Hemoptysis

Hemoptysis is defined as coughing up blood from a source below the vocal cords. Other potential sites of bleeding (nose, mouth, throat, GI system) must be eliminated; it can be particularly difficult to discern hemoptysis from hematemesis. Interestingly, bleeding occurs more commonly from the bronchial arteries than the pulmonary arteries (though the bronchial arteries have less blood flow, they are a higher-pressure system). Massive hemoptysis, although uncommon, may be fatal because of asphyxiation or respiratory failure.

Differential Diagnosis

• Other sources of bleeding (e.g., hematemesis, epistaxis, and other causes of upper airway bleeding)
• Airway disease is the most common cause of hemoptysis
  –Bronchitis (acute or chronic) causes more than 25% of cases
  –Cancers (metastatic and primary lung cancers) cause up to 25% of all cases
  –Bronchiectasis causes up to 10% of cases
  –Foreign body
  –Trauma
• Parenchymal disease
  –Infections: Tuberculosis (5%), pneumonia (5%), lung abscess, aspergilloma
  –Coagulopathy: Anticoagulant use, thrombocytopenia, DIC
  –Cystic fibrosis
  –Inflammatory: SLE, Wegener’s granulomatosis, Goodpasture's syndrome
  –Iatrogenic: Transbronchial or percutaneous lung biopsy, bronchoscopy, intubation
  –Cocaine use
  • Cardiovascular disease
    –Pulmonary infarction/embolism
    –Congestive heart failure
    –Mitral stenosis
    –AVM
    –Trauma to pulmonary artery (e.g., Swan- Ganz catheterization)
    –Aortic aneurysm
    –Osler-Weber-Rendu syndrome: Congenital telangiectasias
  • Fistula formation between vasculature and airway
  • Catamenial hemoptysis (intrathoracic endometriosis): Cyclic bleeding with menses
  • Diffuse alveolar hemorrhage syndromes: ARDS, crack cocaine use, SLE, cytotoxic drug use
  • Inflammatory
    –Behçet syndrome: Recurrent oral and genital ulcers, uveitis, and arthritis
    –Henoch-Schönlein purpura: Most common systemic vasculitis in children; presents with palpable purpura, abdominal pain, hematuria, and arthritis
    –Idiopathic pulmonary hemosiderosis
  • Idiopathic in 20% of cases

  Workup and Diagnosis

  • Initial workup includes a chest X-ray; sputum for acid-fast stain, cytology and Gram stain/culture; pulse oximetry; PT/PTT; CBC; electrolytes; urinalysis; and BUN/creatinine
  • Consider respiratory isolation until TB is ruled out
  • Chest CT may show focal bleeding
  • Minor hemoptysis: Bronchoscopy is required if any risk factors for cancer are present, such as age >40, abnormal chest X-ray, hemoptysis >1 week, tobacco use (>40 pack-years), anemia, and/or weight loss
  • Major hemoptysis:
    –Active bleeding requires immediate bronchoscopy
    –Stable patients may undergo initial chest CT (if there is no active bleeding) followed by bronchoscopy
    –Bronchoscopy is both diagnostic and therapeutic—may localize bleeding and allow for balloon tamponade or vasoconstrictor injection at site of bleeding
    • Consider immunologic tests (e.g., ANCA for Wegener's syndrome; anti-GBM antibodies for Goodpasture's; ANA, anti-dsDNA, and low complement for SLE; ASO titer for poststreptococcal glomerulonephritis)
    • Arterial blood gas may be used to distinguish hemoptysis (alkaline serum pH) from hematemesis (acidic serum pH)

    Treatment

  • Minor hemoptysis: Treat the specific etiology
    • Massive hemoptysis is a medical emergency
      –Attention to airway, breathing, and circulation
      –Administer supplemental O₂ –Stabilize hemodynamics
      –Cough suppression (e.g., guafenesin, codeine)
      –Place bleeding side in dependent position to prevent blood from draining into the opposite lung
      –Intubation as needed for airway control (a double-lumen tube will preserve oxygenation if bleeding is persistent)
      –Control bleeding by bronchoscopic balloon tamponade, arteriography and embolization in persistent bleeding, or emergent thoracic surgery if embolization is not available and bleeding persists
    • Treat underlying etiology as necessary
    • Consider IV estrogen for massive hemoptysis

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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