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hemoptysis

Pulmonary hemorrhage; the spitting of blood derived from the lungs or bronchial tubes. Etiology: 1) pulmonary infections - bronchitis - lung abscess - tuberculosis - pneumonia (most commonly with): - Streptococcus pneumoniae - Klebsiella pneumoniae - bronchiectasis - broncholithiasis & pulmonary mycoses or parasites - HIV-associated infections 2) pulmonary neoplasm - carcinoma (squamous cell, small cell, adenocarcinoma) - bronchial adenoma 3) cardiovascular disease - mitral stenosis - pulmonary embolus - pulmonary vascular malformation - congestive heart failure [3] - pulmonary hypertension - airway-vessel (bronchovascular) fistula 4) autoimmune disorders - ANCA-associated vasculitis - Wegener's granulomatosis - Churg-Strauss syndrome - Goodpasture's syndrome - Lupus pneumonitis 5) trauma - puncture or laceration of lung - contusion of lung - foreign bodies 5) inherited or acquired bleeding disorders - idiopathic pulmonary hemosiderosis - anticoagulant therapy - pulmonary endometriosis - other bleeding disorders 7) pulmonary infarction 8) inherited/congenital disorders - cystic fibrosis - Eisenmenger's syndrome 9) chemotherapy History: - rate of onset, quantity of blood, color, character of sputum (clots, food), dyspnea, pleuritic chest pain, smoking, fever/ chills, exposure to tuberculosis or asbestos, hematuria, weight loss, farm exposure, foreign body aspiration, nasal or sinus pain, HIV risk factors, leg pain or swelling (PE), valvular heart disease, anticoagulants, NSAIDs, family history of bleeding disorder Laboratory: 1) complete blood count (CBC) - platelet count for thrombocytopenia 2) PT/PTT 3) sputum analysis a) cytology b) gram stain c) culture d) fungal stain 4) arterial blood gases 5) urinalysis: look for red cells & red cell casts, seen in: a) Wegener's granulomatosis - cANCA in serum (anti-proteinase-3) b) Goodpasture's syndrome - also anti-glomerular basement membrane (GBM) Special laboratory: - angiography by interventional radiology for massive hemoptysis - 200-1000 mL in 24 hours or > 100 mL in one event [8] - therapeutically useful via arterial embolization [8] - procedure of choice for massive hemoptysis [12] - fiberoptic bronchoscopy: - not the initial test for patients with hemoptysis (MKSAP19) [5,11] - may follow if the CT scan is unrevealing or if the CT scan reveals an abnormality that requires visualization or endobronchial biopsy [5] - formerly indicated for: - age > 40 years - history of smoking - hemoptysis longer than 1 week - unexplained abnormality on chest X-ray - offers little therapeutically [8] Radiology: 1) chest radiograph: initial study all patients 2) contrast-enhanced computed tomography (CT), +/- high resolution a) first test for blood-tinged sputum (MKSAP19) [5,11] b) despite normal chest radiograph c) formerly - patients unable to undergo bronchoscopy - persistent bleeding despite normal bronchoscopy [5] - with or without bronchoscopy if risk factors for malignancy 3) if bronchoscopy follows CT scan, bronchial arteriography if bronchoscopy fails to identify site of bleeding Differential diagnosis: 1) GI bleeding 2) nasopharyngeal hemorrhage 3) epistaxis Complications: asphyxiation with massive hemoptysis (major cause of death) Management: 1) general a) rule out disorders in the differential diagnosis b) check platelet count, prothrombin time, INR & aPTT 2) minor hemoptysis: a) treat underlying etiology b) observation with follow-up chest X-ray at 3 & 6 months may be appropriate - if chest radiograph is normal, & - risk factors are minimal or absent - smoking - age > 40 years - > 30 mL of blood - recurrent episodes c) nebulized tranexamic acid of benefit if hemoptysis < 200 mL [9] 3) massive hemoptysis a) defined as > 600 mL in 48 hours (> 100 mL/24h [5]) - 200-1000 mL in 24 hours or > 100 mL in one event [8] b) 90% result from bleeding of bronchial arteries c) supportive care - airway maintenance - cough suppression - broad spectrum antibiotic coverage if infectious etiology is suspected - lateral decubitus positioning with bleeding side down - if gas exchange is threatened, endotracheal intubation & mechanical ventilation d) angiography by interventional radiology for massive hemoptysis - 200-1000 mL in 24 hours or > 100 mL in one event [8] - therapeutically useful via arterial embolization [8] - procedure of choice for massive hemoptysis [12] e) surgical resection of bleeding site - fiberoptic bronchoscopy (bleeding may be too great for suction capabilities) - rigid bronchoscopy under general anesthesia - localize site of bleeding - isolate & ventilate uninvolved lung - rarely happens quickly enough to be useful for massive hemoptysis [12] - contraindications - inoperable lung cancer - predicted postoperative FEV1 of < 800 mL f) therapy of inoperative patients - tamponade of bleeding bronchial segment with balloon catheter - endobronchial lavage with: - cold saline - fibrinogen-thrombin solution - IV vasopressin - angiography with embolization of bronchial artery supplying bleeding segment

General

hemorrhage (bleeding) lung disease

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 258
  2. Chan & Winkle, Diagnostic History & Physical Examination, Current Clinical Strategies Publishing. Laguna Hills, 1996
  3. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 719-20
  4. contribution from Peter Baylor, M.D., UCSF Fresno
  5. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  6. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 173
  7. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 173
  8. NEJM Knowledge+ Question of the Week. June 19, 2018 https://knowledgeplus.nejm.org/question-of-week/1699/ - Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax. 2003 Sep;58(9):814-9. Review. PMID: 12947147 Free PMC Article - Jean-Baptiste E1. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000 May;28(5):1642-7. https://www.ncbi.nlm.nih.gov/pubmed/10834728
  9. Wand O, Guber E, Guber A et al. Inhaled tranexamic acid for hemoptysis treatment. Chest 2018 Dec; 154:1379 PMID: 30321510 https://journal.chestnet.org/article/S0012-3692(18)32572-8/fulltext
  10. Earwood JS, Thompson TD. Hemoptysis: evaluation and management. Am Fam Physician. 2015 Feb 15;91(4):243-9. PMID: 25955625 Free article. Review.
  11. Gagnon S, Quigley N, Dutau H, et al. Approach to hemoptysis in the modern era. Can Respir J. 2017;2017:1565030. PMID: 29430203
  12. NEJM Knowledge+