Massive hemoptysis: Causes
- David H Ingbar, MD
David H Ingbar, MD
- Professor of Medicine, Physiology, and Pediatrics
- University of Minnesota School of Medicine
When a patient presents with massive hemoptysis, the initial steps are to correctly position the patient, establish a patent airway, insure adequate gas exchange and cardiovascular function, and control the bleeding . The source of bleeding may be identified either during efforts to control the bleeding or during a careful evaluation after the patient has been stabilized. The cause of the bleeding determines the appropriate definitive treatment.
Potential causes of massive hemoptysis are described here. Other aspects of massive hemoptysis (ie, definition, initial management, diagnostic evaluation, and definitive treatment) are reviewed separately. (See "Overview of massive hemoptysis" and "Massive hemoptysis: Initial management".)
CAUSES OF MASSIVE HEMOPTYSIS
Before assuming that the source of bleeding is the lower respiratory tract, the possibility that the blood may be coming from a non-pulmonary source, such as the upper airway or the gastrointestinal tract, should be considered. This distinction can be difficult and may require an otolaryngological or gastrointestinal evaluation. Characteristics of the expectorated material that suggest that a gastrointestinal source is unlikely include an alkaline pH, foaminess, and/or the presence of pus.
There are numerous causes of bleeding from the lower respiratory tract. Many are listed in the table (table 1). Three etiologies accounted for 90 percent of the cases of massive hemoptysis through the 1960s: tuberculosis, bronchiectasis, and lung abscess . Each of these causes has since decreased in frequency, although other etiologies have increased (table 2) [3-7]. There are no more recent large series examining the prevalence of the causes of massive hemoptysis in general hospital settings. In this section, we describe the most common and/or important causes of massive hemoptysis.
Bronchiectasis — The bronchial circulation supplies blood flow to the bronchial wall. In bronchiectasis, chronic airway inflammation causes hypertrophy and tortuosity of the bronchial arteries that accompany the regional bronchial trees, as well as expansion of the submucosal and peribronchial plexus of blood vessels. Rupture of either the tortuous vessels or the capillary plexus results in rapid bleeding because these blood vessels are subjected to systemic blood pressure.
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