Approach to hemoptysis

• Hemoptysis is the expectoration of blood from

the respiratory tract. Bleeding from the
gastrointestinal tract (hematemesis) or nasal
cavities (epistaxis) can mimic hemoptysis. Once
established as hemoptysis, the degree of blood
that is being expectorated (volume and
frequency) is the next step as massive or life-
threatening hemoptysis (>400 mL of blood in 24
h or >150 mL at one time) requires emergent
intervention. This chapter will focus
predominantly on non–life-threatening
hemoptysis. The source of the bleeding as well
as the cause are the next steps when
approaching a patient with hemoptysis.
ANATOMY AND PHYSIOLOGY OF HEMOPTYSIS

Hemoptysis can arise from anywhere in the respiratory tract, from the
glottis to the alveolus. Most commonly, bleeding arises from the bronchi
or medium-sized airways, but a thorough evaluation of the entire
respiratory tree is important.

The dual blood supply of the lungs makes it unique. The lungs have
both the pulmonary and bronchial circulations. The pulmonary
circulation is a low-pressure system that is essential for gas exchange
at the alveolar level; in contrast, the bronchial circulation originates
from the aorta and, therefore, is a higher-pressure system. The
bronchial arteries supply the airways and can neovascularize tumors,
dilated airways of bronchiectasis, and cavitary lesions. Most
hemoptysis originates from the bronchial circulation, and bleeding
from the higher-pressure system makes it more difficult to stop.
ETIOLOGY

Hemoptysis commonly results from infection, malignancy, or vascular disease; In the United
States, the most common causes are viral bronchitis, bronchiectasis, or malignancy. In other
parts of the world, infections such as tuberculosis are the most common causes.

Infections

Most blood-tinged sputum and small-volume hemoptysis are due to viral bronchitis. Patients with
chronic bronchitis are at risk for bacterial superinfection with organisms such as Streptococcus
pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis, increasing airway inflammation
and potential for bleeding. Similarly, patients with bronchiectasis are prone to hemoptysis during
exacerbations. Due to recurrent bacterial infection, bronchiectatic airways are dilated, inflamed,
and highly vascular, supplied by the bronchial circulation. Tuberculosis had long been the most
common cause of hemoptysis worldwide, but it is now surpassed in industrialized countries by
bronchitis and bronchiectasis. In patients with tuberculosis, development of cavitary disease is
frequently the source of bleeding, but rarer complications such as the erosion of a pulmonary
artery aneurysm into a preexisting cavity (i.e., Rasmussen’s aneurysm) can also be the source.

Other infectious agents such as endemic fungi, Nocardia, and nontuberculous mycobacteria can
present as cavitary lung disease complicated by hemoptysis. In addition, Aspergillus species can
develop into mycetomas within preexisting cavities, with neovascularization to these inflamed
spaces leading to bleeding. Pulmonary abscesses and necrotizing pneumonia can cause
bleeding by devitalizing lung parenchyma. Common responsible organisms include
Staphylococcus aureus, Klebsiella pneumoniae, and oral anaerobes.
Vascular

Hemoptysis from a vascular cause can be associated with cardiac disease, pulmonary
embolism, arteriovenous malformation, or diffuse alveolar hemorrhage (DAH). While the
classic description of the sputum expectorated in pulmonary edema (from elevated left
end-diastolic pressure) is “pink and frothy,” a spectrum of hemoptysis including frank
blood can be seen. This observation is particularly true now with the more widespread
use of anticoagulants and antiplatelet medications.

Pulmonary embolism with parenchymal infarction can present with

hemoptysis, but pulmonary emboli do not commonly cause
hemoptysis. An ectatic vessel in an airway or a pulmonary
arteriovenous malformation can be a source of bleeding. A rare
vascular cause of hemoptysis is the rupture of an aortobronchial
fistula; these fistulae arise in the setting of aortic pathology such as
aneurysm or pseudoaneurysm and can cause small bleeding
episodes that herald massive hemoptysis.

DAH causes significant bleeding into the lung parenchyma but,

interestingly, is not often associated with hemoptysis. DAH typically
presents with diffuse ground glass opacities on chest imaging. A
range of insults cause DAH, including immune-mediated capillaritis
from diseases such as systemic lupus erythematosus
pulmonary-renal” syndromes, including granulomatosis with
polyangiitis and anti-glomerular basement membrane disease,
may lead to both hemoptysis and hematuria (though one
manifestation may be present without the other). A recently
identified cause of hemoptysis and DAH is vaping-induced lung
injury.
Malignancy

Bronchogenic carcinoma of any histology is a common cause of

hemoptysis (both massive and nonmassive). Hemoptysis can indicate
airway involvement of the tumor and can be a presenting symptom of
carcinoid tumors, vascular lesions that frequently arise in the proximal
airways. Small cell and squamous cell carcinomas are frequently central
in nature and more likely to erode into major pulmonary vessels,
resulting in massive hemoptysis. Pulmonary metastases from distant
tumors (e.g., melanoma, sarcoma, adenocarcinomas of the breast and
colon) can also cause bleeding
 Mechanical and Other Causes:

Pulmonary endometriosis causes cyclical bleeding

known as catamenial hemoptysis

n body aspiration can lead to airway irritation and bleeding.

Diagnostic and therapeutic procedures

, coagulopathy, anticoagulation, or antiplatelet therapy, even minor insults
can cause hemoptysis.
EVALUATION AND MANAGEMENT History The amount or
severity of bleeding is the first step in assessing a patient with
hemoptysis. A patient’s description of the sputum (e.g., flecks of
blood, pink-tinged, or frank blood or clot) is helpful if you cannot
examine it.

While there is no agreed-upon volume, blood loss of 400 mL in 24 h or

100–150 mL expectorated at one time should be considered life-threatening
hemoptysis. These numbers derive from the blood volume of the
tracheobronchial tree (generally 100–200 mL). Patients rarely die of
exsanguination but, rather, are at risk of death due to asphyxiation from
blood filling the airways and airspaces. Most patients cannot describe the
volume of their hemoptysis in milliliters, so using referents like cups (one
U.S. cup is 236 mL) can be helpful. Fortunately, life-threatening hemoptysis
only accounts for 5–15% of cases of hemoptysis.

The history may point to the cause of hemoptysis. Fever, chills, or

antecedent cough may suggest infection. A history of smoking or
unintentional weight loss makes malignancy more likely. Patients should be
asked about inhalational exposures, including vaping. A thorough medical
history with careful attention to chronic pulmonary disease should be
obtained, with evaluation of risk factors for malignancy and bronchiectatic
lung disease (e.g., cystic fibrosis, sarcoidosis).
Physical Examination

Reviewing the vital signs is an important first step. Patients who

have life-threatening hemoptysis can have hypoxemia,
tachycardia, and hemodynamic instability. As the site of bleeding is
important, evaluation of the nasal and oral cavities is imperative. In
addition, auscultation of the lungs and seeking other relevant
physical findings such as clubbing can point to a cause of the
hemoptysis. A focal area of wheezing could suggest a foreign body
aspiration. Other signs of a bleeding diathesis (e.g., skin or
mucosal ecchymoses and petechiae) or telangiectasias may
suggest other etiologies of the hemoptysis.
Diagnostic Studies

Initial studies should include measurement of a complete blood count to assess

for infection, anemia, or thrombocytopenia; coagulation parameters;
measurement of electrolytes and renal function; and urinalysis to exclude
pulmonary-renal disease. Chest imaging is necessary for every patient.

A chest radiograph is usually obtained first, although it frequently does not

localize bleeding and can appear normal. In patients without risk factors for
malignancy or other abnormalities in the initial evaluation and with a normal
chest radiograph, treating for bronchitis and ensuring close follow-up is a
reasonable strategy, with further diagnostic workup.
In contrast, patients with risk factors for malignancy (i.e., age >40 or a
smoking history) should undergo additional testing. First, chest
computed tomography (CT) with contrast should be obtained to better
identify masses, bronchiectasis, and parenchymal lesions. A CT
looking for pulmonary embolism should be considered if the history
and physical examination are consistent with that diagnosis. Following
a CT, a flexible bronchoscopy should be performed to exclude
bronchogenic carcinoma unless imaging reveals a lesion that can be
sampled without bronchoscopy. Small case series show that patients
with hemoptysis and unrevealing bronchoscopies have good
outcomes.
Interventions

When the amount of hemoptysis is massive or lifethreatening, there are

three simultaneous goals: first, protect the nonbleeding lung; second, locate
the site of bleeding; and third, control the bleeding

1-Protecting the airway and nonbleeding lung is paramount in the

management of massive hemoptysis because asphyxiation can happen
quickly. If the side of bleeding is known, the patient should be positioned
with the bleeding side down to use gravitational advantage to keep blood
out of the nonbleeding lung. Endotracheal intubation should be avoided
unless truly necessary, since suctioning through an endotracheal tube is a
less effective means of removing blood and clot than the cough reflex. If
intubation is required, take steps to protect the nonbleeding lung either by
selective intubation of one lung (i.e., the nonbleeding lung) or insertion of
a double-lumen endotracheal tube.
2-Locating the bleeding site is sometimes obvious, but frequently, it can be
difficult to determine. A chest radiograph, if it shows new opacities, can be
helpful in localizing the side or site of bleeding, although this test is not
adequate by itself. CT angiography helps by localizing active extravasation.
Flexible bronchoscopy may be useful to identify the side of bleeding (although it
has only a 50% chance of locating the site). Experts do not agree on the timing
of bronchoscopy, although in some cases—cystic fibrosis, for instance—
bronchoscopy is not recommended because it may delay definitive
management. Finally, proceeding directly to angiography is also a reasonable
strategy given that it has both diagnostic and therapeutic capabilities.
3-Controlling the bleeding during an episode of life-threatening
hemoptysis can be accomplished in one of three ways: from the airway
lumen, from the involved blood vessel, or by surgical resection of both
airway and vessel involved. Bronchoscopic measures are generally only
temporizing: a flexible bronchoscope can be used to suction clot and
insert a balloon catheter or bronchial blocker that occludes the involved
airway. Rigid bronchoscopy, done by an interventional pulmonologist or
thoracic surgeon, may allow therapeutic interventions of bleeding airway
lesions such as photocoagulation and cautery. Because most life-
threatening cases of hemoptysis arise from the bronchial circulation,
bronchial artery embolization is the procedure of choice for control of the
bleeding. However, bronchial artery embolization can have significant
complications such as embolization of the anterior spinal artery. However,
it is generally successful in the short term, with >80% success rate at
controlling bleeding immediately, although bleeding can recur if the
underlying disease (e.g., a mycetoma) is not treated. Surgical resection
has a high mortality rate (up to 15–40%) and should not be pursued
unless initial measures have failed and bleeding is ongoing. Ideal
candidates for surgery have localized disease but otherwise normal lung
parenchyma.