Hemoptysis

Hemoptysis: Description, Causes and Risk Factors:Alternative Name: Bronchostaxis, spitting up blood.HemoptysisThe word "hemoptysis" comes from the Greek work "haima," meaning "blood" and "ptysis," which means spitting. Thus, spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage is referred as hemoptysis.Types: Endemic hemoptysis, parasitic hemoptysis.Hemoptysis can have many causes, including infection, cardiovascular disease, cancer, and vasculitis.Infectious etiology:Chronic bronchitis. Cardiovascular etiology:Severe left ventricular heart failure.
  • Mitral stenosis.
  • Pulmonary embolism or infarction.
  • Septic pulmonary embolism or right-sided endocarditis.
  • Aortic aneurysm or bronchovascular fistula.
Neoplastic etiology:Lung cancer
  • Bronchial adenoma.
  • Metastatic disease (osteogenic sarcoma, choriocarcinoma).
Other:Wegener's granulomatosis.
  • Systemic lupus erythematosus.
  • Idiopathic pulmonary hemosiderosis.
  • Aspirated foreign body.
  • Pulmonary contusion or trauma.
  • Posttransthoracic needle biopsy or transbronchial lung biopsy.
The amount of blood expectorated is important because the rate of bleeding is a major determinant of morbidity. Massive hemoptysis has been arbitrarily defined as the expectoration of more than 100 to 600 mL of blood in 24 hours. Massive hemoptysis is a medical emergency that places the patient at high risk for asphyxiation and death. Primary care physicians are most likely to encounter nonmassive hemoptysis but also should be familiar with massive hemoptysis.Diagnosis:The most important initial step in diagnosis is to differentiate betweenminor and massive hemoptysis. Through careful questioning of thepatient, the amount of bleeding can be quantified. Massive hemoptysis isa true medical emergency and requires prompt diagnosis and treatment.Physical Examination (PE): The oropharynx and nasopharynx should be carefully inspected underadequate illumination to detect sources of bleeding in the upper airway.Cervical, supraclavicular, or axillary adenopathy suggests intrathoracicmalignancy. Auscultation of the chest may indicate rales due topneumonia or aspirated blood; it may also reveal localized wheezes dueto focal endobronchial lesions, such as lung cancer. A thoroughcardiovascular examination should be performed to detect S gallops,cardiac murmurs, jugular venous distention, and dependent edemasuggesting valvular heart disease or congestive heart failure. Clubbing ofthe fingers may be seen in patients with lung cancer, bronchiectasis, andlung abscess.Standard posteroanterior and lateral chest radiographs should beobtained in all patients with hemoptysis. Important findings includefibrocavitary disease (i.e., tuberculosis, necrotizing bacterial or fungalpneumonia), segmental or lobar atelectasis (from obstruction due tolung cancer, bronchial adenoma, or a foreign body), fungus balls incavitary lesions (aspergillosis), left atrial enlargement, Kerley's B lines(mitral stenosis), thickened bronchial walls (bronchiectasis),lymphadenopathy, and infiltrates. Up to 30% of patients with hemoptysishave a normal chest radiograph. A complete blood cell count,coagulation studies, and urinalysis to detect urinary abnormalities thatsuggest pulmonary-renal syndromes also should be performed routinely.Additional studies should be obtained, depending on the amount ofhemoptysis and patient characteristics.Tests that may be done include:Bronchoscopy.
  • Chest CT scan.
  • Chest x-ray.
  • Coagulation studies, such as PT (prothrombin time) or PTT (partial thromboplastin time).
  • Complete blood count.
  • Lung scan.
  • Lung biopsy.
  • Pulmonary arteriography.
  • Sputum culture and smear.
Patients who have had more than 30 to 50 mL of blood loss in theprevious 24 hours are at increased risk for death and should behospitalized for evaluation. Massive hemoptysis is likely to be a sign ofserious underlying disease and requires immediate workup.Treatment:Remember the 3 principles of management:Maintain airway patency and oxygenation
  1. Localize the source of bleeding.
  2. Control hemorrhage.
Patients with moderate hemoptysis should be hospitalized for observation and further evaluation. They should be kept at bed rest in the semisitting position when awake and with the radiographically abnormal lung down when recumbent. Cough suppression with codeine may be useful; however, oversedation should be avoided. Adequate oxygenation should be ensured. The suspected source and rate of bleeding determine the timing of and the tests used in further workup. Bronchoscopic examination is often the next step.Fewer than 5% of all cases of hemoptysis are massive. However, massive hemoptysis is a medical emergency that requires immediate evaluation and treatment. Treatment of massive hemoptysis is directed toward airway management, oxygenation, and localization of the bleeding site. Most deaths are due to asphyxia and hypoxemia from aspiration of blood into other areas of the lung. Management of massive hemoptysis requires a team approach involving appropriate pulmonary, anesthesia, thoracic surgical, and interventional radiology consultation. Patients should be admitted to an ICU (intensive care unit) for observation and kept at bed rest.Note: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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