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Hemoptysis

Last updated: January 6, 2022

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Hemoptysis is the expectoration of blood from the lower respiratory tract. It most commonly occurs as a result of a pulmonary infection; tuberculosis is the leading cause of hemoptysis worldwide. While lung cancer is the second most frequent cause of hemoptysis, bleeding from the respiratory tract only occurs in a minority of these patients. Typically, management of hemoptysis begins with the identification of the bleeding site using imaging or bronchoscopy. Definitive diagnostic evaluation is then guided by the location and appearance of the hemorrhagic site, patient symptoms, and patient risk factors for lung cancer. Treatment is directed at the underlying cause. Oral or inhaled tranexamic acid may be used for symptomatic relief. A minority of patients may present with massive hemoptysis, which can be life-threatening if not controlled emergently. In these patients, management begins with securing the airway and protecting the functioning lung. Bedside bronchoscopy and/or bronchial artery embolization are then used to control the hemorrhage. Definitive diagnosis and treatment follow respiratory and hemodynamic stabilization.

  • Hemoptysis is the presenting symptom in 0.1% of outpatient visits and hospitalizations. [5][6]

Epidemiological data refers to the US, unless otherwise specified.

Source of bleeding [2][7][8][9]

Overview of common etiologies

Etiology of hemoptysis [5][10][11]
Disease
Pulmonary
Cardiac
Vascular
Hematologic
Trauma
Iatrogenic
Other

Diffuse alveolar hemorrhage is most commonly a result of immune-mediated vasculitis or connective tissue disease. Other causes include congestive heart failure, infection, coagulopathy, and trauma. [1]

Approach [7][8]

See detailed further management of ”Nonmassive hemoptysis” and ”Massive and/or life-threatening hemoptysis” in their dedicated sections.

In cases of massive hemoptysis, stabilize the patient before obtaining further diagnostic studies.

Management priorities are resuscitation, protecting the nondiseased lung, and establishing respiratory and hemodynamic stability. Fatal hypoxia due to impaired gas exchange typically occurs before a hemodynamic change resulting from blood loss. [7][14]

Severity assessment [7]

Nonmassive hemoptysis requires respiratory and hemodynamic stability, a low volume and speed of blood loss, and no red flags for hemoptysis. Assume all other types of hemoptysis to be potentially life-threatening or have a high risk of progression to massive hemoptysis.

Red flags for hemoptysis [15]

The presence of any red flag feature is associated with an increased risk of mortality and the potential for rapid patient deterioration. [15]

Hemoptysis due to diffuse alveolar hemorrhage is frequently severe and life-threatening. [1]

Disposition

Approach

  • Perform initial studies, including CXR and basic laboratory studies.
  • Locate the site of bleeding.
  • Continue with further investigations for the underlying cause once the patient is clinically stable.

Initial studies for hemoptysis

Chest x-ray is mandatory in all patients with hemoptysis as it may quickly indicate the location and underlying cause of the bleeding.

Studies to locate the source of bleeding

Bronchoscopy can accurately determine the site of bleeding but is much less sensitive than chest CT at determining the underlying cause of the hemoptysis. A combination of both studies is often required for optimal management. [18]

Workup for underlying causes

Consider further investigations as directed by clinical suspicion of underlying conditions. See “Etiology of hemoptysis”. [5][19]

Priorities for management are acute stabilization followed by definitive bleeding control. The underlying cause can be investigated and treated once patients have been stabilized.

Description

  • Massive hemoptysis
    • A frequently used term with no universal definition
    • Commonly described using blood loss parameters, e.g., 100–1000 mL/24 hours or > 100 mL/hour [12]
    • Occurs in 5–15% of patients presenting with hemoptysis. [5][20]
  • Life-threatening hemoptysis consists of any volume of expectorated blood that causes any of the following: [21]

The effects of hemoptysis on a patient's airway patency, oxygenation, ventilation, and hemodynamic status are more important predictors of outcome and need for intervention than the absolute value or rate of blood loss. [7]

Acute stabilization

Follow ABCDE approach with simultaneous assessment and management.

Airway management and respiratory support

Avoid using a double-lumen endotracheal tube in the management of massive hemoptysis: The small lumen diameter impedes passage of a flexible bronchoscope and effective removal of large blood clots! [7]

Immediate hemodynamic support

Basic hemostatic measures

  • Reverse anticoagulants.
  • Consider the use of a hemostatic agent.
    • First line: tranexamic acid (TXA)
      • Has been shown to reduce mortality, interventional procedures, and length of hospital stay. [20][22][23][24]
      • Can be administered systemically, orally, or by nebulization. [22][25]
    • Consider desmopressin in patients with severe renal impairment. [26][27]

Bronchoscopic hemostasis [7]

Basic hemostatic measures alone rarely control the bleeding in massive hemoptysis; patients typically require local therapy via bronchoscopy.

Flexible fiberoptic bronchoscopy is the initial procedure of choice for the diagnosis and treatment of massive hemoptysis in an unstable patient. [7]

Definitive therapy

To prevent a recurrence, the majority of patients who have experienced massive hemoptysis undergo either bronchial artery embolization or surgery.

Bronchial artery embolization (BAE) [29]

  • BAE is the preferred treatment method for most patients with massive hemoptysis.
  • Bleeding sites or high-risk vascular abnormalities are detected on CTA or thoracic angiography.
  • Embolic material or coils are introduced to the suspected area under fluoroscopic guidance. [8][14]

BAE should be performed as soon as the patient has been stabilized. [8][30]

Because the aortic origins of the spinal arteries and the bronchial arteries are in close proximity, spinal arteries may be inadvertently occluded during BAE. Therefore, be alert for new neurological symptoms in patients who have recently undergone BAE. [8]

Surgery [8][12]

Management of diffuse alveolar hemorrhage [1][31]

Acute management checklist for massive and/or life-threatening hemoptysis

Description [5][7]

Nonmassive hemoptysis has no universal definition. Commonly described parameters include all of the following:

Initial approach

Treat any patients who develop signs of hemodynamic instability, respiratory compromise, or red flags for hemoptysis as life-threatening hemoptysis!

Symptomatic therapy

  • In 90% of cases, hemoptysis resolves with treatment of the underlying cause. [7]
  • If the symptoms of hemoptysis are distressing for the patient, consider TXA. [22][25]

Management of underlying causes [5]

  • For patients with new opacity or signs of infection on CXR:
  • Obtain CT chest with IV contrast for patients with:
    • CXR showing a mass or evidence of lung disease (e.g., COPD).
    • Any of the following despite normal findings or new opacity on initial CXR:
      • Elevated cancer risk
      • Recurrent hemoptysis at any time
      • Persistent opacity on follow-up CXR
  • Consult pulmonology and consider bronchoscopy for patients with:
    • A mass or evidence of lung disease on imaging
    • Recurrent hemoptysis at any time
    • Elevated cancer risk despite normal imaging [9]

Even after extensive evaluation, up to 50% of patients with nonmassive hemoptysis have no definitive diagnosis. Though the likelihood of underlying malignancy is rare, educate patients on the symptoms of lung cancer and arrange regular follow-up for those with an elevated risk. [11]

Acute management checklist for nonmassive hemoptysis

  • Verify patient is stable, oxygenating well, and that the bleeding is not clinically significant.
  • Verify that bleeding is from the lower respiratory tract.
  • Obtain x-ray chest.
  • Obtain initial laboratory studies for hemoptysis, including cultures.
  • Determine the patient's cancer risk based on history and volume of hemoptysis.
  • CT chest if indicated by x-ray chest findings and cancer risk.
  • Pulmonary consultation for abnormal imaging, abnormal laboratory studies, or recurrent bleeding
  • Investigate and treat underlying causes.
Distinguishing hemoptysis from pseudohemoptysis [5][9]
History Potential findings
Hemoptysis
  • Known pulmonary disease
  • Cough
Gastrointestinal bleeding
  • Known gastrointestinal disease or liver disease
  • Sequelae of liver disease may be present on examination.
  • Blood resembles coffee grounds
  • Food remnants may be visible.
  • Blood visible on gastric suctioning
  • Acidic blood pH
Upper respiratory tract bleeding

The differential diagnoses listed here are not exhaustive.

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