Haemoptysis is a common and non-specific symptom and can be a sign of significant underlying lung disease. However, in up to one-third of cases, no cause is found. An early assessment of the likely underlying cause needs to be made and investigations planned accordingly.
Diagnostic approach to haemoptysis
Small-volume haemoptysis is a commonly encountered problem in the outpatient department. It can be safely and efficiently investigated as an outpatient. Massive haemoptysis is usually encountered in the accident and emergency department or in a patient already on the ward with known underlying lung disease. The approaches to small-volume and massive haemoptysis are different.
• Past history of lung disease?
• Document volume of blood and whether old (altered) or fresh
• Time course (intermittent, constant)
• Definitely from the airway, and not from the nose or mouth, or haematemesis? (haemoptysis may be swallowed and then vomited)
• Presence of systemic features—associated infection, symptoms consistent with underlying malignancy or vasculitis?
May be normal or show signs of underlying lung disease, e.g. bronchiectasis, bronchial carcinoma, or symptoms of circulatory collapse.
Causes of haemoptysis
• Bronchial tumour (benign, e.g. carcinoid, or malignant). Haemoptysis is a common presenting feature of bronchogenic malignancy, indicating endobronchial disease, which is usually visible endoscopically
• Bronchiectasis and CF (see p. [link]). Small-volume haemoptysis is a common feature of bronchiectasis, particularly during exacerbations. It can be a cause of massive haemoptysis from dilated and abnormal bronchial artery branches that form around bronchiectatic cavities
• Active TB. Haemoptysis occurs in cavitating and non-cavitating disease, active disease and inactive disease (e.g. from an old bronchiectatic cavity, which might contain a mycetoma)
• Pneumonia (especially pneumococcal disease)
• Pulmonary thromboembolic disease
• Vasculitides/alveolar haemorrhage syndromes, e.g. GPA (formerly Wegener’s), SLE, anti-GBM disease (Goodpasture’s syndrome)
• Warfarin with any of the above causes.
• Lung abscess
• Fungal/viral/parasitic infections
• Fat embolism
• Foreign body
• Pulmonary endometriosis
• Severe PHT (see p. [link])
• Mitral stenosis
• Congenital heart disease
• Aortic aneurysm
• Aspergillus—invasive fungal disease (intracavity mycetoma) can be a cause of massive haemoptysis
• Coagulopathy, including DIC
• Pulmonary haemosiderosis
• Pseudoaneurysm post-aortic surgery
• Iatrogenic, e.g. post-lung biopsy, bronchoscopy.
The investigation of haemoptysis can be carried out as an outpatient, but patients with significant bleeding or a likely serious underlying cause should be admitted if there is clinical concern. Note: beware of the apparently small bleed, which is a sentinel/herald bleed for massive haemoptysis. This is fortunately rare. Massive haemoptysis is more likely to be from a bronchial artery bleed (at systemic pressure) than from a pulmonary artery bleed (low pressure). See Box 7.1.
Outpatient investigations and management
• Blood tests FBC, clotting, group & save. If systemic vasculitis is suspected, renal function and a urine dip, with microscopy for casts, are necessary, as well as autoantibodies—start with ANCA, anti-GBM, and ANA
• Sputum M, C, & S and AFB if infection suspected
• CXR may show mass lesion, bronchiectasis, consolidation, or an AVM
• CT chest should be done prior to bronchoscopy; prior knowledge of site of abnormality leads to increased pick-up at bronchoscopy. Similarly, a definitive diagnosis, e.g. AVM, may be made from the CT, obviating the need for further investigations. This depends on local resources; CT may miss an upper airway lesion, but bronchoscopy should not. Bronchial artery dilatation may be large enough to be visible on CT with contrast
• Bronchoscopy to visualize the airways and localize the site of bleeding. May also be therapeutic, e.g. if a bleeding tumour can be injected with a vasoconstricting agent (adrenaline) or a catheter inserted for tamponade (see Box 7.1)
• TBB—if vasculitis suspected.
Usually done if first-line investigations fail to demonstrate a cause.
• CTPA to exclude PE. Bronchial artery dilatation may be large enough to be visible on a CTPA
• Bronchial angiogram Diagnostic and therapeutic. Rare for the actual bleeding site to be identified; more often, the bleeding site is assumed from visualizing a mesh of dilated and tortuous vessels, e.g. around a bronchiectatic cavity. Usually done during an episode of bleeding to maximize the chance of identifying the site of bleeding
• Bronchial artery embolization Therapeutic approach to embolize the bleeding artery, usually with coils or glue (specialist centre only). There is a small risk of paraplegia (<1%) if the anterior spinal artery originates from the bronchial arterial circulation and is inadvertently embolized
• ENT review The source of the bleeding may be the upper airway
• Echo Moderate/severe PHT can cause haemoptysis, especially in a patient on anticoagulants.
In about one-third of cases, despite appropriate investigations as described previously, no cause for the haemoptysis can be found. This has a good prognosis. Often the haemoptysis will settle without treatment and will become less worrying to the patient over time, especially as investigations have failed to determine the cause.