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) and etiology and evaluation of nonmassive hemoptysis are reviewed separately. (See "Overview of massive hemoptysis" and "Massive hemoptysis: Initial management" and "Etiology and evaluation of hemoptysis in adults".)
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 endoscopic 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 less developed areas, tuberculosis, bronchiectasis, and bronchogenic carcinoma are the most common causes, particularly in patients with prior pulmonary tuberculosis. 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.
- Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28:1642.
- Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15:147.
- Santiago S, Tobias J, Williams AJ. A reappraisal of the causes of hemoptysis. Arch Intern Med 1991; 151:2449.
- Johnston H, Reisz G. Changing spectrum of hemoptysis. Underlying causes in 148 patients undergoing diagnostic flexible fiberoptic bronchoscopy. Arch Intern Med 1989; 149:1666.
- Knott-Craig CJ, Oostuizen JG, Rossouw G, et al. Management and prognosis of massive hemoptysis. Recent experience with 120 patients. J Thorac Cardiovasc Surg 1993; 105:394.
- Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997; 112:440.
- Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 1999; 115:996.
- Porter DK, Van Every MJ, Anthracite RF, Mack JW Jr. Massive hemoptysis in cystic fibrosis. Arch Intern Med 1983; 143:287.
- Rasmussen, V. On haemoptysis, especially when fatal, in its anatomical and clinical aspects. Edinburgh Med J 1968; 14:385.
- Albelda SM, Talbot GH, Gerson SL, et al. Pulmonary cavitation and massive hemoptysis in invasive pulmonary aspergillosis. Influence of bone marrow recovery in patients with acute leukemia. Am Rev Respir Dis 1985; 131:115.
- Pea L, Roda L, Boussaud V, Lonjon B. Desmopressin therapy for massive hemoptysis associated with severe leptospirosis. Am J Respir Crit Care Med 2003; 167:726.
- Miller RR, McGregor DH. Hemorrhage from carcinoma of the lung. Cancer 1980; 46:200.
- Razazi K, Parrot A, Khalil A, et al. Severe haemoptysis in patients with nonsmall cell lung carcinoma. Eur Respir J 2015; 45:756.
- McGuinness G, Beacher JR, Harkin TJ, et al. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest 1994; 105:1155.
- Müller NL, Miller RR. Diffuse pulmonary hemorrhage. Radiol Clin North Am 1991; 29:965.
- Primack SL, Miller RR, Müller NL. Diffuse pulmonary hemorrhage: clinical, pathologic, and imaging features. AJR Am J Roentgenol 1995; 164:295.
- Panoskaltsis-Mortari A, Griese M, Madtes DK, et al. An official American Thoracic Society research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneumonia syndrome. Am J Respir Crit Care Med 2011; 183:1262.
- Ference BA, Shannon TM, White RI Jr, et al. Life-threatening pulmonary hemorrhage with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia. Chest 1994; 106:1387.
- Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med 1998; 158:643.