What is the evaluation approach for hemoptysis (coughing up blood)?

From the Guidelines

Hemoptysis evaluation should prioritize immediate hospitalization and intervention for massive hemoptysis (>100-200 mL in 24 hours), with bronchial artery embolization (BAE) being a safe and effective treatment option, as demonstrated by a 94% immediate success rate in a study of 344 patients with varying degrees of hemoptysis 1.

Initial Evaluation

The evaluation of hemoptysis should begin with a thorough history and physical examination to determine the severity and potential causes.

• For mild hemoptysis (less than 30-50 mL in 24 hours), outpatient evaluation is appropriate,
• while massive hemoptysis (>100-200 mL in 24 hours) requires immediate hospitalization. Initial testing should include:
• complete blood count,
• coagulation studies,
• chest X-ray, and
• computed tomography (CT) of the chest.

Diagnostic and Therapeutic Interventions

Bronchoscopy is recommended for moderate to severe cases or when imaging is non-diagnostic, as it can both identify the bleeding source and facilitate interventions.

• Common causes include bronchitis, pneumonia, tuberculosis, lung cancer, bronchiectasis, and pulmonary embolism. For patients with active bleeding, management includes:
• positioning the patient with the bleeding side down,
• administering supplemental oxygen, and
• ensuring adequate intravenous access. In severe cases, interventional procedures such as bronchial artery embolization may be necessary. Specific treatment depends on the underlying cause -
• antibiotics for infections,
• anticoagulation reversal for coagulopathies, or
• surgical intervention for tumors. The evaluation pathway is guided by the severity of bleeding, with the primary goals being to identify the source, stop active bleeding, and treat the underlying condition to prevent recurrence, as supported by guidelines for symptom management in patients with lung cancer 1.

Treatment of Massive Hemoptysis

Treatment of significant or massive hemoptysis requires securing and maintaining an adequate airway and optimal oxygenation.

• This usually necessitates endotracheal intubation, and a single-lumen cuffed endotracheal tube is generally more beneficial than a double-lumen endotracheal tube. Selective right or left mainstem intubation can be performed to protect the nonbleeding lung.
• Double-lumen endotracheal tubes are more difficult to place and position, have smaller lumens, and do not permit a therapeutic bronchoscope to be passed through each side of the tube. Bronchoscopy is used for both diagnostic and therapeutic purposes in patients with massive hemoptysis.
• Bronchoscopic visualization will provide the following information: anatomic site and side of bleeding, nature of the bleeding source, severity of bleeding, and therapeutic feasibility. When no direct source of bleeding is found, as in bleeding from a peripheral tumor, bronchoscopic management begins with tamponade of the segment by tightly inserting the tip of the bronchoscope into the bronchus followed by bronchoscopic instillation of iced saline solution to constrict the blood vessels.
• This alone may stop the bleeding in many patients. If the bleeding is brisk, instillation of vasoactive agents like epinephrine is unlikely to help.
• Bronchial blockade balloons can be used to tamponade the bronchus. It may be necessary to leave the balloons in place for 24 to 48 h to allow tamponade of hemoptysis. A study reported that of the 57 patients who had persistent endobronchial bleeding despite bronchoscopic wedging technique, cold saline solution lavage, and instillation of regional vasoconstrictors, bronchoscopic-guided topical hemostatic tamponade therapy using oxidized regenerated cellulose mesh immediately arrested hemoptysis in 56 of 57 patients (98%) 1. If these measures are unsuccessful, consideration should be given to bronchial artery embolization to temporize the bleeding, with a high success rate as demonstrated by recent studies 1.

From the Research

Evaluation of Hemoptysis

• Hemoptysis is the expectoration of blood from the lower respiratory tract, usually from bronchial arteries 2.
• The initial evaluation includes determining the severity of bleeding and stability of the patient, and may require bronchoscopy for airway protection 2.
• A history and physical examination can assist in identifying an etiology, but diagnostic testing is often required 2, 3.

Diagnostic Testing

• Chest radiography is a good initial test, but it has limited sensitivity for determining the site and etiology of the bleeding 2, 3.
• 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 determine the site and etiology of the bleeding 5, 6.

Management

• The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause 5.
• Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with dose monitoring 5.
• Massive hemoptysis has a high mortality rate and requires immediate attention, with treatment options including bronchial arterial embolization and surgery 6, 2, 4.

Common Causes

• 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 5.
• In adults, bronchitis, bronchogenic carcinoma, and pneumonia are the major causes 5.
• Tuberculosis is a major cause of hemoptysis in endemic regions of the world 3.