TABLE 45-1 Common Causes of Hemoptysisa | ||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ||||||||||||||||||||||||||
Managing Hemoptysis
Managing Hemoptysis
Paulo J. Oliveira
Richard S. Irwin
I. GENERAL PRINCIPLES
A. Definitions.
1. Hemoptysis: expectoration of blood from the lungs or airways below the glottis.
2. Massive hemoptysis.
a. Volumetric: most often quoted as expectoration of 600 mL of blood within 24 to 48 hours.
b. Magnitude of effect: clinical (hemodynamic and respiratory compromise) consequences of hemoptysis.
i. Mortality related to asphyxiation not exsanguination typically.
3. Pseudohemoptysis: expectoration of blood from other than the lower respiratory tract (e.g., ENT source with epistaxis or upper GI bleed).
II. ETIOLOGY
A. Nonmassive hemoptysis: Table 45-1 lists the common causes of hemoptysis, including bronchitis, bronchiectasis, lung carcinoma, and tuberculosis.
B. Massive hemoptysis.
1. All causes of hemoptysis may result in massive hemoptysis. The most frequent causes are infection (tuberculosis, mycetoma, bronchiectasis, lung abscess), lung cancer, and diffuse intrapulmonary hemorrhage.
2. Catastrophic, albeit rare, causes include rupture of a pulmonary artery from a balloon flotation catheter and tracheoarterial fistula (consider, until proven otherwise, in massive hemorrhage typically occurring 3 days to 6 weeks after tracheostomy).
C. Idiopathic or cryptogenic hemoptysis.
1. Despite a systematic diagnostic approach, hemoptysis may be idiopathic in 2% to 32%.
2. Most commonly seen in men between ages of 30 and 50 years and smokers.
3. Usually presents as nonmassive hemoptysis but can be massive.
4. Ten percent have recurrence and may require vigilant monitoring for potential and eventual diagnosis of underlying malignancy.
5. Consider Dieulafoy disease of bronchus (superficial, ectatic bronchial artery) in the context of cryptogenic hemoptysis presenting with massive hemoptysis.
III. PATHOGENESIS
A. Bronchial arterial circuit supplies blood to the airways (main stem bronchi to the terminal bronchioles), pleura, intrapulmonary lymphoid tissue, and large branches of the pulmonary vessels and nerves in the hilar regions. The bronchial circulation is responsible for bleeding in approximately 90% of cases.
B. Pulmonary arterial circuit supplies the pulmonary parenchymal tissue, including respiratory bronchioles.
C. Nonbronchial systemic arteries can also be involved when collateral circulation develops in regions of chronic inflammation.
IV. DIAGNOSIS
A. Medical history.
1. Consider frequency, timing, duration, anticoagulant use, illicit drug use, exposure history, immune system status, and epidemiologic factors including travel history (tuberculosis, endemic fungi, parasites).
2. Chronic sputum suggests chronic bronchitis, bronchiectasis, or cystic fibrosis.
3. Orthopnea and paroxysmal nocturnal dyspnea suggest cardiac failure or mitral stenosis.
4. Always consider pulmonary thromboembolism (generally not a contraindication to anticoagulation).
5. Consider suction catheter trauma.
6. Diffuse alveolar hemorrhage (DAH): hemoptysis typical but absence does not rule this out. Hemoptysis present in only approximately 40% of DAH patients.
B. Physical examination.
1. Evaluation of the respiratory system.
a. Inspection: evidence of recent or old chest trauma.
b. Auscultation.
i. Unilateral wheeze or crackles suggest localized disease.
ii. Diffuse crackles in congestive heart failure (CHF) and diffuse alveolar hemorrhage.
2. Evaluation of other systems.
