Diagnostic approach to massive hemoptysis in adults

INTRODUCTION

Massive hemoptysis is variably defined as hemoptysis exceeding 100 to 600 mL over a 24 hour period. The initial approach to the patient is dictated by the clinical presentation. Patients with rapid bleeding or severe functional decompensation first need rapid establishment of airway patency, control of their bleeding, and insurance of adequate gas exchange. Important secondary goals are determining the site and cause of the bleeding and whether or not the patient is a surgical candidate. (See "Causes and management of massive hemoptysis in adults".)

HISTORY AND PHYSICAL EXAMINATION

History and physical examination are helpful in diagnosing some etiologies of hemoptysis. The history is also important for roughly evaluating the severity of chronic lung disease and assessing pulmonary reserve. However, the history, physical examination, and chest roentgenogram usually are not very reliable ways to determine the side or specific location of the bleeding. As an example, wheezing, rhonchi, or chest radiographic abnormalities may occur at sites other than the region that is bleeding. Thus, blood coming from an upper lobe lesion may localize to a lower lobe, causing physical and radiographic findings in the lower lobe. Similarly, a lung mass on CT scan may be a collection of blood that may or may not occur in the area that is actually bleeding.

Important historical points to address are the following:

• Is there a history of prior lung, cardiac, or renal disease?
• Is there a history of cigarette smoking?
• Has the patient had prior hemoptysis, other pulmonary symptoms, or infectious symptoms?
• Is there a family history of hemoptysis or brain aneurysms (suggesting hereditary hemorrhagic telangiectasia)?
• Is there a history of skin rash?
• Has the patient been exposed to trimellitic anhydride or other organic chemicals?
• What is the patient's travel history?
• Does the patient have a history of asbestos exposure?
• Is there a history of bleeding disorders or use of aspirin, nonsteroidal anti-inflammatory drugs, or anticoagulants?
• Is there a history of upper airway or upper gastrointestinal complaints or diseases?
• Is there a history of tuberculosis (TB) or TB exposure?
• Is the patient at high risk for TB or unusual parasitic disorders?
• Is there a history of blood clots in the individual or family? Any recent risk factors for deep vein thrombosis (DVT)?

The physical examination may also provide diagnostic clues.