Hemoptysis

Hemoptysis is a topic covered in the Washington Manual of Medical Therapeutics.

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General Principles

Hemoptysis is the coughing up of blood or blood-stained mucus. It is a sign of an underlying pulmonary pathologic process. It can be life-threatening and as such requires rapid identification, workup, and treatment.

Definition

  • True hemoptysis is expectoration of blood from the lower respiratory tract below the glottis.
  • Massive hemoptysis/life-threatening hemoptysis:
    • Is usually defined by volume per unit time.
    • Definitions range from >100 mL in 16 hours to >1000 mL in 24 hours.
    • It is most commonly defined as >600 mL of blood expectorated per 24 hours.1,2
    • Volumes of >100 mL in 24 hours associated with gas exchange abnormality, airway obstruction, or hemodynamic instability are also considered life-threatening.

Classification

Clinically, hemoptysis is usually classified as being massive/life-threatening or not (see above). It may also be classified by the anatomic location of the bleeding.

  • Airway
  • Parenchyma
  • Vascular
  • Combination

    There are various other classifications in the literature based on appearance, frequency, rate, volume, and potential for clinical consequences of the hemoptysis that may suggest an underlying etiology or predict outcome and thus help guide in diagnosis and management. However, considerable overlap exists in the clinical presentation both within and between etiologies.

Etiology

It is clinically useful to identify etiology according to anatomic location.

  • Airway: bronchitis, bronchiectasis, malignancy, foreign body, trauma, pulmonary endometriosis, broncholithiasis
  • Parenchymal: pneumonia, vasculitides, and pulmonary hemorrhage syndromes (antineutrophil cytoplasmic antibody [ANCA]–positive vasculitis, Goodpasture syndrome, systemic lupus erythematosus, diffuse alveolar hemorrhage, acute respiratory distress syndrome)
  • Vascular: elevated pulmonary venous pressure (LV failure, mitral stenosis), pulmonary embolism, arteriovenous malformation (AVM), pulmonary arterial trauma (i.e., pulmonary arterial catheter balloon overinflation), varices/aneurysms, vasculitides, and pulmonary hemorrhage syndromes
  • Etiologies involving multiple anatomic locations: cavitary lung disease (TB, aspergilloma, lung abscess), thrombocytopenia, disseminated intravascular coagulation, anticoagulants, antiplatelets, cocaine and other inhaled agents, lung biopsy, bronchovascular fistula, bronchopulmonary sequestration, and Dieulafoy disease
  • Idiopathic/undiagnosed lesions may occur in up to 50% of case series. The prognosis in these cases is usually favorable, although up to 4% may eventually be diagnosed with malignancy.3,4

Epidemiology

The incidence of each cause of hemoptysis varies considerably. Listed are some of the most common causes of hemoptysis.4,5

  • Bronchiectasis: 1%–37%
  • Bronchitis: 2%–37%
  • Malignancy: 2%–24%
  • TB/cavitary lung disease: 2%–69%
  • Pneumonia: 1%–16%
  • Pulmonary embolus: 3%
  • Pulmonary edema: 4%
  • Idiopathic: 2%–50%

Pathophysiology

The source of hemoptysis depends on the etiology and location of the underlying pathologic process.

  • The pulmonary arterial circulation supplies 99% of all blood flow to the lung parenchyma under low pressure. Disruption can result in minor hemoptysis or more life-threatening hemoptysis because of processes such as vasculitis, diffuse alveolar hemorrhage, pulmonary embolism, acute respiratory distress syndrome, AVM rupture, pulmonary artery catheter trauma, severe mitral stenosis, LV failure, or Rasmussen aneurysm (pulmonary artery aneurysm associated with TB).
  • The bronchial arterial circulation arises from the aorta and intercostal arteries. It supplies high-pressure blood flow to the lungs but accounts for only 1% of pulmonary blood flow. Disruption by a foreign body, tumor invasion, fungal invasion, or denuded airway mucosa can result in massive, life-threatening hemoptysis. Bleeding from the bronchial circulation may account for up to 88% of all cases of massive hemoptysis.

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