Hemoptysis

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Hemoptysis
ICD-10 ICD-9 DiseasesDB MedlinePlus MeSH R04.2 786.3 5578 003073 D006469

This article does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unverifiable material may be challenged and removed. (September 2007) Hemoptysis or haemoptysis is the expectoration (coughing up) of blood or of bloodstained sputum from the bronchi, larynx, trachea, or lungs (e.g. in tuberculosis or other respiratory infections).

[edit] Causes
This can be due to bronchitis or pneumonia most commonly, but also to lung neoplasm (in smokers, when hemoptysis is persistent), aspergilloma, tuberculosis, bronchiectasis, coccidioidomycosis, pulmonary embolism, or pneumonic plague. Rarer causes include hereditary hemorrhagic telangiectasia (HHT or Rendu-OslerWeber syndrome), or Goodpasture's syndrome and Wegener's granulomatosis. In children it is commonly due to a foreign body in the respiratory tract. It can result from over-anticoagulation from treatment by drugs such as warfarin. Cardiac causes like congestive heart failure and mitral stenosis should be ruled out. The origin of blood can be known by observing its color. Bright red, foamy blood comes from the respiratory tract while dark red, coffee-colored blood comes from the gastrointestinal tract. Extensive injury can cause one to cough up blood.

[edit] Diagnostic workup

[edit] External links

Haemoptysis at GPnotebook Haemoptysis Virtual Cancer Centre [hide]

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Symptoms and signs: circulatory and respiratory systems (R00-R09 785786)

Heart

Tachycardia/Bradycardia Palpitation Heart sounds: Heart murmur (Systolic, Diastolic, Continuous) Gallop rhythm (Third heart sound, Fourth heart sound) Pericardial friction rub Split S2 Heart click

Cardiovascular system Pulse Pulsus alternans Pulsus bigeminus Pulsus bisferiens abnormalitiesPulsus tardus et parvus Pulsus paradoxus Other peripheral blood flow Bruit/Carotid bruit Gangrene Cannon A waves

Hemorrhage Epistaxis Hemoptysis Respiratory sounds: Stridor Wheeze Rales Rhonchi Hamman's sign Dyspnea Hyperventilation/Hypoventilation Hyperpnea/Tachypnea/Bradypnea Abnormalities Orthopnea/Platypnea of breathing Respiratory system Biot's respiration Cheyne-Stokes respiration Kussmaul breathing Hiccup Mouth breathing/Snoring Asphyxia Cough Pleurisy Sputum Other Respiratory arrest Hypercapnia/Hypocapnia Whispered pectoriloquy Egophony Bronchophony Chest, general Chest pain see also eponymous medical signs for circulatory and respiratory systems

Hemoptysis
Overview

Physician-dev -monitored.

Original Date Jun 2000 Reviewed by: Swierzewski, I Last Reviewed Original Source: http://www.pulmonologychannel.com/hemo

Home Hemoptysis Overview Overview

Advertising Disclaimer Hemoptysis (which is pronounced he-MOP-tis-is) is coughing up blood from the respiratory tract. Blood can come from the nose, mouth, throat, the airway passages leading to the lungs, or the lungs. The word "hemoptysis" comes from the Greek "haima," meaning "blood," and "ptysis," which means "a spitting". Blood-tinged mucus in a healthy nonsmoker usually indicates a mild infection. Indeed, the most common cause for coughing up blood is the least seriousa ruptured small blood vessel caused by coughing and/or a bronchial infection. In patients with a history of smoking and those who are otherwise at risk for lung disease, however, hemoptysis is often a sign of serious illness. Serious conditions that can cause hemoptysis include bronchiectasis (chronic dilation and infection of the bronchioles and bronchi), pulmonary embolus (a clogged artery in the lungs that can lead to tissue death), pneumonia (a lung infection), and tuberculosis. Hemoptysis can also result from inhaling a foreign body (e.g., particle of food) that ruptures a blood vessel. Whatever the suspected cause, hemoptysis should always be reported to a physician. Hemoptysis refers specifically to blood that comes from the respiratory tract. Blood also may come from the nose, the back of the throat, or part of the gastrointestinal tract. When blood originates outside of the respiratory tract, the condition is known as "pseudohemoptysis." Vomiting up blood, medically known as hematemesis, is one type of pseudohemoptysis. Differentiating between hemoptysis and hematemesis is an integral part of diagnosis. Since they involve different parts of the body, treatments and prognose (prospect of recovery) are not the same.

Advertising Disclaimer Classifying hemoptysis as mild or massive (some practitioners classify it as trivial, moderate, or massive) is difficult because the amount of blood is often hard to accurately quantify. Life-threatening, "massive" hemoptysis, which requires immediate medical attention, is differentiated from less severe cases. Massive hemoptysis Hemoptysis is considered massive, or major, when there is so much blood that it interrupts breathing (generally more than about 200-240 mL, or about 1 cup, in 24 hours). Massive hemoptysis is a medical emergency: the mortality rate for patients with massive hemoptysis can be as high as 75%. Most patients who die from

hemoptysis suffer from asphyxiation (lack of oxygen) due to too much blood in the airways. Mild hemoptysis If there is a small amount of blood or sputum streaked with blood, the spitting is considered mild hemoptysis. In 60% to 70% of mild hemoptysis cases, the underlying disorder is benign and disappears on its own without causing serious problems or permanent damage. Even mild hemoptysis can result in critical breathing problems, depending on the underlying cause for the bleeding. Additionally, hemoptysis tends to occur intermittently and recur sporadically, and there is no way to predict if patients with mild hemoptysis are at risk for massive hemoptysis. Diagnosis is important to prevent a more serious condition. 1998-2009 Healthcommunities.com, Inc. All Rights Reserved.

Frontline Assessment of Common Pulmonary Presentations

E. Hemoptysis
Introduction
Hemoptysis, the act of coughing up blood, is an important symptom since it frequently reflects serious underlying lung disease. Because many of the lung conditions that are heralded by hemoptysis are treatable, the symptom requires systematic and thorough evaluation to discover its etiology. A possible exception is mild hemoptysis occurring in a patient with chronic bronchitis during an acute exacerbation. Hemoptysis in this situation is common, usually mild, and self-limited. Therefore, it may be observed without further work-up. However, if the hemoptysis is substantial, persistent, or recurrent then further evaluation is indicated, particularly since patients with chronic bronchitis related to smoking are at high risk for lung cancer.

Sources
The first step in the evaluation of hemoptysis is to decide if it is really hemoptysis that is, is the blood coming from the bronchial tree or lungs or from some other site? In most cases, history will suggest that blood is actually being coughed up from the airways or lungs, but it may be difficult at times to distinguish blood being coughed up from the respiratory system from blood coming from two other sites: bleeding in the upper respiratory tract, in the nasopharynx or sinuses, or blood originating in the

gastrointestinal tract that was regurgitated or vomited. A history of frequent nosebleeds, hoarseness, or some other change in the voice or history of mouth lesions might suggest bleeding from the upper respiratory tract. If bleeding is not clearly from the lungs then a thorough examination of the upper respiratory system is indicated. If the source remains equivocal, i.e., no abnormality in the upper respiratory tract is found on initial examination and no source is found after further pulmonary work-up as described below, then an examination by an otolaryngology specialist may be warranted. Hematemesis occasionally may be difficult to distinguish from hemoptysis; moreover, blood from a respiratory source may be swallowed and may present as coffee-ground emesis. Gastrointestinal symptoms suggest an upper GI work-up when the bleeding source is unclear. The second question to be asked is whether the bleeding is massive (or lifethreatening), which if present changes the approach to management as well as affecting the differential diagnosis. Massive or life-threatening hemoptysis has usually been defined by the rate of bleeding, defined as greater than 200 ml per day by various authors. The bleeding rate is critical since the problem with massive hemoptysis is not exsanguination but asphyxiation from blood that floods alveoli or clots that functionally obstruct airways. Thus, any amount of bleeding at a high rate, even over a short period of time, should be managed as being potentially lifethreatening. The approach to massive hemoptysis is described in more detail below.

Differential Diagnosis
The differential diagnosis of hemoptysis is shown in Table 10. The most common causes are bronchitis, lung cancer, pneumonia, lung abscess, tuberculosis, bronchiectasis, and pulmonary thromboembolism. The prevalence of these disorders in causing hemoptysis appears to be changing and varies considerably in different series. In North America, tuberculosis (both active and inactive) and bronchiectasis appear to be decreasing as a cause of hemoptysis whereas they are still extremely frequent causes of hemoptysis in many other parts of the world. In many (but not all) series, a significant proportion of cases remain undiagnosed despite extensive workup. Conditions that cause massive hemoptysis are generally inflammatory disorders which erode into the bronchial circulation. Because the bronchial circulation is under systemic vascular pressure, the bleeding is likely to be more severe than if the source of bleeding were the pulmonary circulation. Thus, causes of massive hemoptysis consist mainly of suppurative or chronic infections or conditions complicated by infection (lung abscess, tuberculosis, bronchiectasis, or cystic fibrosis), but also include lung cancer.

Evaluation of Hemoptysis
The initial evaluation in all patients consists of a careful history, physical examination, and upright postero-anterior and lateral chest x-rays. The history should elicit and detail any acute or chronic pulmonary symptoms, including cough, sputum production, shortness of breath or wheezing, and any previous history of lung disease. Systemic symptoms such as fever, sweats, weight loss, and malaise may reflect

ongoing inflammation or reflect a catabolic process related to cancer or chronic infection. The history should uncover symptoms associated with the specific causes in the differential diagnosis including symptoms of heart disease (especially mitral stenosis), vasculitis, and with particular attention given to pulmonary thromboembolism. In considering pulmonary thromboembolism, in addition to the acute onset of pulmonary symptoms and any leg symptoms reflecting possible deep venous thrombosis, the most important part of the history focuses on asking about possible risk factors for deep venous thrombosis. Physical examination includes auscultation, listening for generalized wheezing (COPD/asthma), localized wheezing (local bronchial obstruction), or diffuse or localized crackles or rhonchi which may reflect infectious or inflammatory processes including lung abscess, pneumonia, and bronchiectasis. A careful cardiovascular examination should be done, particularly looking for congestive heart failure, evidence of mitral stenosis and signs of deep venous thrombosis. It is important to recognize that signs of deep venous thrombosis are lacking in at least half of the cases in which deep venous thrombosis is eventually proven. A negative result of the examination, therefore, clearly does not rule out deep venous thrombosis or the possibility of pulmonary thromboembolism. A complete blood count and coagulation studies should be ordered. A posteroanterior and lateral chest x-ray should be routinely obtained. The chest x-ray may be very helpful in suggesting a source of the hemoptysis, such as pulmonary inflammatory disease or cancer. If the chest x-ray is abnormal, it will often suggest subsequent steps in the work-up. Sputum cytology on expectorated sputum should be obtained in any patient at significant risk for lung cancer based on epidemiologic considerations, whether or not the chest x-ray is suspicious for cancer. This includes all patients with chronic obstructive pulmonary disease. If the chest x-ray is negative or unrevealing it does not rule out important disease as a cause of hemoptysis. Therefore, one must make a clinical decision about how much further to go in the evaluation. This decision should be individualized according to each clinical situation and the availability of diagnostic facilities and subspecialty consultation. Generally, computed tomography (CT) of the chest is the preferred next study since it is noninvasive, can detect small cancers in the bronchial tree and lung parenchyma, and can diagnose bronchiectasis. Chest CT might also provide information useful to the bronchcoscopist if bronchoscopy becomes a consideration. Three forms of chest CT are available that might be helpful in diagnosing the cause of hemoptysis: chest CT with contrast; high resolution chest CT; and spiral CT of the chest. Each has its advantages for diagnosing some of the conditions in the differential diagnosis. Consultation may be indicated to determine which form of chest CT should be ordered for evaluation of a given patient.

Specialized Work-Up
Fiberoptic bronchoscopy is generally the next study to be considered. The decision to perform bronchoscopy should be made in consultation with a pulmonologist. Fiberoptic bronchoscopy may identify an endobronchial lesion, most often lung cancer, as the cause for hemoptysis and can help localize the lobe or segment from

which the blood is coming. The combination of fiberoptic bronchoscopy and chest CT has been shown to give a higher yield of specific diagnoses than either test alone. Fiberoptic bronchoscopy is indicated in certain categories of patients: those in whom the diagnosis is not evident from history, physical examination, chest x-ray, or chest CT; those with significant bleeding (greater than 30 ml per day) or in whom hemoptysis persists for longer than one week; and those who have systemic symptoms suggesting cancer or who are at particularly high risk for lung cancer, especially cigarette smokers over the age of forty. If none of these conditions is present, then the chance of finding lung cancer on bronchoscopy is very low and a decision to observe the patient should be considered. If suspicion of pulmonary embolus is moderate, particularly if risk factors exist for deep venous thrombosis and pulmonary thromboembolism, then a ventilation/perfusion lung scan should be obtained.

Therapy
The therapy of hemoptysis consists of that treatment appropriate for the underlying disease process, for example, antibiotic therapy for infectious etiologies. Otherwise, the treatment is nonspecific. The exception to this is when massive hemoptysis is present.

Management of Massive Hemoptysis

When the rate of bleeding qualifies as massive hemoptysis (a rate of greater than 200 ml per day) the situation should be considered to be a medical emergency requiring referral for immediate diagnostic and therapeutic steps. The treatment of massive hemoptysis includes consideration of either surgical removal of the bleeding site or bronchial angiography with embolization of the bleeding site when feasible. Although there is some debate regarding the role of bronchial embolization, with some authors suggesting it be performed in all cases, the standard management for life-threatening bleeding due to localized disease in a patient with good pulmonary reserve is usually surgical resection. If emergent surgery is being considered, the diagnostic goal consists of localizing the bleeding site, first, as to which lung is bleeding and then, if possible, as to which lobe or segment contains the bleeding source. Bronchial arterial embolization is usually indicated in patients with nonlocalized disease and/or limited breathing reserve to preserve pulmonary parenchyma and function. Localization can also be helpful when bronchial embolization is being considered because it permits selective bronchial angiography to be undertaken, which markedly shortens the angiographic procedure. Bronchoscopy, either fiberoptic or rigid bronchoscopy, should be performed as soon as possible in an attempt to localize the site of bleeding within the lung. Localization of the bleeding source is much more successful if some degree of active bleeding is still occurring. If the lung from which the bleeding is occurring is suspected (e.g., based on the chest x-ray or the patients subjective impression), the patient should be positioned with the affected lung placed in a dependent position to prevent drainage of blood into the contralateral lung. The patient may be lightly sedated or tranquilized to diminish

cough, but the state of consciousness should not be impaired such that the patient is unable to cough and maintain a clear airway. Once it is decided that surgery is indicated, then control of the airways should be obtained. Ideally, a double lumen tube should be inserted. However, if the required experience is not available, a standard endotracheal tube should be placed. If the bleeding is suspected to be from the left lung then the tube can be placed in the right mainstem bronchus and the right lung ventilated while the patient is prepared for emergent surgery.

When to Refer
Indications for referral to subspecialists for evaluation of hemoptysis include the following:

Consideration of CT scan (to help determine type) Consideration of bronchoscopy (see indications above) Presence of massive or life-threatening hemoptysis Persistent or recurrent undiagnosed hemoptysis.

Medicolegal Concerns
The biggest concern for liability on the part of the physician in evaluation of hemoptysis is failure to diagnose lung cancer. A less frequently occurring situation is the failure to diagnose pulmonary thromboembolism. Because these clinical situations have differing concerns they will be treated separately. Eventual diagnosis of lung cancer when the patient presented earlier with hemoptysis is a cause for malpractice litigation. Two considerations allow appropriate evaluation while protecting the physician from risk. The first is to recognize the patient at risk for lung cancer from demographic data and smoking history, and include a sputum cytology (and, if warranted clinically, fiberoptic bronchoscopy) in the initial work-up. The second is to clearly record the advice given to the patient with suspected bronchitis and mild hemoptysis that stops spontaneously to return for further evaluation should hemoptysis recur. Hemoptysis is an infrequent but important symptom in pulmonary thromboembolism. The liability here is failure to consider pulmonary thromboembolism and to order appropriate tests when hemoptysis is associated with other acute symptoms (including shortness of breath and/or pleuritic chest pain) in a patient at risk for deep venous thrombosis.

Summary
There are several important steps in evaluation of the patient with hemoptysis. First, it should be determined whether the bleeding represents true hemoptysis or whether the source of bleeding is in the upper airway or in the gastrointestinal tract. Second, the significance of the bleeding should be evaluated, specifically ascertaining whether life-threatening bleeding is present. Third, a differential diagnosis based on the initial history should be developed; this will help focus subsequent questioning, physical

examination, and laboratory studies on likely sources of bleeding for the specific clinical situation. A chest x-ray should be obtained. If history, physical examination, and a chest x-ray do not reveal the source of bleeding, then a chest CT should be considered. Patients who are candidates for bronchoscopy include those with bleeding of more than 30 ml per day, hemoptysis which has been persistent for one week, and patients at high risk for lung cancer, particularly cigarette smokers older than forty years of age. Massive or life-threatening hemoptysis (bleeding at a rate of greater than 200 ml per day) constitutes an emergency with the major diagnostic objective being localizing the source of the bleeding so that emergent surgery to remove the bleeding site can be carried out. Bronchial arteriography and embolization should be considered in patients with poor pulmonary reserve due to pre-existing lung disease. References Goldman JM. Hemoptysis: Emergency assessment and management. Emerg Med Clin N Amer 1989; 7:325-339. This review addresses the evaluation and management of hemoptysis from the point of view of the emergency physician. Nonetheless, it is relatively thorough and useful to the primary physician. Massive hemoptysis is particularly, but not exclusively, emphasized. Marshall TJ, Flower CDR, Jackson JE. The role of radiology in the investigation and management of patients with haemoptysis. Clinical Radiol 1996; 51:391-400. A thorough review of the literature on this subject, especially focusing on the role of computed tomography of the chest. Santiago S, Tobias J, Williams AJ. A reappraisal of the causes of hemoptysis. Arch Intern Med 1991; 151:2449-2451. Johnston H, Reisz G. Changing spectrum of hemoptysis: Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy. Arch Intern Med 1989; 149:1666-1668. Hirschberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: Etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997; 112:440-444. These three series are the most recent to describe the prevalence of the various causes of hemoptysis. All three reflect prevalence in a subspecialty practice; no recent series exists (to our knowledge) of hemoptysis causes presenting to a primary care physician. The two studies from the U.S. (Santiago and Johnston & Reisz) suggest that the incidence of hemoptysis secondary to tuberculosis and bronchiectasis has decreased in contrast to older series. Bronchitis and bronchogenic carcinoma were the most frequent causes in both series. The study by Hirschberg et. al. from Israel found that bronchiectasis, lung cancer, bronchitis, and pneumonia were the most common causes of hemoptysis. Cahill BC, Ingbar DH. Massive hemoptysis: Assessment and management. Clin Chest Med 1994; 15:147-167. An excellent review of this subject. A step-by-step approach to evaluation and management is described with recommendations by the authors on controversial management issues. D. Chest Pain < back | next > F. Wheezing-Stridor 8 of 23 HTML pages

Copyright The Snowdrift Pulmonary Foundation, Inc. 2000

Hemoptysis: Diagnosis and Management JACOB L. BIDWELL, M.D. and ROBERT W. PACHNER, M.D. University of Wisconsin Medical School, Milwaukee, Wisconsin

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Hemoptysis is the spitting of blood that originated in the lungs or bronchial tubes. The patient's history should help determine the amount of blood and differentiate between hemoptysis, pseudohemoptysis, and hematemesis. A focused physical examination can lead to the diagnosis in most cases. In children, lower respiratory tract infection and foreign body aspiration are common causes. In adults, bronchitis, bronchogenic carcinoma, and pneumonia are the major causes. Chest radiographs often aid in diagnosis and assist in using two complementary diagnostic procedures, fiberoptic bronchoscopy and high-resolution computed tomography, which are useful in difficult cases and when malignancy is suspected. The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause. Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with close monitoring. If hemoptysis persists, consulting with a pulmonologist should be considered. Patients with risk factors for malignancy or recurrent hemoptysis also require further evaluation with fiberoptic bronchoscopy or high-resolution computed tomography. In up to 34 percent of patients, no cause of hemoptysis can be found. (Am Fam Physician 2005;72:1253-60. Copyright 2005 American Academy of Family Physicians.) Hemoptysis is defined as the spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage.1 Hemoptysis is classified as nonmassive or massive based on the volume of blood loss; however, there are no uniform definitions for these categories.2 In this article, hemoptysis is considered nonmassive if blood loss is less than 200 mL per day.3 The lungs receive blood from the pulmonary and bronchial arterial systems.4 The low-pressure pulmonary system tends to produce small-volume hemoptysis, whereas bleeding from the bronchial system, which is at systemic pressure, tends to be profuse.4 Blood loss volume is more useful in directing management than in reaching a diagnosis. After confirming the presence of blood, an initial task is differentiating between hemoptysis, pseudohemoptysis (i.e., the spitting of blood that does not come from the lungs or bronchial tubes), and hematemesis (i.e., the vomiting of blood). The first step in making a diagnosis is to differentiate hemoptysis from pseudohemoptysis or hematemesis.

Causes of Hemoptysis In the primary care setting, the most common causes of hemoptysis are acute and chronic bronchitis, pneumonia, tuberculosis, and lung cancer. The differential diagnosis and underlying etiologies are listed in Table 1.5 infection Infection is the most common cause of hemoptysis, accounting for 60 to 70 percent of cases.5 Infection causes superficial mucosal inflammation and edema that can lead to the rupture of the superficial blood vessels. In a retrospective study6 of inpatient and outpatient hemoptysis in the United States, bronchitis caused 26 percent of cases, pneumonia caused 10 percent, and tuberculosis accounted for 8 percent. Invasive bacteria (e.g., Staphylococcus aureus, Pseudomonas aeruginosa) or fungi (e.g., Aspergillus species) are the most common infectious causes of hemoptysis. Viruses such as influenza also may cause severe hemoptysis.7 Human immunodeficiency virus (HIV) infection predisposes patients to several conditions that may produce hemoptysis, including pulmonary Kaposi's sarcoma.8 SORT: Key Recommendations for Practice Clinical recommendation Patients with evidence of parenchymal disease should have high-resolution CT, and those with a mass should be considered for bronchoscopy. Patients with normal chest radiograph, no risk factors for cancer, and findings not suggestive for infection should be considered for bronchoscopy or high-resolution CT. After extensive initial investigation, closely follow smokers older than 40 years who have unexplained hemoptysis. CT=computed tomography. Evidence rating C C C Reference 5 5 6, 12, 13

A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limitedquality, patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 1154 or http://www.aafp.org/afpsort.xml. cancer Primary lung cancers account for 23 percent of cases of hemoptysis in the United States.6 Bronchogenic carcinoma is a common lung cancer responsible for hemoptysis in 5 to 44 percent of all cases.9,10 Bleeding from malignant or benign tumors can be secondary to superficial mucosal invasion, erosion into blood vessels, or highly vascular lesions. Breast, renal, and colon cancers have a predilection for lung metastasis; however, metastatic lung carcinoma rarely results in bleeding.6 Obstructive lesions may cause a secondary infection, resulting in hemoptysis. Table 1 Differential Diagnosis of Hemoptysis

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication. pulmonary venous hypertension Cardiovascular conditions that result in pulmonary venous hypertension can cause cardiac hemoptysis. The most common of these is left ventricular systolic heart failure. Other cardiovascular causes include severe mitral stenosis and pulmonary embolism. Although hemoptysis is a recognized pulmonary embolism symptom, pulmonary embolism is an uncommon cause of hemoptysis. For example, in a patient without underlying cardiopulmonary disease, the positive and negative likelihood ratios for hemoptysis in pulmonary embolism are 1.6 and 0.95, respectively. Therefore, the presence or absence of hemoptysis alone has no significant effect on the likelihood of pulmonary embolism.11 idiopathy Idiopathic hemoptysis is a diagnosis of exclusion. In 7 to 34 percent of patients with hemoptysis, no identifiable cause can be found after careful evaluation.6,12,13 Prognosis for idiopathic hemoptysis usually is good, and the majority of patients have resolution of bleeding within six months of evaluation.14 However, results from one study13 found an increasing incidence of lung cancer in smokers older than 40 years with idiopathic hemoptysis, and suggested that these patients may warrant close monitoring.13 hemoptysis in children The major cause of hemoptysis in children is lower respiratory tract infection. The second most common cause is foreign body aspiration, with most cases occurring in children younger than four years. Another important cause is bronchiectasis, which often is secondary to cystic fibrosis. Primary pulmonary tuberculosis is a rare cause estimated to occur in less than 1 percent of cases.15 Although uncommon, trauma is another possible cause. Blunt-force trauma may result in hemoptysis secondary to pulmonary contusion and hemorrhage. Bleeding caused by suffocation, deliberate or accidental, also should be considered.16 table 2 Differentiating Features of Hemoptysis and Hematemesis Hemoptysis Hematemesis History Absence of nausea and vomiting Presence of nausea and vomiting Lung disease Gastric or hepatic disease Asphyxia possible Asphyxia unusual Sputum examination Frothy Rarely frothy Liquid or clotted appearance Coffee ground appearance Bright red or pink Brown to black Laboratory

Alkaline pH Mixed with macrophages and neutrophils

Acidic pH Mixed with food particles

Information from references 4, 17, and 18. Patient History Historic clues are useful for differentiating hemoptysis from hematemesis (Table 24,17,18). Patient history also can help identify the anatomic site of bleeding, differentiate between hemoptysis and pseudohemoptysis, and narrow the differential diagnosis (Table 34,5,17,18). Factors such as age, nutrition status, and comorbid conditions can assist in the diagnosis and management of hemoptysis. table 3 Diagnostic Clues in Hemoptysis: Physical History Clinical clues Suggested diagnosis* Anticoagulant use Medication effect, coagulation disorder Association with menses Catamenial hemoptysis Dyspnea on exertion, fatigue, orthopnea, Congestive heart failure, left ventricular paroxysmal nocturnal dyspnea, frothy dysfunction, mitral valve stenosis pink sputum Fever, productive cough Upper respiratory infection, acute sinusitis, acute bronchitis, pneumonia, lung abscess History of breast, colon, or renal cancers Endobronchial metastatic disease of lungs History of chronic lung disease, Bronchiectasis, lung abscess recurrent lower respiratory track infection, cough with copious purulent sputum HIV, immunosuppression Neoplasia, tuberculosis, Kaposi's sarcoma Nausea, vomiting, melena, alcoholism, Gastritis, gastric or peptic ulcer, esophageal chronic use of nonsteroidal antivarices inflammatory drugs Pleuritic chest pain, calf tenderness Pulmonary embolism or infarction Tobacco use Acute bronchitis, chronic bronchitis, lung cancer, pneumonia Travel history Tuberculosis, parasites (e.g., paragonimiasis, schistosomiasis, amebiasis, leptospirosis), biologic agents (e.g., plague, tularemia, T2 mycotoxin) Weight loss Emphysema, lung cancer, tuberculosis, bronchiectasis, lung abscess, HIV HIV = human immunodeficiency virus. *-Arranged from most to least common diagnosis for each clinical clue. Information from references 4, 5, 17, and 18.

Once true hemoptysis is suspected, the investigation should focus on the respiratory system. Blood from the lower bronchial tree typically induces cough, whereas a history of epistaxis or expectorating without cough would be consistent with an upper respiratory source but does not exclude a lower tract site. Bleeding is difficult to quantify clinically. Patients may find it difficult to discern whether they are throwing up, coughing, or spitting out bloody material. The amount of blood loss usually is overestimated by patients and physicians, but an attempt to determine the volume and rate of blood loss should be made. Methods of determination include observing as the patient coughs and the use of a graduated container. Blood-streaked sputum deserves the same diagnostic consideration as blood alone. The amount or frequency of bleeding does not correlate with the diagnosis or incidence of cancer. It is helpful to determine whether there have been previous episodes of hemoptysis and what diagnostic assessments have been done. Mild hemoptysis recurring sporadically over a few years is common in smokers who have chronic bronchitis punctuated with superimposed acute bronchitis. Because smoking is an important risk factor, these patients are at higher risk for lung cancer.19 Chronic obstructive pulmonary disease also is an independent risk factor for hemoptysis. Low-risk patients with normal chest radiographs can be treated on an outpatient basis with close monitoring and appropriate oral antibiotics, if medication is clinically indicated. Environmental exposure to asbestos, arsenic, chromium, nickel, and certain ethers increases risk for hemoptysis. Bronchial adenomas, although malignant, are slow growing and may present with occasional bleeding over many years. Malignancy in general, especially adenocarcinomas, can induce a hypercoagulable state, thereby increasing the risk for a pulmonary embolism. A history of chronic, purulent sputum production and frequent pneumonias, including tuberculosis, may represent bronchiectasis. Association of hemoptysis with menses (i.e., catamenial hemoptysis) may represent intrathoracic endometriosis.20 A travel history may be helpful. Tuberculosis is endemic in many parts of the world, and parasitic etiologies should be considered.21,22 In regions where drinking from springs is common, there are case reports of hemoptysis caused by leeches attaching to the upper respiratory tract mucosa.23 Also, biologic weapons such as plague may cause hemoptysis.17,24 Physical Examination Historic clues often will narrow the differential diagnosis and help focus the physical examination (Table 44,5,17). Examining the expectoration may help localize the source of bleeding.4,17,18 The physician should record vital signs, including pulse oximetry levels, to document fever, tachycardia, tachypnea, weight changes, and hypoxia. Constitutional signs such as cachexia and level of patient distress also should be noted. The skin and mucous membranes should be inspected for cyanosis, pallor, ecchymoses, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa.

table 4 Diagnostic Clues in Hemoptysis: Physical Examination Clinical clues Suggested diagnosis* Cachexia, clubbing, voice hoarseness, Cushing's Bronchogenic carcinoma, small syndrome, hyperpigmentation, Horner's syndrome cell lung cancer, other primary lung cancers Clubbing Primary lung cancer, bronchiectasis, lung abscess, severe chronic lung disease, secondary lung metastases Dullness to percussion, fever, unilateral rales Pneumonia Facial tenderness, fever, mucopurulent nasal Acute upper respiratory infection, discharge, postnasal drainage acute sinusitis Fever, tachypnea, hypoxia, hypertrophied Acute exacerbation of chronic accessory respiratory muscles, barrel chest, bronchitis, primary lung cancer, intercostal retractions, pursed lip breathing, pneumonia rhonchi, wheezing, tympani to percussion, distant heart sounds Gingival thickening, mulberry gingivitis, saddle Wegener's granulomatosis nose, nasal septum perforation Heart murmur, pectus excavatum Mitral valve stenosis Lymph node enlargement, cachexia, violaceous Kaposi's sarcoma secondary to tumors on skin human immunodeficiency virus infection Orofacial and mucous membrane telangiectasia, Osler-Weber-Rendu disease epistaxis Tachycardia, tachypnea, hypoxia, jugulovenous Congestive heart failure caused by distention, S3 gallop, decreased lung sounds, left ventricular dysfunction or bilateral rales, dullness to percussion in lower lung severe mitral valve stenosis fields Tachypnea, tachycardia, dyspnea, fixed split S2, Pulmonary thromboembolic pleural friction rub, unilateral leg pain and edema disease Tympani to percussion over lung apices, cachexia Tuberculosis *-Arranged from most to least common diagnosis for each clinical clue. Information from references 4, 5, and 17. The examination for lymph node enlargement should include the neck, supraclavicular region, and axillae. The cardiovascular examination includes an evaluation for jugular venous distention, abnormal heart sounds, and edema. The physician should check the chest and lungs for signs of consolidation, wheezing, rales, and trauma. The abdominal examination should focus on signs of hepatic congestion or masses, with an inspection of the extremities for signs of edema, cyanosis, or clubbing.4,25 Diagnostic Evaluation

Figure 15 presents an algorithm for the evaluation of nonmassive hemoptysis. After a careful history and examination, a chest radiograph should be obtained (Table 54,17). If a diagnosis remains unclear, further imaging with chest computed tomography (CT) or direct visualization with bronchoscopy often is indicated. In high-risk patients with a normal chest radiograph, fiberoptic bronchoscopy should be considered to rule out malignancy. Risk factors that increase the likelihood of finding lung cancer on bronchoscopy include male sex, older than 40 years, a smoking history of more than 40 pack-years, and duration of hemoptysis for more than one week.26 Diagnosing Nonmassive Hemoptysis

Figure 1. Algorithm for diagnosing nonmassive hemoptysis. (CT = computed tomography.) Adapted with permission from Harrison TR, Braunwald E. Cough and hemoptysis. In: Harrison's Principles of internal medicine. 15th ed. New York: McGraw-Hill, 2001:208. Fiberoptic bronchoscopy is preferred if neoplasia is suspected; it is diagnostic for central endobronchial disease and allows for direct visualization of the bleeding site. It also permits tissue biopsy, bronchial lavage, or brushings for pathologic diagnosis.

Fiberoptic bronchoscopy also can provide direct therapy in cases of continued bleeding. Rigid bronchoscopy is the preferred tool for cases of massive bleeding because of its greater suctioning and airway maintenance capabilities. table 5 Diagnostic Clues in Hemoptysis: Chest Radiograph Chest radiograph findingSuggested diagnosis* Cardiomegaly, increased Chronic heart failure, mitral valve stenosis pulmonary vascular distribution Cavitary lesions Lung abscess, tuberculosis, necrotizing carcinoma Diffuse alveolar Chronic heart failure, pulmonary edema, aspiration, toxic infiltrates injury Hilar adenopathy or Carcinoma, metastatic disease, infectious process, sarcoid mass Hyperinflation Chronic obstructive pulmonary disease Lobar or segmental Pneumonia, thromboembolism, obstructing carcinoma infiltrates Mass lesion, nodules, Carcinoma, metastatic disease, Wegener's granulomatosis, granulomas septic embolism, vasculitides Normal or no change Bronchitis, upper respiratory infection, sinusitis, pulmonary from embolism baseline Patchy alveolar Bleeding disorders, idiopathic pulmonary hemosiderosis, infiltrates Goodpasture's syndrome (multiple bleeding sites) *-Arranged from most to least common diagnosis for each clinical clue. Information from references 4 and 17. High-resolution CT has become increasingly useful in the initial evaluation of hemoptysis and is preferred if parenchymal disease is suspected. Its complementary use with bronchoscopy gives a greater positive yield of pathology12,27,28 and is useful for excluding malignancy in high-risk patients.29 Its role in hemoptysis continues to evolve, and further studies are needed to evaluate its effect on patient management and outcome. Patients with recurrent or unexplained hemoptysis may need additional laboratory evaluation to establish a diagnosis (Table 65,17). table 6 Diagnostic Clues in Hemoptysis: Laboratory Tests Test Diagnostic findings White blood cell count and Elevated cell count and differential shifts may be differential present in upper and lower respiratory tract infections Hemoglobin, hematocrit Decreased in anemia Platelet count Decreased in thrombocytopenia Prothrombin time, International Increased in anticoagulant use, disorders of

Normalized Ratio, partial coagulation thromboplastin time Arterial blood gases Hypoxia, hypercarbia d-dimer Elevated in pulmonary embolism Sputum Gram stain, culture, Pneumonia, lung abscess, tuberculosis, acid-fast bacillus smear and mycobacterial infections culture Sputum cytology Neoplasm Purified protein derivative skin Positive increases risk for tuberculosis test Human immunodeficiency virus Positive increases risk for tuberculosis, Kaposi's test sarcoma Erythrocyte sedimentation rate Elevated in infection, autoimmune disorders (e.g., Wegener's syndrome, systemic lupus erythematosus, sarcoid, Goodpasture's syndrome), may be elevated in neoplasia Information from references 5 and 17. Management Nonmassive hemoptysis The overall goals of management of the patient with hemoptysis are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause. As with any potentially serious condition, evaluation of the "ABCs" (i.e., airway, breathing, and circulation) is the initial step. The most common presentation is acute, mild hemoptysis caused by bronchitis. Lowrisk patients with normal chest radiographs can be treated on an outpatient basis with close monitoring and appropriate oral antibiotics, if clinically indicated. If hemoptysis persists or remains unexplained, an outpatient evaluation by a pulmonologist should be considered. An abnormal mass on a chest radiograph warrants an outpatient bronchoscopic examination. For patients with a normal chest radiograph and risk factors for lung cancer or recurrent hemoptysis, outpatient fiberoptic bronchoscopy also is indicated to rule out neoplasm. High-resolution CT is indicated when clinical suspicion for malignancy exists and sputum and bronchoscopy do not yield any pathology. Highresolution CT also is indicated when chest radiography reveals peripheral or other parenchymal disease. massive hemoptysis The mortality rate from massive hemoptysis depends on the bleeding rate and etiology. Hemoptysis greater than 1,000 mL per 24 hours in the presence of malignancy carries a mortality rate of 80 percent30; therefore, massive hemoptysis warrants a more aggressive, expedient approach. These patients require intensive care and early consultation with a pulmonologist. In cases of massive or life-threatening hemoptysis, diagnosis and therapy must occur simultaneously. Airway maintenance is

vital because the primary mechanism of death is asphyxiation, not exsanguination. Supplemental oxygen and fluid resuscitation are essential. Assistance by a cardiothoracic surgeon should be considered because emergency surgical intervention may be needed. Author disclosure: Nothing to disclose.

The Authors JACOB L. BIDWELL, M.D., is a University of Wisconsin assistant professor of Family Medicine at St. Luke's Medical Center in Milwaukee and serves as medical director of Walker's Point Community Clinic. Dr. Bidwell received his undergraduate and medical degrees from the University of Wisconsin, Madison. He completed his family medicine residency at St. Luke's Medical Center. ROBERT W. PACHNER, M.D., is clinical assistant professor with the University of Wisconsin Department of Family Medicine in Milwaukee. Dr. Pachner graduated from the Medical College of Wisconsin and completed a family practice residency at St. Luke's Medical Center. Address correspondence to Jacob L. Bidwell, M.D., University of Wisconsin Medical School, 2801 W. Kinnickinnie River Parkway, Suite 175, Milwaukee, WI 53215 (email: jbidwell@fammed.wisc.edu). Reprints are not available from the authors.

Hemoptysis

Buy the Book PDA Download Update Me E-mail alerts The Merck Manual Minute Print This Topic Email This Topic Hemoptysis is coughing up of blood from the respiratory tract. Most of the lung's blood (95%) circulates through low-pressure pulmonary arteries and ends up in the pulmonary capillary bed, where gas is exchanged; about 5% of the blood

supply circulates through high-pressure bronchial arteries, which originate at the aorta and supply major airways and supporting structures. The blood in hemoptysis generally arises from this bronchial circulation, except when pulmonary arteries are damaged by trauma, by erosion of a granulomatous or calcified lymph node or tumor, or, rarely, by pulmonary arterial catheterization or when pulmonary capillaries are affected by inflammation. Blood-streaked sputum is common in many minor respiratory illnesses, such as URI and viral bronchitis. Massive hemoptysis is production of 600 mL of blood (about a full kidney basin's worth) within 24 h. The differential diagnosis is broad (see Table 2: Approach to the Patient With Pulmonary Symptoms: Differential Diagnosis of Hemoptysis ). Bronchitis, bronchiectasis, TB, and necrotizing pneumonia or lung abscess account for 70 to 90% of cases. Cavitary Aspergillus infection is being increasingly recognized as a cause but is not as common as malignancy; hemoptysis in smokers 40 yr triggers suspicion of primary lung cancer. Metastatic cancer rarely causes hemoptysis. Pulmonary-renal and diffuse alveolar hemorrhage syndromes (see Diffuse Alveolar Hemorrhage and Pulmonary-Renal Syndromes), pulmonary embolism and infarction (see Pulmonary Embolism (PE)), and left ventricular failure (especially secondary to mitral stenosis) are less common causes of hemoptysis. Hemoptysis in heart failure is unusual but occurs as a result of pulmonary venous hypertension from left ventricular failure. Primary bronchial adenoma and arteriovenous malformations are rare but tend to cause severe bleeding. Rarely, hemoptysis occurs during menstruation (catamenial hemoptysis) because of intrathoracic endometriosis. Table 2 Differential Diagnosis of Hemoptysis Larynx and pharynx Acute pneumonia Carcinoma Lymphoma Goodpasture's syndrome or variants Tuberculous ulceration Idiopathic hemosiderosis Trachea and large bronchi Infarct Benign or malignant primary tumor (carcinoma and adenoma) Bronchogenic cyst Broncholithiasis Erosion by an aortic aneurysm Erosion by a caseocalcific node Primary or metastatic tumor Trauma Heart and blood vessels Aortic aneurysm with leakage into the pulmonary parenchyma Fungus ball (aspergilloma) in an old cavity

Erosion by a tumor from nodes, esophagus, or other mediastinal structures Severe acute bronchitis

Atrial myxoma Fibrous mediastinitis with pulmonary vein obstruction Left ventricular failure

Telangiectasia Mitral stenosis Trauma Pulmonary arteriovenous malformation Smaller bronchial structures Pulmonary embolism/infarct Acute bronchitis Primary pulmonary hypertension Adenoma (carcinoid or cylindromatous) Bleeding diathesis Bronchiectasis Anticoagulant therapy Bronchopulmonary sequestration Carcinoma Chronic bronchitis Disseminated intravascular coaulation Trauma Pulmonary parenchyma Abscess Active granulomatous disease (tuberculous, fungal, parasitic, syphilitic) Miscellaneous congenital coagulation defects Thrombocytopenia Evaluation History: A key objective is to distinguish hemoptysis from hematemesis and from nasopharyngeal or oropharyngeal bleeding. This distinction can generally be accomplished with history and physical examination. An extensive smoking history suggests malignancy. A patient's sensation of where the bleeding may be coming from may help identify its origin if it is emanating from one of the upper lobes. Physical examination: Examination focuses on ruling out upper airway sites of bleeding and on listening over the lungs for focal abnormalities that may indicate the area where bleeding may be occurring. Unfortunately, blood originating from Fibrinolytic therapy: urokinase, streptokinase Some Trade Names STREPTASE Deficiency of vitamin Kdependent factors: prothrombin (II), Stuart factor (X), factor VII, Christmas factor (IX)

any area can be aspirated throughout the lung. Testing: Patients with minor hemoptysis can undergo testing on an outpatient basis. A chest x-ray is mandatory. Patients with normal results, a consistent history, and nonmassive hemoptysis can undergo empirical treatment for bronchitis. Those with abnormal results and those without a supporting history should undergo CT and bronchoscopy. CT may reveal pulmonary lesions that are not apparent on the chest x-ray and can help locate lesions in anticipation of bronchoscopy and biopsy. A ventilation/perfusion scan or CT angiogram can confirm the diagnosis of pulmonary embolism; CTs and pulmonary angiography can also detect pulmonary arteriovenous fistulas. When the etiology is obscure, fiberoptic inspection of the pharynx, larynx, esophagus, and/or airways may be indicated to distinguish hemoptysis from hematemesis and from nasopharyngeal or oropharyngeal bleeding. Patients with massive hemoptysis require treatment and stabilization before testing. The cause of hemoptysis remains unknown in 30 to 40% of cases. The prognosis for patients with cryptogenic hemoptysis is generally favorable, usually with resolution of bleeding within 6 mo of evaluation. Treatment The two objectives of treatment are to prevent aspiration of blood to the uninvolved lung (which can cause asphyxiation) and to prevent exsanguination from ongoing bleeding. Protection of the uninvolved lung can be difficult because the site of bleeding often is unclear. Strategies include positioning maneuvers (eg, having the patient lie with the bleeding lung in a dependent position) and selective intubation and obstruction of the bronchus going to the bleeding lung. Prevention of exsanguination involves reversal of any bleeding diathesis and direct efforts to stop the bleeding. Clotting deficiencies can be reversed with fresh-frozen plasma and factor-specific or platelet transfusions. Laser therapy, cauterization, or direct injection with epinephrine Some Trade Names ADRENALIN PRIMATENE MIST Click for Drug Monograph or vasopressin Some Trade Names PITRESSIN Click for Drug Monograph can be performed bronchoscopically. Massive hemoptysis is one of the few indications for rigid bronchoscopy, which provides control of the airway, allows for a larger field of view than flexible bronchoscopy, allows better suctioning, and is more suited to therapeutic interventions, such as laser therapy. Embolization of a pulmonary segment is becoming the preferred method with which to stop massive hemoptysis, with reported success rates of up to 90%. Emergency surgery is indicated for massive

hemoptysis not controlled by rigid bronchoscopy or embolization and is generally considered a last resort. Early resection may be indicated for bronchial adenoma or carcinoma. Broncholithiasis (erosion of a calcified lymph into an adjacent bronchus) may require pulmonary resection if endobronchial removal of the stone via rigid bronchoscopy cannot be performed. Bleeding secondary to heart failure or mitral stenosis usually responds to specific therapy for heart failure, but in rare cases, emergency mitral valvulotomy is necessary for life-threatening hemoptysis due to mitral stenosis. Bleeding from a pulmonary embolism is rarely massive and almost always stops spontaneously. If emboli recur and bleeding persists, anticoagulation may be contraindicated, and placement of an inferior vena cava filter is the treatment of choice. Because bleeding from bronchiectatic areas usually results from infection, treatment of the infection with appropriate antibiotics and postural drainage is essential. Sedatives and opioids suppress the ventilatory drive and should be avoided. Last full review/revision November 2005 Content last modified November 2005