From the Guidelines
Hemoptysis requires prompt evaluation and management to determine its cause and severity, and hospitalization is recommended for moderate to severe cases, with potential interventions including bronchoscopy, bronchial artery embolization, and correction of any underlying coagulopathy, as outlined in the ACR Appropriateness Criteria for hemoptysis 1.
Causes and Severity of Hemoptysis
Hemoptysis can range from blood-streaked sputum to massive bleeding, and its causes vary based on the level of medical care and geographic location, with common causes including bronchitis, pneumonia, tuberculosis, lung cancer, pulmonary embolism, and bronchiectasis 1. The severity of hemoptysis is inconsistently defined, but a growing consensus supports the use of a reproducible scoring system for the assessment of in-hospital mortality from hemoptysis, which includes a chest radiograph to assess the amount of lung affected by aspirated blood 1.
Management of Hemoptysis
Initial management involves assessing the patient's hemodynamic stability and respiratory status, and for mild hemoptysis, outpatient management may be appropriate with follow-up imaging such as chest X-ray or CT scan 1. For moderate to severe hemoptysis, hospitalization is recommended, and potential interventions include:
- Bronchoscopy to locate the bleeding source
- Bronchial artery embolization for persistent bleeding
- Correction of any underlying coagulopathy Specific treatments depend on the underlying cause, such as antibiotics for infections, anticoagulation management for pulmonary embolism, or oncologic therapy for malignancies 1.
Massive Hemoptysis
Massive hemoptysis (>100-200 mL in 24 hours) is a medical emergency requiring airway protection, possible intubation, positioning the patient with the bleeding side down, and urgent consultation with interventional radiology or thoracic surgery, as outlined in the ACR Appropriateness Criteria for hemoptysis 1. Hemoptysis warrants urgent attention because it can indicate serious underlying pathology and, in severe cases, can lead to asphyxiation from airway obstruction with blood.
From the Research
Definition and Causes of Hemoptysis
- Hemoptysis is the expectoration of blood from the lower respiratory tract, usually from bronchial arteries 2.
- The most common causes of hemoptysis are acute respiratory infections, cancer, bronchiectasis, and chronic obstructive pulmonary disease 2.
- In children, lower respiratory tract infection and foreign body aspiration are common causes, while in adults, bronchitis, bronchogenic carcinoma, and pneumonia are the major causes 3.
- No cause is identified in 20% to 50% of cases 2, 3.
Diagnosis of Hemoptysis
- A history and physical examination can assist in identifying an etiology, but diagnostic testing is often required 2.
- Chest radiography is a good initial test, but it has limited sensitivity for determining the site and etiology of the bleeding 2, 4.
- Computed tomography (CT) and CT angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding 2, 4.
- Bronchoscopy may also be needed to localize the bleeding site and to provide airway protection 5, 4.
- Multidetector computed tomography (MDCT) angiography can pinpoint the presence, origin, number, and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding 4.
Management of Hemoptysis
- The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause 3.
- Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with dose monitoring 3.
- Bronchial artery embolization is used to treat massive hemoptysis, particularly when an involved artery is noted on CT angiography 2, 6.
- Surgery is reserved for patients whose medical treatment and embolization are not effective 2, 6.
- Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis 4.
- Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis and can be used for immediate control of bleeding and to locate the source of the hemorrhage 4.