Hemoptysis

Kathryn M. Larsen and Mary Knudtson

Hemoptysis is defined as the coughing up or expectoration of blood from the tracheobronchial tree, which can be from the trachea, major airways, or the lung parenchyma. It is an alarming symptom that usually prompts the patient to seek immediate medical attention. Hemoptysis can range in severity from trivial to life-threatening and has numerous causes.

Approach

 The clinician must determine the anatomic bleeding site and the underlying cause for the bleeding (1). Bleeding originating from the nasopharynx or bleeding from the gastrointestinal tract, can mimic hemoptysis (Chapter 9.7). A thorough evaluation is necessary because the amount of blood expectorated does not correlate with the seriousness of the cause. After extensive evaluation, up to 30% of patients have no identifiable cause for their hemoptysis; these patients are classified as having cryptogenic hemoptysis.

The pathogenesis of hemoptysis generally results from inflammation or injury to the tracheobronchial mucosa (e.g., bronchitis, bronchiectasis, tuberculosis, sarcoidosis, and bronchogenic carcinoma); injury to the pulmonary vasculature (e.g., lung abscess, necrotizing pneumonia, and pulmonary infarction secondary to embolization); or elevation of the pulmonary capillary pressure (e.g., pulmonary edema, Wegener’s granulomatosis, and Goodpasture’s syndrome). The most common causes are acute and chronic bronchitis, followed by bronchogenic carcinoma and pneumonia (2). Lung tumors account for 20% of the cases of hemoptysis; they are usually associated with smokers aged more than 40 years who have had a change in cough pattern with an ache or pain in the chest. A bleeding diathesis or the use of anticoagulant medicine may present with hemoptysis but underlying pulmonary disease must always be excluded. Chest trauma is a less common cause of hemoptysis.

History

 A. Identification of the site of bleeding. What is the source of the bleeding? Is the problem truly hemoptysis or could the bleeding originate in a nonpulmonary location such as the nose and oropharynx or the gastrointestinal tract? Blood that is coughed from the respiratory tract is bright red in color and may be frothy or mixed with sputum. Hemoptysis is more likely with a history of underlying pulmonary disease, smoking, or mitral valve disease. Hematemesis is associated with blood that is dark red, brown, or coffee ground in appearance and that may be mixed with food particles. Hematemesis is favored in the presence of preexisting gastrointestinal condition, especially with a history of liver disease, alcohol use, or peptic ulcer disease. Sputum that is blood-streaked often arises from the nasal mucosa and oropharynx.

 B. Characteristics of the sputum. What are the characteristics of the sputum in terms of color, odor, and consistency? A description of the sputum can assist in defining the disease process causing the hemoptysis: (a) frothy, pink sputum is suggestive of pulmonary edema fluid; (b) putrid or foul-smelling sputum suggests a lung abscess; (c) currant jelly sputum may suggest a necrotizing pneumonia; (d) the sputum of pneumococcal pneumonia is typically rust-colored and can be confused with true hemoptysis; (e) large amounts of blood-streaked sputum often suggest bronchiectasis.

C. Other information. Does the patient have other associated symptoms? Cough, dyspnea, and sputum production over several years may suggest chronic bronchitis or bronchiectasis. Weight loss and fatigue may suggest an underlying malignancy, and fever and night sweats might indicate tuberculosis. Does the patient have a history of known pulmonary, cardiac, or hematologic problems? Does the patient have hematuria, which might suggest a pulmonary-renal syndrome (Chapter 10.2)? Is the patient a smoker or have specific environmental exposures? Is the patient taking medications, especially anticoagulants, that might contribute to the bleeding?

Physical examination

 A focused physical examination should include vital signs and examinations of the nose, sinuses, oropharynx, neck, lungs, and heart. The neck should be palpated for the presence of lymphadenopathy and inspected for jugular venous distension. The lower extremities should be checked for edema. Examination of the skin may reveal lesions associated with systemic lupus erythematosus; Kaposi’s sarcoma; clubbing (consistent with neoplasm, bronchiectasis, or lung abscess); or ecchymosis related to a coagulopathy.

Testing

The evaluation should begin with a chest x-ray study to look for possible clues to the diagnosis: a mass lesion, focal or diffuse parenchymal disease, pneumonitis, abscess, infiltrate, hilar adenopathy, enlarged heart, pulmonary edema, coin lesion of aspergilloma, or the peribronchial cuffing suggestive of bronchiectasis. A computed tomography scan may be necessary to define a lesion seen on chest x-ray film (3). Additional basic testing should include a complete blood count with differential and a coagulation profile. For patients in whom infection is suspected, skin testing, a Gram’s stain, acid fast stain, or sputum cultures may be appropriate. Cytologic examination of the sputum is indicated in cases of suspected malignancy.

A. Other special tests. Fiberoptic bronchoscopy is used to localize the bleeding site of specific lesions noted on x-ray film. It is also used in cases of persistent or recurrent bleeding and for smokers aged more than 40 years with a negative chest x-ray study. Ventilation-perfusion scanning is indicated if pulmonary embolism is suspected.

Diagnostic assessment

Determining the site of bleeding is the first step. If the bleeding is from the nasopharynx or gastrointestinal tract then it is not classified as hemoptysis. The basic approach depends on the severity of the bleeding. Most cases of blood-tinged sputum are upper respiratory in nature and do not require extensive workup. Bronchitis is the most common cause. However, bronchogenic carcinoma and bronchiectasis are also common causes that do require further evaluation (4). Mild hemoptysis can be evaluated with elective bronchoscopy of the respiratory tract. Massive hemoptysis (definitions in the literature range from 100 ml/24 hours to 1,000 ml over several days) requires an emergent diagnostic approach, typically with rigid bronchoscopy (5). If hemoptysis persists despite treatment of a presumed infection, bronchial arteriography with embolization or resection of the involved segment may be necessary.

References

1. Colice GL. Hemoptysis: three questions that can direct management. Postgrad Med 1996;100(1):227–236.

2. DiLeo MD, Amedee RG, Butcher RB. Hemoptysis and Pseudohemoptysis: the patient expectorating blood. Ear Nose Throat J 1995;74(12):822–824, 826, 828.

3. Marshall TJ, Flower CD, Jackson JE. The role of radiology in the investigation and management of patients with hemoptysis. Clin Radiol 1996;51(6):391–400.

4. Marwah OS, Sharma OP. Bronchiectasis: how to identify, treat, and prevent. Postgrad Med 1995;97(2):149–150, 153–156, 159.

5. Cahill BC, Ingbar DH. Massive hemoptysis: assessment and management. Clin Chest Med 1994;15(1):147–167.

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

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