Evaluation of hemoptysis

Summary

Hemoptysis is the coughing of blood from a source below the glottis.[1] It can range from a small amount of blood-streaked sputum to massive bleeding with life-threatening consequences due to airway obstruction, hypoxemia, and hemodynamic instability.

In a study of patients in primary care, the incidence of hemoptysis was found to be 1 case in 1000 patients per year.[2] Massive hemoptysis occurs in around 5% to 15% of patients presenting with hemoptysis.[3] The rate of bleeding is the most important factor determining mortality.[4]

Massive hemoptysis

Various definitions of massive hemoptysis exist. A common definition is the expectoration of blood from a source below the glottis exceeding 600 mL of blood over a 24-hour period or 150 mL of blood (which may flood the lung dead space) over a 1-hour period. However, quantifying blood loss accurately can be a challenge.

Massive hemoptysis can also be defined by its clinical effect:[3] [5]

Airway compromise: obstruction, aspiration, hypoxemia, need for intubation
Hemodynamic instability
Requirement for blood transfusion.

Massive hemoptysis is a medical emergency and should be addressed immediately. Initial priorities are stabilization of the patient and protection of the nonbleeding lung.[5]

Common causes

Hemoptysis has numerous possible causes, including tracheobronchial, pulmonary parenchymal, and pulmonary vascular diseases. In the primary care setting, major causes are acute and chronic bronchitis, tuberculosis, lung cancer, pneumonia, and bronchiectasis.

Pseudohemoptysis versus hemoptysis

The initial diagnostic evaluation should aim to differentiate between hematemesis (i.e., the vomiting of blood), pseudohemoptysis (i.e., the coughing of blood from a source other than the lower respiratory tract), and hemoptysis. Pseudohemoptysis can occur when:[6]

Hematemesis is aspirated into the lungs
Bleeding from the upper airway or the mouth stimulates a cough reflex
Material is expectorated that looks like blood but is not (e.g., Serratia marcescens infection).

Characteristically, hemoptysis tends to be indicated by bright red, frothy sputum that is alkaline.

Blood from extrapulmonary sources tends to be darker, may have admixed food particles, and is acidic.[6] [7] The exception is when brisk bleeding in the gastrointestinal tract overcomes the acidic environment of the stomach.

Bleeding from the posterior nasal passage or nasopharynx may mimic hemoptysis without obvious epistaxis. Examining the oral and nasal cavities can provide important clues to the source of the bleeding (e.g., telangiectasia in the mouth or nose, etc.).

Library

Hypervascular endobronchial mucosa
Aspergillus infection
Tracheal tumor
Right upper lobe metastatic renal cell carcinoma
Endobronchial metastatic melanoma
Endobronchial signs of coagulopathy in a patient taking clopidogrel and aspirin
Loquat seed completely occluding the bronchus intermedius

Citations

Key Articles

Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration. 2010 Jan 8;80(1):38-58.[Abstract][Full Text]
Davidson K, Shojaee S. Managing massive hemoptysis. Chest. 2020 Jan;157(1):77-88.[Abstract]
American College of Radiology. ACR appropriateness criteria: hemoptysis. 2019 [internet publication].[Full Text]

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