Presentation

Classic presentation

• Worldwide, tuberculosis (TB) is the most common cause of massive hemoptysis. In the United States, patients frequently have a history of pulmonary disease and/or smoking, cancer, prior hemoptysis, immunosuppression, cardiac disease, or coagulopathy/anticoagulant use.
  
• Patients may present with a sentinel bleed, with only a small amount of initial hemoptysis.

Critical presentation

• The clinical course of these patients can be difficult to predict, as small amounts of hemoptysis may suddenly become massive.
  
• Patients may present to the ED in extremis with active hemorrhage and respiratory failure.

Diagnosis and evaluation

• Focused history and physical examination
  
  
  
  • One must exclude bleeding from nonpulmonary source, such as a GI (hematemesis) or ENT (epistaxis) etiology. Expectorated material that has an alkaline pH, is foamy, or contains purulence suggests lower respiratory source rather than GI source.
    
  • One should inquire about prior episodes of hemoptysis, known etiology of hemoptysis, and the location of the lesion, if known.
    
  • History of cancer, pulmonary disease, or smoking should be obtained. A history of anticoagulant use or other coagulation disorders should be determined.
  
  
• Laboratory tests
  
  
  
  • All patients should have complete blood count, prothrombin time and partial thromboplastin time, electrolytes, arterial blood gas, liver function tests.
    
  • Rapid type and cross-matching of blood should be performed.
    
  • If necessary, consider arterial blood gases to assess oxygenation status.
    
  • When obtainable, sputum samples should be sent for bacterial, fungal, and mycobacterial cultures.
  
  
• Imaging studies
  
  
  
  • Chest radiography may be helpful in identifying infiltrates, lymphadenopathy, or cavitary/mass lesions.
    
  • If the patient does not have active bleeding and is stable enough to go to radiology, chest CT may assist finding the etiology of hemoptysis. Bronchiectasis, lung abscess, pulmonary artery aneurysm, pulmonary embolism, and mass lesions are all abnormalities that are difficult to detect by bronchoscopy and angiography but can be identified by chest CT.

Critical management

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