
To consider systemic vasculitides, pulmonary- Hematuria – renal involvement
renal syndromes, rheumatic diseases, etc.
MALIGNANCY Bronchial artery involvement Risk factors for malignancy, such
(Bronchogenic CA) Life-threatening bleeding may be heralded by as > 40 y/o and history of smoking
prior smaller, sentinel bleeding events
MECHANICAL AND OTHER CAUSES
Pulmonary Ectopic endometrial tissue outside the Recurrent hemoptysis that
endometriosis confines of uterine cavity and musculature coincides with menses
 Foreign body aspiration Bleeding due to airway irritation or direct Risk factors in history
trauma
Iatrogenic Pulmonary vein stenosis, artery rupture Ask for history of interventions
Minor insults can cause bleeding in those with and risk factors for bleeding
thrombocytopenia, coagulopathy, diathesis
anticoagulation, or antiplatelet therapy

Approach to the Patient with Hemoptysis

In a patient that presents with hemoptysis, it is important to rule out bleeding from the
oropharynx or the GI tract, especially since they both require different diagnostic workup and
therapeutic plans. Ask the patient to estimate the amount of bleeding in cups (1 cup = 236 mL)
to gauge the urgency of his/her condition. If the patient claims to have an estimate of more than
400 mL within the last 24 hours, or at least 100 to 150 mL in a single expectoration, it is classified
as a massive hemoptysis. This is a medical emergency, since patients are more likely to succumb
from asphyxiation due to “drowning” in aspirated blood than from exsanguination. Other key
points to ask in the history are the following:
1. Sputum characteristics (blood-tinged, purulent, pink frothy, or pure blood)
2. Previous episodes and recurrences (t/c catamenial if with monthly patterns)
3. Triggers (i.e. occupational hazard)
4. RTI symptoms (fever, chills, dyspnea to consider infectious etiology)
5. Smoking and unintentional weight loss (t/c malignancy)
6. Malignancy (or treatment of), rheumatologic, or other vascular diseases
7. Illicit substance use (i.e. cocaine)
8. Risk factors for venous thromboembolism
9. Renal insufficiency

The physical examination should start with vital signs and oxygenation. Tachycardia,
hypotension, and decreased oxygen saturation warrants a more expedited evaluation. Cardiac
and respiratory systems should be given more focus, but one must also check for presence of
bleeding diatheses, such as ecchymoses and petechiae. Here are some key points to look out for:
1. General Survey
a. Vital signs and oxygen saturation
b. Signs of respiratory distress (cyanosis, unable to speak in full sentences, etc.)
2. Skin, HEENT and extremities
a. Skin rash (t/c vasculitides)
b. Ecchymoses, petechiae, or telangectasia (t/c bleeding diatheses)
c. Conjunctival or splinter hemorrhages (t/c endocarditis, vasculitides)
d. Finger clubbing (t/c malignancy)
 e. Symmetric VS asymmetric edema of lower extremities
3. CVS and Respiratory
a. Adventitious breath sounds (i.e. wheezes, rales, stridor)
b. Bruit or murmur that increases with inspiration (t/c AV malformation)
c. Tricuspid regurgitation, augmented P2 (t/c pulmonary hypertension)
d. Other heart murmurs

Initial workup consists of the following: (1) CBC to rule out anemia, infection or
thrombocytopenia; (2) coagulation studies; (3) electrolyte panel; and (4) serum creatinine and
urinalysis to check for renal involvement. Chest radiograph is the preferred initial imaging, but a
chest CT scan is ordered for those with risk factors for malignancy, followed by flexible
bronchoscopy to exclude bronchogenic carcinoma.

Management of hemoptysis should be individualized for each patient, and is relatively

dependent on the stability of the patient. For massive bleeding, there are three main goals:
1. Protection of the airway and non-bleeding lung
a. Lateral decubitus position, with the bleeding side down (gravitational advantage)
b. Double-lumen endotracheal tubes should be used sparingly
2. Locating the lesion via CT angiography or flexible bronchoscopy
3. Control of bleeding
a. Bronchoscopy – temporizing effect only
b. Bronchial artery embolization – procedure of choice for massive hemoptysis
c. Surgical resection if all else fails

The approach to hemoptysis is summarized in an algorithm on the next page.

 HEMOPTYSIS

History
Exclude bleeding from oropharynx or GI tract
Amount of bleed; other specific questions

Physical Examination
Vital signs and O2 sat% → CVS and Respiratory
Expedite PE if ↑HR and ↓ BP and desaturation
*Massive hemoptysis defined as:
400 mL within the last 24 hours
100 to 150 mL in a single expectoration

Non-massive Massive hemoptysis*

Secure airway and restore

No risk factors With risk factors hemodynamic stability
Position w/ bleeding side down

Chest X-ray CBC, electrolytes,

PT/APTT, SCr, U/A
Flexible bronchoscopy
Chest CT if stable
Consider infectious
etiology, especially in Chest CT followed by
patients that present bronchoscopy
CT Angiography
with fever, chills,
dyspnea, etc.
Consider malignancy,
bronchiectasis, masses
or other parenchymal Controlled bleed Uncontrolled bleed
Treat underlying cause
lesions

Definitive Tx based on Consider surgical

If bleeding persists etiology options
Treat underlying cause

If bleeding persists

References:
1. Jameson et al., Harrison’s Principles of Internal Medicine. 20th. ed. McGraw Hill; 2018. p. 232-234
2. Kassutto SM, Weinberger SE. Evaluation of non-life threatening hemoptysis in adults. UpToDate; 2019 December 17 (cited 09
September 2020). Available from: https://www.uptodate.com/contents/evaluation-of-nonlife-threatening-hemoptysis-in-
adults?search=hemoptysis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H296832433
3. Ingbar DH, Dincer HE. Evaluation and management of life-threatening hemoptysis. UpToDate; 2020 January 31 (cited 09
September 2020). Available from: https://www.uptodate.com/contents/evaluation-and-management-of-life-threatening-
hemoptysis?search=hemoptysis&topicRef=15663&source=see_link
4. Earwood JS, Thompson TD. Hemoptysis: Evaluation and management. Am Fam Physician. 2015 Feb 15;91(4):243-249.