Create a concept map for hemoptysis.

Hemoptysis Concept Map

Definition and Classification

Hemoptysis is the expectoration of blood from the lower respiratory tract, most commonly originating from bronchial arteries (>90% of cases). 1, 2

Volume-Based Classification

• Scant hemoptysis: <5 mL in 24 hours 1
• Mild-to-moderate hemoptysis: 5-240 mL in 24 hours 1
• Massive hemoptysis: >240-300 mL in 24 hours OR any amount causing respiratory compromise/asphyxiation risk 1, 3, 2

Clinical Risk Stratification (More Important Than Volume)

• The rate of bleeding is more closely associated with morbidity and mortality than the absolute volume expectorated 1, 3
• Massive hemoptysis is best defined as hemoptysis placing the patient at high risk for asphyxiation or exsanguination, regardless of exact volume 1, 2
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 3, 2

Hemodynamic Stability Assessment

• Clinically unstable: Requires immediate airway protection and resuscitation 1, 3
• Clinically stable: Allows for comprehensive diagnostic evaluation 1, 3
• Evaluate for orthostatic hypotension, tachycardia, or hemoglobin drop ≥1.5 g/dL—these require ICU admission 3

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Common Etiologies by Setting

Primary Care/Outpatient Setting

• Acute respiratory tract infections (most common) 1, 4
• Chronic obstructive pulmonary disease 1
• Malignancy 1
• Bronchiectasis 1

Tertiary Referral Centers (North America/Europe)

• Bronchiectasis (most common in many series) 1, 2
• Respiratory infections 1
• Lung carcinomas 1

Developing Countries

• Tuberculosis and its sequelae (most prevalent cause) 1

Additional Important Causes

• Sarcoidosis 1
• Autoimmune disease with capillaritis or cavitation 1, 4
• Coagulopathies 1
• Pulmonary arteriovenous malformations 1, 4
• Pulmonary pseudoaneurysms 1
• Aspergillomas (55% recurrence rate after treatment) 2
• Pulmonary embolism is an uncommon cause 1, 4
• Cryptogenic hemoptysis accounts for approximately 20% of cases despite extensive investigation 1, 2

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Initial Assessment and Stabilization

Immediate Actions for Massive Hemoptysis

• Prioritize airway protection over diagnostic procedures when respiratory distress is present 2
• Intubate immediately with a single-lumen cuffed endotracheal tube (allows bronchoscopic suctioning and clot removal) 2
• Avoid BiPAP entirely—positive pressure ventilation worsens bleeding 2
• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation 2
• Administer high-flow oxygen 2

Laboratory Assessment

• Obtain complete blood count, PT/aPTT, fibrinogen (Clauss method, NOT derived), type and cross-match 2
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity 2
• Do not use derived fibrinogen levels—they are misleading; use Clauss fibrinogen 2

Supportive Measures

• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 2
• Avoid hyperventilation and excessive positive end-expiratory pressure in hypovolemic patients 2
• Admit all patients with hemoptysis ≥5 mL to hospital for monitoring and treatment 2

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Diagnostic Approach

For Massive (Life-Threatening) Hemoptysis

Clinically Unstable Patients

• Proceed directly to bronchial artery embolization (BAE) without bronchoscopy or CT imaging—delaying BAE significantly increases mortality 2
• Bronchoscopy is performed for airway clearance and tamponade, NOT for diagnosis 1, 2
• Chest radiograph to assess opacified lung quadrants and endotracheal tube placement 1

Clinically Stable Patients

• CT chest with IV contrast is the preferred initial diagnostic test (77% diagnostic accuracy) 2
• CTA provides better vessel opacification, detects aberrant bronchial arteries in 36% of cases, and identifies pulmonary artery pseudoaneurysms 2
• Bronchoscopy provides valuable information on anatomic site and side of bleeding 2

For Mild-to-Moderate Hemoptysis

• Chest radiograph is reasonable initial imaging when confirming benign causes (acute bronchitis, pneumonia), but has limited sensitivity (suggests etiology in only 26% of cases) 2
• CT chest with IV contrast should be performed if hemoptysis is significant, chest X-ray shows abnormalities, or etiology remains unclear 2, 4
• Bronchoscopy is indicated to identify the source of bleeding and for visible central airway lesions 2

For Scant Hemoptysis (<5 mL)

• Contact healthcare provider if first-ever episode or if persistent 1
• Chest radiograph as initial imaging 2
• Continue airway clearance therapies and aerosol therapies (except hypertonic saline) 2

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Management Strategies

Medical Management

For All Hemoptysis ≥5 mL

• Administer antibiotics—bleeding may represent pulmonary exacerbation or superimposed bacterial infection 2
• Stop all NSAIDs immediately due to their effect on platelet function that worsens bleeding 2
• Stop anticoagulants during active hemoptysis—continuing can worsen bleeding 2

For Massive Hemoptysis

• Stop all airway clearance therapies immediately to allow clot formation 2
• Stop aerosolized hypertonic saline—it can exacerbate bleeding 2
• Start venous thromboprophylaxis as soon as bleeding is controlled 2

For Mild-to-Moderate Hemoptysis

• Active cycle of breathing and autogenic drainage are least concerning airway clearance techniques 2
• Continue aerosol therapies except hypertonic saline 2

Bronchoscopic Interventions

Immediate Airway Management

• Tamponade by wedging bronchoscope tip into bleeding bronchus 2
• Instillation of iced saline solution to constrict blood vessels 2
• Bronchial blockade balloons 2
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate) 2

Thermal Ablation for Visible Central Airway Lesions

• Argon plasma coagulation 2
• Nd:YAG laser 2
• Electrocautery 2
• Achieves 80-90% success rates 2

Bronchial Artery Embolization (BAE)

Indications and Efficacy

• BAE is the first-line therapy for massive hemoptysis with immediate success rates of 73-99% 2
• Over 90% of massive hemoptysis originates from bronchial arteries 2
• For the remaining ~10% with pulmonary arterial bleeding, pulmonary artery embolization achieves 88-90% success rates 2

Timing

• Perform BAE without delay in clinically unstable patients—do not wait for CT imaging or bronchoscopy 2
• Conventional arteriography is performed with therapeutic intent, not as a diagnostic modality 2

For Nonmassive Hemoptysis

• BAE is increasingly utilized when conservative medical therapy fails or for palliation, with immediate bleeding cessation in 93% of patients 2

Recurrence Management

• Recurrence occurs in 10-55% of cases after initial BAE 2
• Higher recurrence rates with chronic pulmonary aspergillomas (55%), malignancy, and sarcoidosis 2
• Recurrent hemoptysis within 3 months is often due to incomplete/missed embolization; after 3 months is due to vascular collateralization or recanalization 2
• Repeat BAE is the primary therapeutic option for recurrent hemoptysis—recent studies show no increased risk of morbidity or mortality for repeat interventions 2
• Perform CTA or CT with IV contrast before repeat BAE for arterial mapping 2

Radiation Therapy

For Unresectable Lung Cancer

• External beam radiation therapy (EBRT) provides palliation in approximately 60% of patients, with hemoptysis being the best-palliated symptom (81-86% relief) 2
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone 2
• Fatal hemoptysis rates range from 7-22% with brachytherapy 2

Surgical Management

Indications

• Surgery is reserved as a final therapeutic option when BAE is unsuccessful 2
• For surgically resectable tumors in stable patients (50-70% survival rates) 2
• For aspergillomas causing hemoptysis—definitive surgical treatment following initial BAE is recommended due to high recurrence rates 2

Risks

• Surgery for massive hemoptysis carries 16% mortality, associated with blood aspiration into contralateral lung and pneumonectomy 2
• Surgery is currently only indicated when bleeding is secondary to surgery and its source can be accurately located 5

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Special Considerations

Cystic Fibrosis Patients

• Patients with at least mild hemoptysis (>5 mL) should contact their healthcare provider 1
• Patients with scant hemoptysis (<5 mL) should contact their provider if it is the first-ever episode or if persistent 1
• All patients with massive hemoptysis should contact their healthcare provider immediately 1

Malignancy-Related Hemoptysis

• BAE for malignancy is typically palliative or a temporizing measure prior to definitive surgery 2

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Critical Pitfalls to Avoid

• Never delay airway protection in favor of diagnostic procedures when respiratory distress is present 2
• Never use BiPAP in massive hemoptysis—positive pressure worsens bleeding 2
• Never delay BAE for CT imaging or bronchoscopy in unstable patients—this significantly increases mortality 2
• Never continue NSAIDs or anticoagulants during active hemoptysis 2
• Never stop airway clearance therapies in scant hemoptysis—this is inappropriate 2
• Never rely on chest radiograph alone for diagnosis—it has limited sensitivity 2

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Monitoring and Follow-Up

ICU Admission Criteria

• All patients with massive hemoptysis 2
• Patients with orthostatic hypotension, tachycardia, or hemoglobin drop ≥1.5 g/dL 3

Monitoring Parameters

• Coagulation parameters 2
• Hemoglobin 2
• Blood gases 2
• Ongoing bleeding 2

Follow-Up for Idiopathic Hemoptysis

• Close follow-up is required, as cryptogenic hemoptysis accounts for 20% of cases even after extensive workup 2