190

PERSPECTIVE

Epidemiology

Hemoptysis is defined as the expectoration of blood from the respiratory tract below the vocal cords. Most cases seen in the emergency department (ED) are mild episodes of small-volume hemoptysis, typically consisting of either blood-tinged sputum or minute amounts of frank blood, most often associated with bron-chitis. Although hemoptysis is commonly seen in the ED, only 1% to 5% of hemoptysis patients have massive or life-threatening hemorrhage. Many definitions exist, but massive hemoptysis is generally accepted as 100 to 600 mL of blood loss in any 24-hour period, which can result in hemodynamic instability, shock, or impaired alveolar gas exchange and has a mortality rate approach-ing 80%.

Large, contemporary series of patients with massive hemopty-sis are lacking, and most causative data originate from small, often rural, studies in which tuberculosis (TB) and bronchiectasis are responsible for the majority of cases. In developed nations, cancer, cystic fibrosis, arteriovenous malformations, anticoagulant use, and postprocedural complications play more prominent roles. Pediatric hemoptysis is rare but can be caused by infection, con-genital heart disease, cystic fibrosis, or bleeding from a preexisting tracheostomy. Major causes of hemoptysis are listed in Box 21.1.

Pathophysiology

Minor hemoptysis typically originates from tracheobronchial capillaries that are disrupted by vigorous coughing or minor bronchial infections. Conversely, massive hemoptysis nearly always involves disruption of bronchial or pulmonary arteries, which are the two sets of vessels that constitute the lung’s dual blood supply. Bronchial arteries, which are direct branches from the thoracic aorta, are responsible for supplying oxygenated blood to lung parenchyma, and disruption of these vessels from arteritis, trauma, bronchiectasis, or malignant erosion can result in sudden and profound hemorrhage. Although small in caliber, the bron-chial circulation is a high-pressure system and the culprit in nearly 90% of the cases of massive hemoptysis requiring emboli-zation. Pulmonary arteries, although transmitting large volumes of blood, do so at much lower pressures and, unless affected cen-trally, are less likely to cause massive hemoptysis.

Nearly all causes of hemoptysis have a common mechanism—vascular disruption within the trachea, bronchi, small-caliber airways, or lung parenchyma. Modes of vessel injury include acute and chronic inflammation (from bronchitis and arteritis), local infection (especially lung abscesses, TB, and aspergillosis), trauma, malignant invasion, infarction following a pulmonary embolus, and fistula formation (specifically aortobronchial fistulae).

In the 1960s, nearly all cases of massive hemoptysis were a result of TB, bronchiectasis, or lung abscess. Each of these has since decreased in frequency, whereas pneumonia and bleeding diathesis have become more prevalent.

Bronchiectasis, a chronic necrotizing infection resulting in bronchial wall inflammation and dilation, is one of the most common causes of massive hemoptysis worldwide. As tissue destruction and remodeling occur, rupture of nearby bronchial vessels can result in bleeding. Bronchiectasis can complicate chronic airway obstruction, necrotizing pneumonia, TB, or cystic fibrosis. Broncholithiasis, the formation of calcified endo-bronchial lesions following a wide array of granulomatous infec-tions, is an uncommon problem with a similar propensity to erode nearby vessels. Hemorrhage control often requires surgical intervention.

Iatrogenic hemoptysis complicates 2% to 10% of all endobron-chial procedures, especially percutaneous lung biopsies. Right (pulmonary artery) heart catheterization using a Swan Ganz cath-eter can cause iatrogenic pulmonary artery perforation especially in patients with pulmonary hypertension. Although this compli-cation is rare, the mortality is between 50% to 70%.1,2 Diffuse alveolar hemorrhage can be seen with autoimmune vasculitides, such as Wegener’s granulomatosis, systemic lupus erythematosus (SLE), and Goodpasture’s syndrome. An uncommon cause of hemoptysis occurs when ectopic endometrial tissue within the lung results in monthly catamenial episodes of bleeding. Less common causes include pulmonary hereditary telangiectasias and hydatidiform infections. Any episode of hemoptysis can be exac-erbated by coagulopathy and thrombocytopenia.

DIAGNOSTIC APPROACH

Differential Diagnosis Considerations

First, the clinician should be convinced that the source of the bleeding is pulmonary. Distinguishing hemoptysis from hematemesis is accomplished by the clinician working with the patient to clarify details of the history, particularly differentiation between coughing and vomiting or spitting. Nasal, oral, or hypo-pharyngeal bleeding may contaminate the tracheobronchial tree, mimicking true hemoptysis. The clinician should closely inspect the nasopharynx and oral cavity to exclude this possibility. Gastric or proximal duodenal bleeding can similarly mimic hemoptysis, and differentiating a gastrointestinal (GI) source of bleeding is especially important because further evaluation and management of these two pathologies follow divergent pathways. In unclear cases, inspection and pH testing may help to distinguish GI from tracheobronchial hemorrhage. Unless an active, brisk upper GI hemorrhage is present, the acidification of blood in the stomach results in fragmentation and darkening, producing specks of brown or black material often referred to as coffee-ground emesis. Pulmonary blood appears bright red or as only slightly darker clots and is alkaline.

Inflammatory disorders that secondarily involve the lungs or pulmonary vasculature include Wegener’s granulomatosis, Good-pasture’s syndrome, and SLE, and a history of these should be elicited. Any risk factors for platelet dysfunction, thrombocytope-nia, and coagulopathy should be noted, as should, conversely, any

C H A P T E R 21

HemoptysisCalvin A. Brown III

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191CHAPTER 21  Hemoptysis

Signs

A targeted examination may suggest the location and cause of bleeding but does so in less than 50% of cases. Focal adventitious breath sounds in a febrile patient may indicate pneumonia or pulmonary abscess. A new heart murmur, especially in a febrile patient, may reflect endocarditis causing septic pulmonary emboli. A rash might hint at underlying rheumatologic disorders, such as SLE or vasculitis. Symptoms and signs of deep venous thrombosis suggest pulmonary embolism. Ecchymoses and petechiae can indicate coagulopathy and thrombocytopenia, respectively.

Ancillary Testing

Initial laboratory studies include a complete blood count, coagu-lation tests, and a type and crossmatch for packed red blood cells. Renal function tests should be performed if vasculitis is suggested or contrast computed tomography (CT) is planned. Plain chest radiography plays a limited role in evaluating patients with minor hemoptysis. Although chest x-rays can screen for causes of hemoptysis (including infection and malignancy), their sensitivity is poor and often cannot identify the source of bleeding, a critical step in triage and management (see the Empirical Management section). Up to half of hemoptysis patients with a normal chest radiograph will have positive findings on chest CT.

When there is massive hemoptysis, plain films localize the site of hemorrhage in as many as 80% of patients; however, high-resolution CT of the chest is the principle diagnostic test for investigating both bronchial and non-bronchial causes of massive hemoptysis. A chest CT scan should be obtained in the high-risk patient (ie, smokers, oncology patients) or in any patient with moderate to severe bleeding even if the initial chest radio-graph is normal. CT localization of hemorrhage can expedite bronchoscopic evaluation and guide subsequent interventional procedures.

CT is diagnostically comparable to conventional angiography but less invasive and more rapidly available. Angiography is the first-line study when the cause of the hemoptysis is known (eg, malignancy), bronchial artery hemorrhage is suspected or when angiography-assisted embolization therapy is contemplated. Suc-cessful embolization rates range to 95%.

DIAGNOSTIC ALGORITHM

Critical Diagnoses

Box 21.2 shows critical diagnoses and emergent diagnoses. Proper management hinges not only on standard resuscitative measures but also specific therapies, such as reversal of coagulopathy or emergent surgical intervention. For example, in patients with pre-existing tracheostomies, new hemoptysis (especially within 3 to 4 weeks of surgery) often represents a tracheo-innominate artery fistula (TIF) for which the need for hemorrhage control is imme-diate and can often be accomplished in the ED.

Although management decisions hinge on the volume and rate of bleeding, the initial diagnostic strategy is the same for all patients with hemoptysis (Fig. 21.1). Patients with trace hemop-tysis or blood tinged sputum only and a classic story for viral bronchitis may not require laboratory or radiology investigation of any type. For all others, the initial screening test obtained in the ED is a chest x-ray. Since the advent of high-resolution CT, radiologic evaluation has had an integral role in the evaluation and treatment of patients with hemoptysis. Unless the initial chest radiograph is diagnostic or the patient is hemodynamically unsta-ble, a chest CT should be obtained. Further management deci-sions should be guided by the CT results and made in conjunction with pulmonary and thoracic surgery consultants.

hypercoagulable states that might contribute to venous thrombo-embolic disease.

Primary or metastatic cancer can cause hemoptysis by erosion into pulmonary and bronchial vessels. Recent percutaneous or transbronchial procedures can cause immediate or delayed post-procedural bleeding, and any recent history of trauma should also be noted. A pertinent travel history to areas in which TB or pul-monary paragonimiasis is endemic is crucial.

A history of chronic alcoholism, cancer, and pulmonary fungal infections are other critical historical elements, because these independently predict increased in-hospital mortality.3

Pivotal Findings

Symptoms

Although patient reports of bleeding severity can be inaccu-rate, an estimate of the rate, volume, and appearance of expec-torated blood should be obtained. Additional pertinent history includes prior episodes of hemoptysis or parenchymal pulmo-nary disorders, including bronchiectasis, recurrent pneumonia, chronic obstructive pulmonary disease, bronchitis, TB, and fungal infection.

BOX 21.1

Differential Diagnosis of Hemoptysis

AIRWAY DISEASEBronchitis (acute or chronic)BronchiectasisNeoplasm (primary and metastatic)TraumaForeign body

PARENCHYMAL DISEASETuberculosis (TB)Pneumonia, lung abscessFungal infectionNeoplasm

VASCULAR DISEASEPulmonary embolismArteriovenous malformationAortic aneurysmPulmonary hypertensionVasculitis (Wegener’s granulomatosis, systemic lupus erythematosus

[SLE], Goodpasture’s syndrome)

HEMATOLOGIC DISEASECoagulopathy (cirrhosis or warfarin therapy)Disseminated intravascular coagulation (DIC)Platelet dysfunctionThrombocytopenia

CARDIAC DISEASECongenital heart disease (especially in children)Valvular heart diseaseEndocarditis

MISCELLANEOUSCocainePostprocedural injuryTracheal-arterial fistulaSLE

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192 PART I  Fundamental Clinical Concepts | SECTION TwO  Signs, Symptoms, and Presentations

mismatch that follows submersion of the small airways and alveoli with blood.

All patients with massive hemoptysis should have multiple large bore peripheral intravenous lines placed. Volume resuscita-tion should begin immediately for patients with ongoing bleeding or shock. Coagulopathy, in the setting of severe bleeding, should be reversed by infusing 2 to 4 units of fresh frozen plasma (FFP) and 10 mg of intravenous vitamin K. Prothrombin complex con-centrates (PCCs) have been successful in reversing warfarin-induced intracranial hemorrhage, but there is no information to guide the use of PCC in patients with severe hemoptysis.4 Patients with thrombocytopenia should have a platelet transfusion with a goal platelet count of 50,000 to 60,000.

If a TIF is suspected, the emergency clinician should immedi-ately attempt to overinflate the tracheostomy balloon in an effort to tamponade the bleeding. If this fails, the tracheostomy tube should be removed, the patient should be orally intubated, and the operator’s index finger should be placed through the tracheostomy hole with pressure applied at the sight of bleeding (Fig. 21.3).

Aortobronchial artery fistulae are highly lethal; but if caught early, general resuscitative measures should be undertaken in addition to immediate consultation with or transfer to an endo-vascular surgeon. Pulmonary embolus only rarely affiliated with massive hemoptysis. When trace hemoptysis accompanies pulmonary embolism, usual care with anticoagulation is standard treatment.

Hemoptysis as a complication of disseminated intravascular coagulation (DIC) should be treated following the general man-agement guidelines for DIC. Treatment of DIC remains contro-versial; but when bleeding is present thrombocytopenia with platelet counts less than 50,000, transfusion is indicated. FFP and cryoprecipitate have been advocated to replace factors lost due to consumptive coagulopathy.

Patients with a known or suspected lateralizing source of bleeding should be placed in the “bleeding lung-down” position such that the bleeding lung is more dependent, promoting con-tinued protection and ventilation of the unaffected lung and improved oxygenation. If intubation is required, a large diameter

Bronchoscopy

Early bronchoscopy may be the right option because it facilitates both localization of bleeding and therapeutic intervention. Chest CT is as diagnostically accurate as bronchoscopy in locating bleed-ing peripheral vessels not accessible by a flexible bronchoscope. Chest CT can be used to identify the site of bleeding to determine whether angiography is indicated. There may be little added benefit to bronchoscopy before interventional angiography if the bleeding source has already been accurately identified on CT.

EMPIRICAL MANAGEMENT

Figure 21.2 outlines the management algorithm for patients with hemoptysis. Although hemodynamic instability can occur as a result of hemorrhage, the most lethal sequela of massive hemop-tysis is hypoxia, which results from the ventilation-perfusion

Fig. 21.1.  The emergency department (ED) diagnostic approach to hemoptysis. BNP, B-type natriuretic peptide;  CBC,  complete  blood  count;  CT,  computed  tomography;  CXR,  chest  x-ray;  D/C,  discharge; INR, international normalized ratio; PT, prothrombin time. 

Trace bleeding and viralbronchitis? D/C home with follow-up

CBC, PT/INR, CXRConsider: BNP, D-dimer, troponin,

type and screen

CXR diagnostic?

Consider oncology, CT surgery,pulmonary consult based on findings

Chest CT with contrastdiagnostic?

Consider oncology, CT surgery,pulmonary consult based on findings Bronchoscopy

Y

N

Y N

Y N

BOX 21.2

Critical and Emergent Diagnoses in Patients Presenting With Hemoptysis

CRITICAL DIAGNOSESDisseminated intravascular coagulopathy (DIC)Tracheo-innominate artery fistula (TIF)Aortobronchial fistulaIatrogenic (postprocedural) hemoptysisPulmonary embolism

EMERGENT DIAGNOSESTraumaBronchiectasisPneumoniaAbscess/fungal infectionOral anticoagulant overdoseEndocarditis

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193CHAPTER 21  Hemoptysis

simple lung-down positioning is not sufficient to stabilize the patient’s airway and oxygenation.

When these measures fail or the hemoptysis is life-threatening, anesthesia consultation is sought for consideration of placement of double-lumen endotracheal tubes for lung isolation. The correct positioning of blindly placed double-lumen tubes is dif-ficult and requires confirmation by auscultation and fiberoptic bronchoscopy, both of which are severely impaired by massive hemoptysis. Complications of double-lumen tubes include unilateral and bilateral pneumothoraces, pneumomediastinum, carinal rupture, lobar collapse, and tube malposition.

Fiberoptic bronchoscopy, in addition to being one of the first diagnostic maneuvers, is a first line therapeutic option as well. Balloon and topical hemostatic tamponade, thermocoagulation, and injection of vasoactive agents can all effectively control arte-rial bleeding. Optimal timing for bronchoscopy remains conjec-tural. Although stable patients with mild to moderate bleeding may benefit from early bronchoscopy, in unstable patients or those with brisk hemorrhage, bronchoscopy may facilitate airway management but is less likely to control bleeding.

Bronchial arterial embolization is an effective first-line therapy for massive hemoptysis and is the procedure of choice for patients either unable to tolerate surgery or in whom bronchoscopy has been unsuccessful. Hemostatic rates range from 85% to 98%, but as many as 20% to 50% of patients have early episodes of repeat bleeding. The risk of delayed bleeding may exist for up to 36 months. To guide therapy, initial localization of bleeding by bron-choscopy or CT is preferred. Rare complications include arterial perforation and dissection.

Emergency thoracotomy, in the operating room, is reserved for life-threatening hemoptysis or for persistent, rapid bleeding that is uncontrolled by bronchoscopy and percutaneous embolization. Although lung resection for massive hemoptysis carries with it high morbidity and mortality, it is a permanent solution to ongoing life-threatening hemoptysis. Pulmonary arterial hemor-rhage from tumor necrosis represents a surgical emergency.

Healthy patients with blood-streaked sputum or intermittent small-volume hemoptysis in the context of an acute or subacute respiratory infection with resolved hemoptysis and normal vital signs do not require imaging beyond plain chest radiography and

(8.0) endotracheal tube should be used to facilitate emergent flex-ible bronchoscopy.

If the patient has marginal hemodynamic status, the intuba-tion should proceed with a “shock-sensitive” strategy focusing on preload maximization with isotonic fluids or blood, reduced dose induction agents and peri-intubation pressors, such as phen-ylephrine (Neo-Synephrine) (see Chapter 1). In selected cases of confirmed left-sided bleeding, a single-lumen right-mainstem intubation often can be successfully performed through advance-ment of the tube in the neutral position or use of a 90-degree rotational technique, during which the tube is rotated 90 degrees in the direction of desired placement and advanced until resis-tance is met. Left-mainstem intubations are more difficult but may be attempted when the bleeding site is the right lung and

Fig. 21.3.  Pressure placed by the clinician’s finger through the trache-ostomy hole occluding the tracheo-innominate artery. 

Fig. 21.2.  The  emergency  department  (ED)  management  approach  to  hemoptysis.  IV,  Intravenous; IVF, intravenous fluid; FFP, fresh frozen plasma; OBS, observation. 

Massive hemoptysis?

Hemodynamic instability orhypoxia?

Two IVs, IVFs/blood, FFP, cardiacmonitor, pulse oximetry, intubation

Cardiothoracic surgery,pulmonary consult

Suspected bronchial arteryhemorrhage?

Cardiothoracic surgery,pulmonary consult angiogram

Admit or OBS unit for consultsand further evaluation

N

Y

Y

Consider “bleeding lung-down”positioning

Hemodynamic instability orhypoxia?

N

N Y

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194 PART I  Fundamental Clinical Concepts | SECTION TwO  Signs, Symptoms, and Presentations

can be discharged. High-risk patients (such as, those with known lung cancer, pulmonary vascular abnormalities, or coagulopathy with minor hemoptysis) and all patients with moderate or large amounts of hemoptysis should undergo emergent chest CT scan. There is little value in obtaining a plain chest radiograph before CT, and a plain x-ray film should not be obtained if chest CT is

• Hemoptysis is caused by infection, trauma, cancer, coagulopathy, or as a complication of invasive pulmonary procedures.

• Plain radiographs are the initial screening test in most cases of massive hemoptysis, although CT scans are more sensitive and can supplant plain chest x-rays as the initial diagnostic test.

• Bronchial artery embolization is highly effective with hemostasis rates ranging from 85% to 95%.

• With massive hemoptysis, hypoxia is the more immediate concern than volume resuscitation, and early intubation to ensure adequate oxygenation is paramount.

• If a tracheo-innominate artery fistula (TIF) is suspected, then overinflation of the tracheostomy balloon or digital pressure at the site of bleeding should be performed for immediate hemorrhage control.

KEY CONCEPTS

planned regardless of the findings on the plain film. Brief hospi-talization or admission to an observation unit for bronchoscopy should be considered. All patients with massive hemoptysis require admission to an intensive care unit and expedited multi-disciplinary treatment involving the emergency physician, pulmo-nologist, and thoracic surgeon.

The references for this chapter can be found online by accessing the accompanying Expert Consult website.

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194.e1CHAPTER 21  Hemoptysis

REFERENCES

1. Booth KL, Mercer-Smith G, McConkey C, et al: Catheter-induced pulmonary artery rupture: haemodynamic compromise necessitates surgical repair. Interact Cardiovasc Thorac Surg 15(3):531–533, 2012.

2. Kalra A, Heitner S, Topalian S: Iatrogenic pulmonary artery rupture during Swan-Ganz catheter placement—a novel therapeutic approach. Catheter Cardiovasc Interv 81(1):57–59, 2013.

3. Fartoukh M, Khoshnood B, Parrot A, et al: Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis. Respiration 83(2):106–114, 2012.

4. Cabral KP, Fraser GL, Duprey J, et al: Prothrombin complex concentrates to reverse warfarin-induced coagulopathy in patients with intracranial bleeding. Clin Neurol Neurosurg 115(6):770–774, 2013.

CHAPTER 21: QUESTIONS & ANSWERS

21.1. What is the most common cause of trace hemoptysis (blood-tinged sputum)?A. BronchiectasisB. BronchitisC. CancerD. Congestive heart failureE. Pulmonary embolism

Answer: B. The most common cause of small-volume hemoptysis is bronchitis.

21.2. Disruption of which of the following vessels is responsible for the vast majority of cases of massive hemoptysis?A. AortaB. Bronchial arteriesC. Pulmonary arteriesD. Pulmonary veinsE. Tracheobronchial capillaries

Answer: B. Massive hemoptysis almost exclusively involves one of the two sets of vessels that constitute the lung’s dual blood supply. Bronchial arteries, direct branches from the thoracic aorta, are responsible for supplying oxygenated blood to the lung paren-chyma. Disruption of these vessels can result in sudden and profound hemorrhage. Although small in caliber, the bronchial circulation is a high-pressure system and the cause in nearly 90% of the cases of massive hemoptysis requiring embolization. Although they transmit large volumes of blood, pulmonary arter-ies are at much lower pressure and, unless affected at a very central location, are less likely to cause massive hemoptysis. Trace hemop-tysis typically originates from tracheobronchial capillaries that become disrupted with vigorous coughing or minor bronchial infections.

21.3. Which of the following statements regarding the evaluation of hemoptysis is true?A. Chest computed tomography (CT) should not be

obtained in patients with massive hemoptysis if this delays initiation of bronchoscopy.

B. Chest CT should be obtained in any patient with moderate bleeding even if the initial chest radiograph is normal.

C. Conventional angiography is the preferred diagnostic test to detect both bronchial and non-bronchial arterial causes of massive hemoptysis.

D. High-resolution multidetector CT, even with recent advances in technology, remains diagnostically inferior to angiography.

E. In patients with massive hemoptysis, plain films accurately localize the site of hemorrhage in less than 50% of patients.

Answer: B. In patients with massive hemoptysis, plain films may localize the site of hemorrhage in as many as 80% of patients.

However, high-resolution multidetector CT of the chest is the principal diagnostic test to detect both bronchial and non-bronchial arterial causes of massive hemoptysis. CT is diagnosti-cally comparable with, but less invasive than, conventional angiography, which currently is done as a combined diagnostic/therapeutic modality. A chest CT scan should be obtained in high-risk patients (smokers and oncology patients) or in any patient with moderate-to-severe bleeding even if the initial chest radio-graph is normal. CT localization of hemorrhage can expedite bronchoscopic evaluation or guide subsequent interventional procedures.

21.4. A 50-year-old man presents after an episode of hemoptysis. He describes coughing up several large clots of dark blood. During his evaluation, he coughs and expectorates approximately 5 mL of clotted blood. The patient’s vital signs are normal, and no abnormalities are noted on physical examination. His chest radiograph is normal. Which of the following is the most appropriate next step in the management of this patient?A. Admission to an observation unitB. Consultation for bronchoscopyC. Consultation for percutaneous embolizationD. Discharge home with follow-up in 24 hoursE. Obtain chest CT scan

Answer: E. Since the advent of high-resolution CT, radiologic evaluation has had an integral role in the evaluation and manage-ment of patients with hemoptysis. Unless the initial chest radio-graph is diagnostic or the patient is hemodynamically unstable, a chest CT scan should be obtained in most cases. Further manage-ment strategy should occur in conjunction with pulmonary and thoracic surgery consultants, guided by the CT results.

21.5. A 58-year-old man with a single lung transplant presents to the emergency department (ED) with what appears to be large-volume hemoptysis. He was just discharged from the endoscopy suite, where he had a number of surveillance biopsies performed. He looks pale and diaphoretic with an initial oxygen saturation of 71%. After placement of an intravenous line and supplemental oxygen, the next most appropriate step is:A. Blood transfusionB. Contrast-enhanced CT scan of the chestC. IntubationD. Thoracic surgery consultation

Answer: C. This patient is profoundly hypoxic, will need imaging outside of the ED, and invasive procedures. All resuscitative and procedural efforts will be futile without intubation and maximal oxygenation.

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