Pulmonary Medicine

Hemoptysis (as a cardinal symptom/sign)

What every physician needs to know

Hemoptysis is the expectoration of blood. When the volume of blood expectorated is greater than 100-500 ml over 24 hours, the hemoptysis is categorized as massive. Massive hemoptysis, which occurs in approximately 5 percent of all cases, is often a sign of a serious underlying medical condition that constitutes a medical emergency.

The mortality rate in massive hemoptysis is as high as 75 percent; death is due to acute airway obstruction and hypoxemic respiratory failure, rather than exsanguination. Since total airway dead space measures approximately 150 ml, the conducting airways may become obstructed with even minimal bleeding if a patient is unable to clear blood effectively.

Classification:

Hemoptysis is generally considered either massive or submassive. Massive hemoptysis is broadly defined as production of 100-500 ml of blood over 24 hours.

Are you sure your patient has hemoptysis? What should you expect to find?

Hemoptysis is evident as a cough with accompanying expectoration of blood or blood-streaked sputum. Some patients note "gurgles" or "rattles" in their chests before hemoptysis begins.

Beware: there are other diseases that can mimic hemoptysis:

Epistaxis and hematemesis are two common disorders that may mimic hemoptysis. Patients may be unable to differentiate among the various potential bleeding sources. If epistaxis of hematemesis can not be excluded, consultation with an otolaryngologist or gastroenterologist is warranted.

How and/or why did the patient develop hemoptysis?

When a patient presents with massive hemoptysis, several major etiologic categories should be considered as diagnostic and management plans are implemented.

Etiologies of hemoptysis

Infection

   Tuberculosis

   Bronchiectasis

   Fungal (primary or mycetoma)

   Lung abscess

   Paragonimiasis

   Hydatid cysts

   Necrotizing pneumonia

   Septic emboli

Neoplasm

   Lung cancer (small-cell and non-small-cell)

   Pulmonary carcinoid

   Endobronchial metastases

   Parenchymal metastases

Autoimmune

   Diffuse alveolar hemorrhage

   ANCA-associated granulomatous vasculitis (formerly Wegener's granulomatosis)

   Goodpasture syndrome

   Microscopic polyangiitis

   Polyarteritis nodosum

   Systemic lupus erythematosis

   Rheumatoid arthritis

   Systemic sclerosis

Cardiac/vascular

   Arterior-venous malformation

   Mitral stenosis

   Pulmonary embolism/infarct

   Congenital heart defects

   Pulmonary hypertension

   Aortic aneurysm

   Bronchoarterial fistula

   Congestive heart failure

   Pulmonary vein stenosis (following atrial fibrillation ablation)

Latrogenic

   Bronchoscopy

   Trans-thoracic needle aspiration

   Transbronchial biopsy

   Tracheo-inominate artery fistula

   Radiotherapy

   Targeted chemotherapeutic agents (e.g., bevacizumab)

Trauma

   Blunt or penetrating chest trauma

Which individuals are at greatest risk of developing hemoptysis?

A detailed history and physical examination may provide initial clues regarding the underlying etiology. Physicians should elicit any recent history of symptoms of infection. Particular attention should be focused on eliciting any prior underlying lung or cardiac disease, occupational or tobacco exposures, history of symptoms associated with connective tissue disease, and family history of lung disorders or bleeding disorders.

What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?

Initial laboratory tests should include a complete blood count, coagulation studies, blood urea nitrogen, creatinine, and urinalysis. These study results may provide clues to the presence of any underlying systemic disorders (e.g., coagulopathy, autoimmune pulmonary-renal syndromes). Serologies (ANA, rheumatoid factor, ANCA) should be evaluated for a suspected pulmonary-renal syndrome. Sputum and blood cultures should be performed to look for pathogenic organisms when an infectious source is suspected.

What imaging studies will be helpful in making or excluding the diagnosis of hemoptysis?

Radiographic studies form the diagnostic evaluation backbone in massive hemoptysis. A guiding principle is to localize a lesion upon which intervention may be performed, if necessary. The standard chest radiograph (CXR) is an important initial tool that may identify a number of pathologic entities, including cavitary lesions, tumors, lobar or alveolar infiltrates, pulmonary infarcts, and mediastinal masses. However, the false-negative rate of the standard CXR may be as high as 40 percent.

Computed tomography (CT) greatly enhances radiographic evaluation because of enhanced sensitivity over standard chest radiography. CT may detect nodules, masses, cavitary lesions, infiltrates, and mediastinal adenopathy that might be otherwise missed on the CXR. Contrast-enhancement may detect pulmonary emboli, arteriovenous malformations (AVMs), or aneurysms.

Moreover, multifocal CT abnormalities may help identify bleeding laterality. Two major limitations of CT imaging are the time required to obtain the study and the need for supine positioning of the patient, which may impair airway clearance with ongoing bleeding. Therefore, in rapidly-progressive, life-threatening hemoptysis, definitive intervention should not be delayed for purposes of obtaining a CT.

What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of hemoptysis?

Since hemoptysis is generally an acute, anxiety-provoking event, most patients present to their primary care doctor or pulmonologist or to an emergency department for evaluation. Laboratory, radiographic, and bronchoscopic evaluations are usually undertaken in the emergency department or in an inpatient setting, including the intensive care unit.

What diagnostic procedures will be helpful in making or excluding the diagnosis of hemoptysis?

Fiberoptic bronchoscopy is an important procedure to consider in identifying the souce of hemoptysis when it is unclear from radiographic studies. The overall goal of bronchoscopy is identification of the bleeding site so that definitive interventions may be performed if bleeding continues or becomes life-threatening. If the source of bleeding is unclear, and upper airway or gastrointestinal sources are suspected, nasopharygolaryngoscopy or esophagogastroduodenoscopy may be performed.

What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of hemoptysis?

If primary bronchogenic carcinoma is believed to be the source of hemoptysis, sputum cytology may be sent; however, in contemporary thoracic oncology management, this should not be the only diagnostic evaluation performed, as patients should have full radiographic and minimally-invasive staging procedures performed.

If you decide the patient has hemoptysis, how should the patient be managed?

Bronchial artery embolization (BAE), which was first performed in the 1970s, has become the non-surgical treatment modality used most often because of its effectiveness on both a short-term (over 90%) and long-term (over 80%) basis. Successful embolization depends largely on the ability to delineate the vascular anatomy angiographically. In patients with recurrent bleeding despite embolization (10-20% over six to twelve months), repeat embolization can be attempted.

Patients with lateralized, uncontrolled bleeding should be assessed early for possible surgery in case they prove to be refractory to temporary measures or BAE. Surgical intervention is usually the treatment choice in massive hemoptysis cases that are due to leaking aortic aneurysms, hydatid cysts, iatrogenic pulmonary vascular ruptures, or chest trauma. However, surgery is contraindicated in carcinomatous invasion of the trachea, mediastinum, heart, and great vessels and in advanced lung fibrosis.

The surgical mortality rate in massive hemoptysis (defined as death within seven days postoperatively) ranges from 1 percent to 50 percent, with emergent cases having the highest mortality rate. Common surgical complications include empyema, bronchopleural fistula, postoperative pulmonary hemorrhage, prolonged respiratory failure, wound infection, and hemothorax. Recently, some centers have demonstrated reduced mortality by avoiding surgical intervention within 48 hours from onset of hemoptysis if bleeding can be temporized with less invasive measures.

Late rebleeding (past one year) is usually due to neovascularization or recanalization. BAE complications are uncommon in experienced hands, but bronchial wall necrosis and ischemic myelopathy from inadvertent spinal artery embolization can occur.

(1) tracheostomy tube cuff hyperinflation

(2) tracheostomy tube exchange with standard oral endotracheal intubation, followed by finger insertion into the tracheostomy stoma with anterior pressure against the sternum to tamponade bleeding.

With either of these balloon occlusion methods, the balloon must be deflated every several hours to prevent mucosal and airway ischemia from the hydrostatic pressure exerted by the balloon. Ideally, this evaluation should be done under bronchoscopic vision in the event of continued brisk bleeding, for which the balloon would need re-inflation.

Allowing the patient to clear his or her own airway is more effective than any mechanical intervention. Patients should be admitted to and monitored very closely in an intensive care unit (ICU), and endotracheal intubation should proceed if a patient cannot clear the bleeding or if the patient develops progressive respiratory distress or hypoxemia.

Intubation with large-bore endotracheal tubes (e.g., 8.5 or 9 mm diameter) is recommended to facilitate suctioning and to allow bronchoscope insertion. If the patient has ongoing large-volume hemoptysis, the physician should proceed directly to rigid bronchoscopy to allow simultaneous large volume suctioning, ventilation, mechanical temporizing maneuvers (balloon exclusion), and photocoagulation modalities (if needed).

Rigid bronchoscopy allows simultaneous large-bore suction, airway maintenance, and ventilation, so it is the preferred modality in life-threatening hemoptysis. However, the effectiveness of rigid bronchoscopy can be limited by physician experience and inability to access beyond the trachea and mainstem bronchi. Consequently, rigid and flexible bronchoscopy are often combined to achieve optimal bleeding evaluation and control.

What is the prognosis for patients managed in the recommended ways?

The prognosis for patients with life-threatening hemoptysis depends on two factors: the ability to prevent acute asphyxiation from airway obstruction and the underlying etiology. In patients in whom massive hemoptysis is controlled and for whom the hemoptysis is found to be due to an underlying, treatable pulmonary or systemic condition (e.g., infection, pulmonary-renal syndrome, or septic emboli), the prognosis is good. In contrast, in patients who have significant hemoptysis and untreatable or advanced diseases (e.g.,lung cancer or metastatic pulmonary lesions), the prognosis is poor.

What other considerations exist for patients with hemoptysis?

In patients with arteriovenous malformations and hemoptysis from hereditary hemorrhagic telangectasia, genetic screening and counselling may be important considerations for patients and families.

What’s the evidence?

Sakr, L, Dutau, H. "Massive hemoptysis: An update on the role of bronchoscopy in diagnosis and managment". Respiration. vol. 80. 2010. pp. 38-58.

An excellent and thorough review highlighting the role of bronchoscopy in massive hemoptysis.

Cahill, B, Ingbar, D. "Massive hemoptysis". Clin Chest Med. vol. 15. 1994. pp. 147-168.

Cremashi, P, Nascimbene, C, Vitulo, P. "Therapeutic embolization of the bronchial artery: A successful treatment in 209 cases of relapse hemoptysis". Angiology. vol. 44. 1993. pp. 295-299.

Ibrahim, WH. "Massive haemoptysis: The definition should be revised". Eur Respir J. vol. 32. 2008. pp. 1131.

An editorial describing the shortcomings of using “volume of blood” to define massive hemoptysis and proposing a more functional, clinically relevant definition.

Johnston, H, Reisz, G. "Changing spectrum of hemoptysis. Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy". Arch Intern Med. vol. 149. 1989. pp. 1666-1668.

A single-center retrospective study that examines the etiology of hemoptysis in 148 patients undergoing diagnostic bronchoscopy.

Lee, E, Grant, J, Loh, C. "Bronchial and pulmonary arterial and venous interventions". Semin Respir Crit Care Med. vol. 29. 2008. pp. 95-404.

A brief review of interventional radiology procedures available for several vascular diseases in the pulmonary critical care setting.

Miller, R, McGregor, D. "Hemorrhage from carcinoma of the lung". Cancer. vol. 46. 1980. pp. 200-5.

A retrospective review of 877 cases of lung cancer patients that considers the associations among malignant cell type, presence of cavitation, use of radiation therapy, and degree of hemoptysis.

Rasmussen, V. "On haemoptysis, especially when fatal, in its anatomical and clinical aspects". Edinburgh Med J. vol. 14. 1968. pp. 385.

The first published description of Rasmussen’s aneurysm and its relationship to hemoptysis.

Remy-Jardin, M, Bouaziz, N, Dumont, P. "Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography". Radiology. vol. 233. 2004. pp. 741-9.

A retrospective evaluation of 48 patients with hemoptysis that compares the quality of angiography between conventional methods and CT.

Santiago, S, Tobias, J, Williams, A. "A reappraisal of the causes of hemoptysis". Arch Intern Med. vol. 151. 1991. pp. 2449-51.

A single-center retrospective review of 293 cases that underwent bronchoscopic examination for unexplained hemoptysis with comment on the changing incidence of several etiologies compared to older studies.

Shigemura, N, Wan, I, Yu, S. "Multidisciplinary management of life-threatening massive hemoptysis: A 10-year experience". Ann Thorac Surg. vol. 87. 2009. pp. 849-53.

A single-center retrospective review of 120 cases of massive hemoptysis with outcome comparison made between cases in 2000 to 2005 with that of 1995 to 1999 and emphasis placed on the need for implementation of a multidisciplinary approach to management of massive hemoptysis.

Swanson, K, Johnson, C, Prakash, U. "Bronchial artery embolization: Experience with 54 patients". Chest. vol. 121. 2002. pp. 789-95.

One center’s experience with bronchial artery embolization.

Wang, G, Ensor, J, Gupta, S. "Bronchial artery embolization for the management of hemoptysis in oncology patients: Utility and prognostic factors". J Vasc Interv Radiol. vol. 20. 2009. pp. 722-9.

A single-center retrospective review of 30 cases of hemoptysis managed with BAE in the oncology population with the aim of determining prognostic factors. The review includes observation of poor prognosis in cases of hemoptysis related to malignant disease.

Chawla, M, Getzen, T, Simoff, M. "Medical pneumonectomy: Interventional bronchoscopic and endovascular management of massive hemoptysis due to pulmonary artery pseudoaneurysm, a consequence of endobronchial brachytherapy". Chest. vol. 135. 2009. pp. 1355-8.

A case report of massive hemoptysis associated with endobronchial brachytherapy managed successfully with bronchoscopic and endovascular techniques.A single center retrospective review of 209 cases treated with multiple embolization techniques.
Loading links....

Sign Up for Free e-newsletters

Regimen and Drug Listings

GET FULL LISTINGS OF TREATMENT Regimens and Drug INFORMATION

Bone Cancer Regimens Drugs
Brain Cancer Regimens Drugs
Breast Cancer Regimens Drugs
Endocrine Cancer Regimens Drugs
Gastrointestinal Cancer Regimens Drugs
Genitourinary Cancer Regimens Drugs
Gynecologic Cancer Regimens Drugs
Head and Neck Cancer Regimens Drugs
Hematologic Cancer Regimens Drugs
Lung Cancer Regimens Drugs
Other Cancers Regimens
Rare Cancers Regimens
Skin Cancer Regimens Drugs