Key Clinical Questions
What is the definition of hemoptysis and what is the difference between massive and nonmassive hemoptysis?
What are the initial assessments and diagnostic tests that should be performed when evaluating a patient with hemoptysis?
What are the most common causes of hemoptysis in the hospitalized patient?
What are the recommended management strategies for both massive and nonmassive hemoptysis?
A 24-year-old white male with cystic fibrosis presents to the emergency department with two weeks of daily hemoptysis. He states that he has been coughing up a half cup of blood daily and has had worsening dyspnea on exertion for the last week. His baseline cough is more frequent and his sputum has increased in production. He also denies fever, chills, chest pain, and abdominal pain. On exam, he is tachypneic and in mild distress, with an oxygen saturation of 95% on room air. His lungs have crackles bilaterally in the upper lung fields. He is admitted to the hospital for further workup of his hemoptysis. What are the next steps in the evaluation and treatment of this patient with hemoptysis? |
Introduction
Hemoptysis (from the Latin heme meaning blood and the Greek ptysis meaning to spit) is defined as the coughing up of blood or blood-tinged sputum and can be further categorized as being massive or nonmassive based on the volume of blood that is expectorated. The definition of massive hemoptysis varies as it has been defined as anywhere from over 100 mL to 1000 mL of blood expectorated in a 24-hour period. The exact frequency with which hemoptysis occurs is not known, but it is estimated that 5% of all hemoptysis is massive, and the mortality rate of massive hemoptysis is estimated to approach 80%.
The first step in the assessment of a patient with reported hemoptysis is to make sure that the blood is coming from the respiratory tract. Pseudohemoptysis is the coughing up of blood that is not from a pulmonary source and hematemesis is bloody vomitus. Hematemesis can often be confused with hemoptysis because vomiting and retching are often accompanied by coughing and gagging. Patients are frequently unsure whether they coughed or vomited up blood. Bloody vomitus is often aspirated into the lungs and then coughed back up. Additionally, bleeding sites in the nose or pharynx can sometimes be confused with hemoptysis, particularly when this blood is aspirated. Another mimicker of hemoptysis is the pink frothy sputum that is often seen in massive pulmonary edema secondary to heart failure. This sputum is different from hemoptysis as it is not red and is typically light and frothy. A more detailed discussion of pseudohemoptysis and hematemesis is beyond the scope of this chapter; only true hemoptysis is discussed here.
Pathophysiology and Causes of Hemoptysis
To understand why the pulmonary system can bleed, it is best first to understand the pulmonary blood supply. Both pulmonary and bronchial arteries are possible culprits of bleeding. Although the pulmonary arteries have just about the entire cardiac output coursing through them (high volume), they are under low pressure. In contrast, the bronchial arteries receive much less blood (low volume) but are under high pressure because they are part of the systemic circulation. Because the bronchial arteries—which typically come off the aorta but occasionally come off the intercostal arteries—are under higher pressure, they are usually the source of bleeding, as opposed to the pulmonary arteries.
The exact pathophysiologic mechanism of bleeding is dependent upon the cause and source. For example, in bronchiectasis, bleeding occurs because the bronchial arteries become tortuous and hyperplastic and are thus friable and easily disturbed. To identify the exact cause, it is best to think in general terms of what can bleed in the pulmonary system: airways, parenchyma, and vasculature. The most common causes of hemoptysis are bronchitis, bronchogenic carcinoma, bronchiectasis, and pneumonia, but there is a long list of causes as shown in Table 88-1.
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In developing countries tuberculosis (TB) remains an important cause of hemoptysis. In the United States TB was a leading cause prior to 1960. Currently infection is the most common cause, accounting for 60–70% of cases of hemoptysis. Infection causes hemoptysis due to superficial bleeding from mucosal irritation and edema. Primary lung cancers have been implicated in about 20% of hemoptysis cases, with the most common cancer being bronchogenic carcinoma. Of note, metastatic lung cancers do not usually cause hemoptysis.
Approach to the Patient
The most important initial determination is the volume of hemoptysis. Massive hemoptysis is life threatening and needs emergent stabilization and then intervention to stop the bleeding (to be discussed further in the management section).
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