Approach
Hemoptysis has variously been defined as anything from a small amount of blood-streaked sputum through to massive bleeding with life-threatening consequences due to airway obstruction and hemodynamic instability.[43] Although arbitrary and variable in the literature, the following definitions allow hemoptysis to be clinically characterized by the volume of expectorated blood:
Mild hemoptysis: <30 mL over 24 hours
Frank or moderate hemoptysis: ≥30 mL and <600 mL over 24 hours
Massive hemoptysis: 600 mL or more over 24 hours.
Pathophysiologically, it is intuitive to consider >150 mL hemoptysis as life-threatening, as this volume of blood could flood the conducting airways completely (i.e., fill the anatomic dead space to the level of gas-exchanging lung units). It is important to distinguish between hemoptysis and massive hemoptysis, as the differential diagnosis is narrower for the latter and therapeutic urgency is greater.
The initial diagnostic evaluation should aim to:
Differentiate between hematemesis (the vomiting of blood), pseudohemoptysis (the coughing of blood from a source other than the lower respiratory tract), and hemoptysis
Identify the site of bleeding
Narrow the differential diagnosis.
History and physical exam
A detailed history and physical exam can help rule out hematemesis or pseudohemoptysis, and may provide clues to the site and cause of the hemoptysis.
Pseudohemoptysis can occur when hematemesis is aspirated into the lungs, or when bleeding from the nasopharynx, sinuses, or oral cavity stimulates a cough reflex.[6] Other rare causes of pseudohemoptysis include pneumonia due to Serratia marcescens producing a red-pigmented sputum, or sputum pigmentation due to rifampin use.[44]
Characteristically, hemoptysis tends to be indicated by bright red, frothy sputum that is alkaline and with an oxygen saturation (SaO₂) similar to peripheral arterial saturation. Blood from gastrointestinal sources tends to be darker, may have admixed food particles, is acidic, and has an SaO₂ similar to that found in venous blood.[6][7] The exception is when brisk bleeding in the gastrointestinal tract overcomes the acidic environment of the stomach.
Key features of the history include the following points.
A history of untreated tuberculosis, lung cancer, or extrapulmonary metastatic cancer, and significant weight loss increase the risk for hemoptysis.
A history of smoking or exposure to asbestos or silica confers an increased risk of lung cancer.
A history of chronic mucopurulent sputum production with chronic lung disease is suggestive of bronchiectasis.
A history of exertion, orthopnea, or paroxysmal nocturnal dyspnea suggests the presence of congestive heart failure or mitral stenosis.
Dyspnea and pleuritic chest pain may indicate pulmonary embolism.
Detailed medication history: the use of anticoagulation therapy may indicate coagulopathy. A history of deep venous thrombosis, pulmonary embolism, or hypercoagulable state with inadequate anticoagulation suggests the possibility of pulmonary embolism as the source of hemoptysis.
Travel history to endemic areas: this may point to potential endemic sources of lung infection such as histoplasmosis in the Midwest river valleys of the US; coccidioidomycosis in the southwestern US; paragonimiasis in East Asia; or schistosomiasis in the tropics of South America, Africa, and the Far East.
Physical findings are uncommon but may help to establish the cause of hemoptysis.
The presence of ecchymoses and/or petechiae suggests hematologic diseases.
The presence of clubbing may be associated with non small-cell bronchogenic carcinoma, bronchiectasis, and chronic lung abscess.
A unilateral wheeze may be heard in cases of bronchial adenoma or endobronchial carcinomas that block the laminar flow of air.
The presence of a diastolic rumble, with an opening snap, loud S1, and loud P2 in the precordial exam suggest the presence of mitral stenosis.
Other systemic findings such as arthralgias, synovitis, and/or nose deformity are clues to rheumatologic causes such as granulomatosis with polyangiitis (formerly Wegener granulomatosis).
Chest x-ray and chest computed tomography
After a careful history and exam, a chest x-ray (CXR) should be obtained. This has been shown to localize the site of bleeding in 47% of patients.[45] It may also provide clues to any specific entity that may be responsible for hemoptysis, including tuberculosis, malignancy, bronchiectasis, aspergilloma, and lung abscess.
Aspiration of blood into the contralateral lung can cause the CXR to be misleading in determining the site of bleeding.[46] In addition, some causes of hemoptysis may not produce changes on a CXR; these include bronchitis, mild bronchiectasis, small areas of infection, angioma, infarction, aortopulmonary fistula, or an endobronchial lesion that is not large enough to cause bronchial occlusion.[7][47]
Chest computed tomography
If diagnosis remains unclear, chest computed tomography (CT) is indicated. Patients with moderate, or recurrent hemoptysis with high risk for lung cancer (>40 years old and >30 pack-year smoking history) or massive hemoptysis may also benefit from a chest CT scan if it can be done safely.[48][49] The American College of Radiology recommends the use of CT chest with contrast for optimal enhancement of the systemic arterial circulation most commonly implicated in hemoptysis.[50]
A dual source CT scanner enables the rapid acquisition of two x-ray sources at two different energy levels (dual energy mode) simultaneously, allowing for the acquisition of two data sets of diverse information. When coupled with split timing angiography, it enables the simultaneous evaluation of the systemic (bronchial) and pulmonary arteries for localizing the source of hemoptysis, including bronchial-pulmonary fistula.[51][52]
If pulmonary embolism is suspected due to acute shortness of breath with or without pleuritic chest pain, a chest CT angiogram or a ventilation/perfusion (V/Q) scan is indicated.[53]
CT chest is also useful to delineate the vascular anatomy prior to therapeutic arterial embolization.[48]
Bronchoscopy
If the history, exam, and chest imaging do not identify a clear cause for the hemoptysis, bronchoscopy is indicated. Bronchogenic carcinoma is found in 9.6% of patients with hemoptysis with normal CXR.[54]
The flexible bronchoscope is the instrument of choice for evaluating nonmassive hemoptysis, as flexible bronchoscopy (FB) can be performed in the outpatient setting, or at the bedside under moderate sedation. FB allows for subsegmental visualization of the airways including the upper lobe orifices.[14] To identify the bleeding site, FB is the most accurate method during active bleeding, with a success rate of 86%, and is widely recognized as the study of choice.[55][56][57] It can also be used as a therapeutic tool to block the bleeding site, and to introduce mechanical or thermal tools to treat it.[29] Although identification of the bleeding bronchopulmonary segment cannot be achieved in every patient, the yield can be increased by examining and performing diagnostic washing in every bronchial orifice. Sometimes, a bleeding tumor can be identified in the subsegmental bronchus. All abnormalities must be appropriately biopsied, brushed, or lavaged for adequate specimens when possible. The bronchoscopist should pay special attention and document vascular capillaries, bronchial inflammation, and subtle mucosal abnormalities. [Figure caption and citation for the preceding image starts]: Hypervascular endobronchial mucosaFrom the personal collection of Dr Erik Folch [Citation ends].
Available studies show a higher success rate when bronchoscopy is carried out early.[55][58][59] Identification of the bleeding site allows the clinician to focus on appropriate treatment. The flexible bronchoscope can be used to evacuate clots from the airway, obtain diagnostic sampling, and deliver local heat- or cold-based therapy.
The use of a rigid versus flexible bronchoscope in massive hemoptysis is debated. The choice is mostly driven by the experience of the operator and the clinical scenario. The advantages of the rigid bronchoscope (airway control, larger lumen, the opportunity to use larger instruments, and suction capability) may be offset by the disadvantages (need for an available operating room, general anesthesia, and reduced reach into distal airways).[5][28]
Urgent bronchoscopy in an unstable patient facilitates the introduction of a balloon-tip catheter into the bleeding bronchus to tamponade the hemorrhagic site, thereby protecting the nonbleeding lung from aspiration.[60]
Flexible bronchoscopy and rigid bronchoscopy are considered to be complementary techniques by many experts.[5][14][29][61]
Other imaging techniques
Bronchial arteriography can be used as a diagnostic and therapeutic intervention if available. This technique involves injecting radiocontrast dye into the thoracic aorta to visualize and localize the major systemic arteries to the lung, often guided by localization of the bleeding source on bronchoscopy. Once the feeding vessels are localized, selective bronchial arteriography can be performed and abnormal vessels identified. Abnormalities may include dilation, tortuosity, hypervascularity, and contrast extravasation. Once the bleeding source is identified, an embolizing agent (e.g., polyvinyl alcohol particles, gelfoam, dextran microspheres, or metal coils) can be injected. A post-embolization arteriogram is performed to ensure complete blockage of the bleeding vessel. The success rates reported with bronchial arteriography range from 70% to 99%, with a recurrence rate of up to 57%.[31]
Neurologic complications of paraparesis or paraplegia are potential complications of bronchial arteriography, occurring in 0.6% to 4.4% of procedures, as the anterior spinal artery originates from the bronchial arterial circulation in about 5% of the population.[31][62][63]
Angiography has been compared with flexible bronchoscopy (FB) for the diagnosis of the bleeding site in hemoptysis.[59] FB appeared to have a higher diagnostic yield (particularly when performed early), but angiography was able to identify the bleeding site in 2 out of 8 patients with non-diagnostic bronchoscopies.[59]
CT angiography
Useful for identifying airway and parenchymal disease and vascular anatomy and anomalies. In patients presenting with hemoptysis, it has been shown to provide new diagnostic information in 47%, clarify abnormalities in 15%, and localize the site of bleeding in 88%.[46] With the use of iterative model reconstruction and ECG-synchronized prospective-triggered technology in multidetector-row CT angiography, the bronchial anatomy can be depicted in patients with hemoptysis.[64] In patients with hemoptysis of unknown source and a normal CXR, such CT technology may help identify the possible source of bleeding. The 3-dimensional volume rendering reconstruction allows a virtual trip down the airways and may facilitate the bronchoscopic procedure.[65] The role of this technology in the workup of patients with hemoptysis remains unclear. From a practical standpoint, CT angiography should be the CT of choice in the initial workup of patients presenting with hemoptysis, a nondiagnostic CXR, and clinically suspected pulmonary thromboembolic disease. If pulmonary thromboembolism is ruled out, information gleaned from the CT angiogram is usually adequate to map the way for bronchoscopy and for subsequent bronchial artery embolization, should the latter become necessary. In most cases, identifying a bronchial artery source of hemoptysis is most useful in guiding therapy, which usually means embolization of the vessel.
Virtual bronchoscopy and CT angiogram, despite the high quality of image renderings, still require conventional bronchial angiography for therapeutic purposes.
Laboratory evaluation
The laboratory evaluation should be focused toward the suspected diagnosis.
Complete blood count may help identify infection, chronic blood loss, or a hematologic disorder (e.g., leukemia).
Coagulation studies may suggest treatable coagulopathies that facilitate the occurrence of hemoptysis.
Arterial blood gases are indicated, particularly when hemoptysis is severe or there is concern about respiratory failure.
Uremia should be considered as a factor contributing to hemoptysis due to the adverse effect of uremia on platelet aggregation.
Urinalysis may help identify a pulmonary-renal syndrome or vasculitis. If there is clinical suspicion for a pulmonary-renal syndrome, an antiglomerular basement membrane antibody test, antineutrophil cytoplasmic antibody test, and/or renal biopsy should be considered.
Sputum and serum studies should be obtained if an infective cause is suspected. If there is suspicion for granulomatous or cavitary lung infection, sputum collection for acid-fast bacilli and fungal cultures should be obtained. If endemic fungal infection (e.g., histoplasmosis, blastomycosis, coccidioidomycosis) is suspected, fungal serologies should be obtained.[66]
ECG and echocardiogram
If a cardiac cause of hemoptysis is suspected, an ECG and echocardiogram can help identify the presence of pulmonary hypertension, left ventricular failure, endocarditis, mitral stenosis, or ischemic heart disease.
How to record an ECG. Demonstrates placement of chest and limb electrodes.
Predictors of mortality
Retrospective data indicate that mechanical ventilation at the time of referral, cancer, aspergillosis, chronic alcoholism, pulmonary artery involvement, and infiltrates involving two quadrants or more on admission are independent predictors of increased mortality among in-hospital patients with hemoptysis.[67]
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