A. Introduction. Hemoptysis, defined as the expectoration of blood, can be an insignificant symptom of a benign illness, a first manifestation of serious malignancy, or a fatal process in and of itself. Hemoptysis is usually classified as either massive or nonmassive.
a. Massive hemoptysis, defined as expectorating >200–600 mL of blood in a 24-hour period, requires immediate evaluation. While the exact volume that is considered “massive” is variably defined in the literature, prompt evaluation is necessary because airway compromise or hemodynamic instability may occur.
b. Nonmassive hemoptysis, usually defined as expectorating <200–600 mL of blood in a 24-hour period, accounts for more than 90% of cases. Patients with new-onset nonmassive hemoptysis, however, also warrant attention and investigation because they may go on to develop massive hemoptysis.
c. The focus in this chapter is on massive hemoptysis because these are the patients usually admitted to the hospital. However, all causes of hemoptysis are briefly discussed because some patients may also be admitted to expedite evaluation, depending on the clinical scenario.
While the precise volume of expectorated blood is often difficult to ascertain, if a patient reports having coughed up about one cup (~236 mL) or more of blood in the past 24 hours, consider this “massive” hemoptysis.
B. Causes of Hemoptysis. The list of differential diagnoses is long, and no large case series of patients presenting with hemoptysis have been performed since the 1990s. Nevertheless, the most worrisome culprits include the following diagnoses: cancer, tuberculosis, bronchiectasis, and aspergillosis. The following mnemonic can help you to remember the four most important causes of hemoptysis—think of a bunch of patients with tuberculosis (TB), coughing up blood, being transported in a cab: “TB CAB.”
MNEMONIC: Most Common Causes of Massive Hemoptysis (“TB CAB”)
Other Causes of Hemoptysis
Bronchitis (most common cause of trivial hemoptysis)
Severe mitral stenosis
a. Tuberculosis. Massive hemoptysis in patients with active tuberculosis is often caused by cavitary lung necrosis or rupture of dilated pulmonary arteries that traverse tuberculous cavities (so-called Rasmussen’s aneurysms). Inactive tuberculosis leaves behind residual bronchiectatic airways and parenchymal cavities where mycetomas (fungal occupation of cavity) may develop and similarly erode into blood vessels. Because the pathology involves blood vessels and vascular tissue, bleeding can be brisk and unpredictable.
b. Cancer should always be suspected in a smoker older than 40 years presenting with hemoptysis, especially if there is radiographic evidence of a mass.
c. Aspergillosis. A fungus ball comprised of Aspergillus hyphae (“aspergilloma”) can develop within a preexisting pulmonary cavity and can cause massive hemoptysis. Angioinvasive fungal pneumonia, termed aspergillosis, can also cause hemoptysis and often occurs in immunocompromised patients. In contrast, aspergillomas are not angioinvasive and occur in immunocompetent patients.
d. Bronchiectasis is defined as permanent dilation and destruction of the bronchi or bronchioles. The incidence in the United States has declined in the past few decades because of better recognition and treatment of tuberculosis and pneumonia. However, patients with cystic fibrosis (CF; a disease that often leads to bronchiectasis) are now living into adulthood and have about a 5% lifelong incidence of massive hemoptysis. Patients with CF who develop hemoptysis should therefore receive prompt and urgent attention.
e. Bronchitis is the most common cause of trivial hemoptysis. Bronchitis rarely causes massive bleeding, unless coexisting bronchiectasis is present.
f. Pulmonary embolism. Pulmonary embolism can cause lung infarction, which often bleeds after initiation of anticoagulation as parenchymal necrosis occurs. Septic emboli from right-sided endocarditis may also be associated with massive bleeding secondary to ischemic tissue necrosis or vasculitis with vessel damage.
g. Pulmonary edema. Pulmonary edema due to congestive heart failure can present with hemoptysis or blood-tinged sputum production.
h. Pneumonia associated with hemoptysis is often caused by abscess forming and/or necrotizing organisms (e.g., Staphylococcus aureus, Streptococcus species, and certain gram-negative organisms).
i. Coagulopathy. Anticoagulation is often associated with hemoptysis but is generally not the sole cause. An underlying lesion should be sought. Rarely, anticoagulation can cause alveolar hemorrhage (see below).
j. Arteriovenous malformation is usually congenital and is often associated with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome).
k. Diffuse alveolar hemorrhage is a clinical syndrome in which the alveoli fill with blood. It results from rupture or damage to the alveolar capillaries and is most commonly due to an autoimmune-mediated attack of these vessels (e.g., Churg-Strauss syndrome, granulomatous vasculitis, microscopic polyangiitis). Some of these conditions may also involve the kidneys (e.g., Goodpasture’s syndrome, granulomatous vasculitis, systemic lupus erythematosus [SLE]) and present with concomitant hematuria and a cellular urinary sediment (e.g., dysmorphic red blood cells, proteinuria, red cell casts). Other nonimmune causes of alveolar hemorrhage include pulmonary edema, idiopathic pulmonary hemosiderosis, and acute interstitial pneumonitis.
l. Severe mitral stenosis can lead to pulmonary venous hypertension, rupture of pulmonary capillaries, and subsequent hemoptysis.
C. Approach to the Patient with Massive Hemoptysis
a. Maintain airway patency and oxygenation. Because death from massive hemoptysis usually results from alveolar flooding and resultant hypoxemia from inadequate gas exchange, ensuring adequate oxygenation is the most important first step. Arterial blood gas analysis and chest radiographs should be performed immediately to assess oxygenation and determine the extent of blood retained in the lung.
To prevent aspiration of blood into the unaffected lung in a patient with massive hemoptysis, have the patient lie in the lateral decubitus position with the bleeding side down. How do you know which lung is bleeding? Ask the patient; he or she may know (clues: known cancer, recent procedure or surgery).
i. If emergent intubation is indicated (see Chapter 14), a large-bore endotracheal tube (8.0 or larger) should be used to enable adequate suctioning and allow for bronchoscopy.
ii. In cases of unilateral hemorrhage, selective right or left mainstem bronchus intubation with specialized endotracheal tubes can protect against spillage of blood into the unaffected lung.
b. Identify the bleeding lesion
i. Ensure a bronchopulmonary source. It is necessary to ensure that the patient truly has bronchopulmonary bleeding; gastrointestinal or nasopharyngeal bleeding commonly masquerades as hemoptysis. If the source of the bleeding is not obvious, helpful techniques include:
1. Evaluation of the pH of the expectorated substance can provide clues—gastrointestinal contents are usually acidic, whereas pulmonary expectorations are alkaline.
2. Direct examination of the nasopharynx, oropharynx and larynx may reveal the cause of the bleeding.
ii. Lung auscultation and chest radiographs can help to localize the bleeding but may not be helpful if the bleeding is diffuse or if blood has been aspirated from one lung into the other. A chest radiograph may show a mass lesion or cavity.
iii. Urinalysis and assessment of renal function may show an active urinary sediment, suggesting a vasculitis or pulmonary-renal syndrome.
iv. Computed tomography (CT) may reveal a space-occupying lesion (e.g., lung cancer, cavity, or abscess).
v. Early flexible bronchoscopy is indicated in most patients for localization and diagnosis. Rigid bronchoscopy allows for therapeutic interventions.
vi. Arteriography is useful for actively bleeding patients to localize the bleeding lesion and deliver therapy. Massive hemoptysis most commonly comes from the bronchial artery circulation and can sometimes be localized and embolized by interventional radiology during arteriography.
c. Control the hemorrhage
i. General measures indicated for all patients with massive hemoptysis include bed rest, cough suppressants, sedatives, and stool softeners or laxatives to prevent sudden increases in intrathoracic pressure that may worsen bleeding. On presentation, these measures may impair the patient’s ability to expectorate, possibly worsening hypoxemia and clinical status. Therefore, await clinical stability and/or intubation before initiating therapies such as sedatives.
ii. Coagulopathies should be corrected, if present.
iii. Bronchoscopic maneuvers such as topical application of epinephrine or thrombin or balloon tamponade may be useful in selected patients.
iv. External radiation therapy may be effective in reducing bleeding from tumors.
v. Definitive therapy for massive hemoptysis often requires angiographic arterial embolization or surgical lung resection.
Consult a pulmonologist immediately if a patient presents with massive hemoptysis.
Suggested Further Readings
Ibrahim WH. Massive haemoptysis: the definition should be revised. Eur Respir J 2008;32:1131–2.Find this resource:
Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000;28:1642–7. (Classic Article.)Find this resource:
Yendamuri S. Massive airway hemorrhage. Thorac Surg Clin 2015;25:255–60.Find this resource: