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 Emeritus
- 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.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28:1642.
- Corder R. Hemoptysis. Emerg Med Clin North Am 2003; 21:421.
- Amrhein TJ, Kim C, Smith TP, Washington L. Bronchial artery arising from the left vertebral artery: case report and review of the literature. J Clin Imaging Sci 2011; 1:62.
- Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15:147.
- Johnston H, Reisz G. Changing spectrum of hemoptysis. Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy. Arch Intern Med 1989; 149:1666.
- Santiago S, Tobias J, Williams AJ. A reappraisal of the causes of hemoptysis. Arch Intern Med 1991; 151:2449.
- Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997; 112:440.
- Prasad R, Garg R, Singhal S, Srivastava P. Lessons from patients with hemoptysis attending a chest clinic in India. Ann Thorac Med 2009; 4:10.
- Dave BR, Sharma A, Kalva SP, Wicky S. Nine-year single-center experience with transcatheter arterial embolization for hemoptysis: medium-term outcomes. Vasc Endovascular Surg 2011; 45:258.
- Dixit MD, Gan M, Narendra NG, et al. Aortopulmonary fistula: a rare complication of an aortic aneurysm. Tex Heart Inst J 2009; 36:483.
- Hung JJ, Hsu HS, Huang CS, Yang KY. Tracheoesophageal fistula and tracheo-subclavian artery fistula after tracheostomy. Eur J Cardiothorac Surg 2007; 32:676.
- Komatsu T, Sowa T, Fujinaga T, et al. Tracheo-innominate artery fistula: two case reports and a clinical review. Ann Thorac Cardiovasc Surg 2013; 19:60.
- Choudhary C, Bandyopadhyay D, Salman R, et al. Broncho-vascular fistulas from self-expanding metallic stents: A retrospective case review. Ann Thorac Med 2013; 8:116.
- Savale L, Parrot A, Khalil A, et al. Cryptogenic hemoptysis: from a benign to a life-threatening pathologic vascular condition. Am J Respir Crit Care Med 2007; 175:1181.
- Kuzucu A, Gürses I, Soysal O, et al. Dieulafoy's disease: a cause of massive hemoptysis that is probably underdiagnosed. Ann Thorac Surg 2005; 80:1126.
- Kolb T, Gilbert C, Fishman EK, et al. Dieulafoy's disease of the bronchus. Am J Respir Crit Care Med 2012; 186:1191.
- Muniappan A, Tapias LF, Butala P, et al. Surgical therapy of pulmonary aspergillomas: a 30-year North American experience. Ann Thorac Surg 2014; 97:432.
- Farid S, Mohamed S, Devbhandari M, et al. Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence--a National Centre's experience. J Cardiothorac Surg 2013; 8:180.
- Ahmed S, Mohammad WW, Hamid F, et al. The 2011 dengue haemorrhagic fever outbreak in Lahore - an account of clinical parameters and pattern of haemorrhagic complications. J Coll Physicians Surg Pak 2013; 23:463.
- Sareli AE, Janssen WJ, Sterman D, et al. Clinical problem-solving. What's the connection? - A 26-year-old white man presented to our referral hospital with a 1-month history of persistent cough productive of white sputum, which was occasionally tinged with blood. N Engl J Med 2008; 358:626.
- Drent M, Wessels S, Jacobs JA, Thijssen H. Association of diffuse alveolar haemorrhage with acquired vitamin K deficiency. Respiration 2000; 67:697.
- Ikeda M, Tanaka H, Sadamatsu K. Diffuse alveolar hemorrhage as a complication of dual antiplatelet therapy for acute coronary syndrome. Cardiovasc Revasc Med 2011; 12:407.
- Chen BC, Sheth NR, Dadzie KA, et al. Hemodialysis for the treatment of pulmonary hemorrhage from dabigatran overdose. Am J Kidney Dis 2013; 62:591.
- Heck SL, Blom P, Berstad A. Accuracy and complications in computed tomography fluoroscopy-guided needle biopsies of lung masses. Eur Radiol 2006; 16:1387.
- Choi JW, Park CM, Goo JM, et al. C-arm cone-beam CT-guided percutaneous transthoracic needle biopsy of small (≤ 20 mm) lung nodules: diagnostic accuracy and complications in 161 patients. AJR Am J Roentgenol 2012; 199:W322.
- Lee SM, Park CM, Lee KH, et al. C-arm cone-beam CT-guided percutaneous transthoracic needle biopsy of lung nodules: clinical experience in 1108 patients. Radiology 2014; 271:291.
- Augoulea A, Lambrinoudaki I, Christodoulakos G. Thoracic endometriosis syndrome. Respiration 2008; 75:113.
- Sandler A, Gray R, Perry MC, et al. Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. N Engl J Med 2006; 355:2542.
- Cho YJ, Murgu SD, Colt HG. Bronchoscopy for bevacizumab-related hemoptysis. Lung Cancer 2007; 56:465.
- Karlson-Stiber C, Höjer J, Sjöholm A, et al. Nitrogen dioxide pneumonitis in ice hockey players. J Intern Med 1996; 239:451.
- Centers for Disease Control and Prevention (CDC). Exposure to nitrogen dioxide in an indoor ice arena - New Hampshire, 2011. MMWR Morb Mortal Wkly Rep 2012; 61:139.
- Kahan ES, Martin UJ, Spungen S, et al. Chronic cough and dyspnea in ice hockey players after an acute exposure to combustion products of a faulty ice resurfacer. Lung 2007; 185:47.
- Khalid U, Saleem T. Hughes-Stovin syndrome. Orphanet J Rare Dis 2011; 6:15.
- Chen Y, Gilman MD, Humphrey KL, et al. Pulmonary Artery Pseudoaneurysms: Clinical Features and CT Findings. AJR Am J Roentgenol 2017; 208:84.
- Martí-Almor J, Jauregui-Abularach ME, Benito B, et al. Pulmonary hemorrhage after cryoballoon ablation for pulmonary vein isolation in the treatment of atrial fibrillation. Chest 2014; 145:156.
- van Opstal JM, Timmermans C, Blaauw Y, Pison L. Bronchial erosion and hemoptysis after pulmonary vein isolation by cryoballoon ablation. Heart Rhythm 2011; 8:1459.
- Conte G, Chierchia GB, Casado-Arroyo R, et al. Pulmonary vein intramural hematoma as a complication of cryoballoon ablation of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol 2013; 24:830.
- Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin. Chest 2001; 120:1592.
- Delage A, Tillie-Leblond I, Cavestri B, et al. Cryptogenic hemoptysis in chronic obstructive pulmonary disease: characteristics and outcome. Respiration 2010; 80:387.
- Revel MP, Fournier LS, Hennebicque AS, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol 2002; 179:1217.
- Ketai LH, Mohammed TL, Kirsch J, et al. ACR appropriateness criteria® hemoptysis. J Thorac Imaging 2014; 29:W19.
- Poe RH, Israel RH, Marin MG, et al. Utility of fiberoptic bronchoscopy in patients with hemoptysis and a nonlocalizing chest roentgenogram. Chest 1988; 93:70.
- O'Neil KM, Lazarus AA. Hemoptysis. Indications for bronchoscopy. Arch Intern Med 1991; 151:171.
- Thirumaran M, Sundar R, Sutcliffe IM, Currie DC. Is investigation of patients with haemoptysis and normal chest radiograph justified? Thorax 2009; 64:854.
- Khalil A, Soussan M, Mangiapan G, et al. Utility of high-resolution chest CT scan in the emergency management of haemoptysis in the intensive care unit: severity, localization and aetiology. Br J Radiol 2007; 80:21.
- Lee YJ, Lee SM, Park JS, et al. The clinical implications of bronchoscopy in hemoptysis patients with no explainable lesions in computed tomography. Respir Med 2012; 106:413.
- Lederle FA, Nichol KL, Parenti CM. Bronchoscopy to evaluate hemoptysis in older men with nonsuspicious chest roentgenograms. Chest 1989; 95:1043.
- Set PA, Flower CD, Smith IE, et al. Hemoptysis: comparative study of the role of CT and fiberoptic bronchoscopy. Radiology 1993; 189:677.
- McGuinness G, Beacher JR, Harkin TJ, et al. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest 1994; 105:1155.
- Tak S, Ahluwalia G, Sharma SK, et al. Haemoptysis in patients with a normal chest radiograph: bronchoscopy-CT correlation. Australas Radiol 1999; 43:451.
- Gong H Jr, Salvatierra C. Clinical efficacy of early and delayed fiberoptic bronchoscopy in patients with hemoptysis. Am Rev Respir Dis 1981; 124:221.
- 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