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Hemoptysis is coughing up of blood from the respiratory tract. Most of the lung's blood (95%) circulates through low-pressure pulmonary arteries and ends up in the pulmonary capillary bed, where gas is exchanged; about 5% of the blood supply circulates through high-pressure bronchial arteries, which originate at the aorta and supply major airways and supporting structures. The blood in hemoptysis generally arises from this bronchial circulation, except when pulmonary arteries are damaged by trauma, by erosion of a granulomatous or calcified lymph node or tumor, or, rarely, by pulmonary arterial catheterization or when pulmonary capillaries are affected by inflammation. Blood-streaked sputum is common in many minor respiratory illnesses, such as URI and viral bronchitis. Massive hemoptysis is production of 600 mL of blood (about a full kidney basin's worth) within 24 h.
The differential diagnosis is broad (see Table 2: Approach to the Patient With Pulmonary Symptoms: Differential Diagnosis of Hemoptysis ). Bronchitis, bronchiectasis, TB, and necrotizing pneumonia or lung abscess account for 70 to 90% of cases. Cavitary Aspergillus infection is being increasingly recognized as a cause but is not as common as malignancy; hemoptysis in smokers ≥ 40 yr triggers suspicion of primary lung cancer. Metastatic cancer rarely causes hemoptysis. Pulmonary-renal and diffuse alveolar hemorrhage syndromes (see Diffuse Alveolar Hemorrhage and Pulmonary-Renal Syndromes), pulmonary embolism and infarction (see Pulmonary Embolism (PE)), and left ventricular failure (especially secondary to mitral stenosis) are less common causes of hemoptysis. Hemoptysis in heart failure is unusual but occurs as a result of pulmonary venous hypertension from left ventricular failure. Primary bronchial adenoma and arteriovenous malformations are rare but tend to cause severe bleeding. Rarely, hemoptysis occurs during menstruation (catamenial hemoptysis) because of intrathoracic endometriosis.
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Table 2
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Differential Diagnosis
of Hemoptysis
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Larynx and pharynx
Carcinoma
Lymphoma
Tuberculous ulceration
Trachea and large bronchi
Benign or malignant primary tumor (carcinoma and adenoma)
Bronchogenic cyst
Broncholithiasis
Erosion by an aortic aneurysm
Erosion by a caseocalcific node
Erosion by a tumor from nodes, esophagus, or other mediastinal structures
Severe acute bronchitis
Telangiectasia
Trauma
Smaller bronchial structures
Acute bronchitis
Adenoma (carcinoid or cylindromatous)
Bronchiectasis
Bronchopulmonary sequestration
Carcinoma
Chronic bronchitis
Trauma
Pulmonary parenchyma
Abscess
Active granulomatous disease (tuberculous, fungal, parasitic, syphilitic)
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Acute pneumonia
Fungus ball (aspergilloma) in an old cavity
Goodpasture's syndrome or variants
Idiopathic hemosiderosis
Infarct
Primary or metastatic tumor
Trauma
Heart and blood vessels
Aortic aneurysm with leakage into the pulmonary parenchyma
Atrial myxoma
Fibrous mediastinitis with pulmonary vein obstruction
Left ventricular failure
Mitral stenosis
Pulmonary arteriovenous malformation
Pulmonary embolism/infarct
Primary pulmonary hypertension
Bleeding diathesis
Anticoagulant therapy
Deficiency of vitamin K–dependent factors: prothrombin (II), Stuart factor (X), factor VII, Christmas factor (IX)
Disseminated intravascular coaulation
Fibrinolytic therapy: urokinase, streptokinase
Miscellaneous congenital coagulation defects
Thrombocytopenia
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Evaluation
History:
A key objective is to distinguish hemoptysis from hematemesis and from nasopharyngeal or oropharyngeal bleeding. This distinction can generally be accomplished with history and physical examination. An extensive smoking history suggests malignancy. A patient's sensation of where the bleeding may be coming from may help identify its origin if it is emanating from one of the upper lobes.
Physical examination:
Examination focuses on ruling out upper airway sites of bleeding and on listening over the lungs for focal abnormalities that may indicate the area where bleeding may be occurring. Unfortunately, blood originating from any area can be aspirated throughout the lung.
Testing:
Patients with minor hemoptysis can undergo testing on an outpatient basis. A chest x-ray is mandatory. Patients with normal results, a consistent history, and nonmassive hemoptysis can undergo empirical treatment for bronchitis. Those with abnormal results and those without a supporting history should undergo CT and bronchoscopy. CT may reveal pulmonary lesions that are not apparent on the chest x-ray and can help locate lesions in anticipation of bronchoscopy and biopsy. A ventilation/perfusion scan or CT angiogram can confirm the diagnosis of pulmonary embolism; CTs and pulmonary angiography can also detect pulmonary arteriovenous fistulas. When the etiology is obscure, fiberoptic inspection of the pharynx, larynx, esophagus, and/or airways may be indicated to distinguish hemoptysis from hematemesis and from nasopharyngeal or oropharyngeal bleeding.
Patients with massive hemoptysis require treatment and stabilization before testing. The cause of hemoptysis remains unknown in 30 to 40% of cases. The prognosis for patients with cryptogenic hemoptysis is generally favorable, usually with resolution of bleeding within 6 mo of evaluation.
Treatment
The two objectives of treatment are to prevent aspiration of blood to the uninvolved lung (which can cause asphyxiation) and to prevent exsanguination from ongoing bleeding.
Protection of the uninvolved lung can be difficult because the site of bleeding often is unclear. Strategies include positioning maneuvers (eg, having the patient lie with the bleeding lung in a dependent position) and selective intubation and obstruction of the bronchus going to the bleeding lung.
Prevention of exsanguination involves reversal of any bleeding diathesis and direct efforts to stop the bleeding. Clotting deficiencies can be reversed with fresh-frozen plasma and factor-specific or platelet transfusions. Laser therapy, cauterization, or direct injection with epinephrine or vasopressin can be performed bronchoscopically.
Massive hemoptysis is one of the few indications for rigid bronchoscopy, which provides control of the airway, allows for a larger field of view than flexible bronchoscopy, allows better suctioning, and is more suited to therapeutic interventions, such as laser therapy. Embolization of a pulmonary segment is becoming the preferred method with which to stop massive hemoptysis, with reported success rates of up to 90%. Emergency surgery is indicated for massive hemoptysis not controlled by rigid bronchoscopy or embolization and is generally considered a last resort.
Early resection may be indicated for bronchial adenoma or carcinoma. Broncholithiasis (erosion of a calcified lymph into an adjacent bronchus) may require pulmonary resection if endobronchial removal of the stone via rigid bronchoscopy cannot be performed. Bleeding secondary to heart failure or mitral stenosis usually responds to specific therapy for heart failure, but in rare cases, emergency mitral valvulotomy is necessary for life-threatening hemoptysis due to mitral stenosis. Bleeding from a pulmonary embolism is rarely massive and almost always stops spontaneously. If emboli recur and bleeding persists, anticoagulation may be contraindicated, and placement of an inferior vena cava filter is the treatment of choice.
Because bleeding from bronchiectatic areas usually results from infection, treatment of the infection with appropriate antibiotics and postural drainage is essential.
Sedatives and opioids suppress the ventilatory drive and should be avoided.
Last full review/revision November 2005
Content last modified November 2005
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