Etiology and evaluation of hemoptysis in adults
- Steven E Weinberger, MD
Steven E Weinberger, MD
- Adjunct Professor of Medicine
- University of Pennsylvania School of Medicine
- Executive Vice President and CEO
- American College of Physicians
Hemoptysis, or the expectoration of blood, can range from blood-streaking of sputum to the presence of gross blood in the absence of any accompanying sputum. Hemoptysis has a broad differential, but the cause can be determined in the majority of patients (table 1). It is important to identify the cause and location of bleeding in order to guide treatment.
The evaluation of nonmassive hemoptysis that is not immediately life-threatening will be reviewed here. The acute evaluation and management of massive (life-threatening) hemoptysis are discussed separately. (See "Overview of massive hemoptysis" and "Massive hemoptysis: Causes" and "Massive hemoptysis: Initial management".)
DEFINITION OF MASSIVE HEMOPTYSIS
The term massive hemoptysis is reserved for bleeding that is potentially acutely life-threatening; it has been defined by a number of different criteria, ranging from 100 mL to more than 600 mL of blood over a 24 hour period [1,2]. In our clinical practice, we define massive hemoptysis as either ≥500 mL of expectorated blood over a 24 hour period or bleeding at a rate ≥100 mL/hour.
Patients with mild-to-moderate hemoptysis and adequate gas exchange generally do not require hospitalization and the evaluation can proceed in a stepwise fashion as described below. Massive hemoptysis requires a prompt response to ensure adequate ventilation, protect the airway, and control the hemoptysis. (See "Overview of massive hemoptysis" and "Massive hemoptysis: Initial management".)
BRONCHIAL VERSUS PULMONARY VASCULAR ORIGINS OF HEMOPTYSIS
Blood traversing the lungs can arrive from one of two sources: pulmonary arteries or bronchial arteries. Virtually the entire cardiac output courses through the low-pressure pulmonary arteries and arterioles en route to being oxygenated in the pulmonary capillary bed. In contrast, the bronchial arteries are under much higher systemic pressure, but carry only a small portion of the cardiac output. Bleeding from a bronchial artery is the cause of massive hemoptysis in 90 percent of cases.
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- DEFINITION OF MASSIVE HEMOPTYSIS
- BRONCHIAL VERSUS PULMONARY VASCULAR ORIGINS OF HEMOPTYSIS
- CAUSES OF HEMOPTYSIS
- Airways diseases
- Pulmonary parenchymal diseases
- Pulmonary vascular disorders
- INITIAL EVALUATION
- Physical examination
- Laboratory studies
- Risk factors for malignancy
- DIRECTED EVALUATION BASED ON PRESENTATION
- Massive hemoptysis
- Patients with a normal chest radiograph
- - Minimal hemoptysis with likely infectious cause
- - Active hemoptysis
- - Recurrent hemoptysis with normal chest radiograph
- - Recurrent hemoptysis with normal HRCT
- Chest radiograph suggestive of bronchogenic cancer
- Chest imaging with multiple nodules or cavitary opacities
- Chest imaging showing diffuse opacities
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS