Overview of massive hemoptysis
- 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 massive hemoptysis may be identified either during the initial efforts to control the bleeding or later during a diagnostic evaluation once the patient has been stabilized. It is important to identify the cause of the massive hemoptysis even if the bleeding has ceased, since the cause determines the appropriate definitive treatment and the risk of recurrence. It also will help in early management of major re-bleeding.
The definition, diagnostic evaluation, and definitive treatment of massive hemoptysis are reviewed here. The initial management of massive hemoptysis (ie, positioning, airway control, controlling the bleeding) and the causes of massive hemoptysis are discussed separately. (See "Massive hemoptysis: Initial management" and "Massive hemoptysis: Causes".)
Massive hemoptysis is generally used to describe the expectoration of a large amount of blood and/or a rapid rate of bleeding, although the precise thresholds that constitute massive hemoptysis are controversial . Thresholds of 100 mL , 200 mL , 240 mL , 500 mL , 600 mL , and 1000 mL  over 24 hours have been proposed, but none has been universally accepted. Some clinicians argue that a large volume of expectorated blood alone should not define massive hemoptysis, but rather, that abnormal gas exchange and hemodynamic instability should also be present . 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, regardless of whether abnormal gas exchange or hemodynamic instability exists.
RISK FACTORS FOR MORTALITY
The volume of blood expectorated has traditionally been used by clinicians to determine the severity of the hemoptysis. However, the identification of other risk factors may also be helpful in characterizing the severity of the hemoptysis. The physiologic impact and threat to the patient who presents with massive hemoptysis are greatly affected by the degree of underlying lung and heart disease. If a patient has little cardiopulmonary reserve, smaller amounts of bleeding may be life-threatening. For example if a patient has poor lung reserve for gas exchange, a relatively small amount of alveolar bleeding in this area may make it impossible to oxygenate the patient, even with high intubation and effective ventilation with high fractions of inspired oxygen. A retrospective cohort study of 1087 consecutive patients admitted to an intensive care unit (ICU) over a 14-year period found that independent risk factors for in-hospital mortality included mechanical ventilation, lung densities involving two or more quadrants on an admission chest radiograph, bleeding from the pulmonary artery, cancer, aspergillosis, and alcoholism .
There are numerous causes of bleeding from the lower respiratory tract, as listed in the table (table 1). This list is not comprehensive as there are many diseases that can rarely cause hemoptysis, including massive hemoptysis. These etiologies are described in detail separately. (See "Massive hemoptysis: Causes".)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:
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- RISK FACTORS FOR MORTALITY
- INITIAL MANAGEMENT
- DIAGNOSTIC APPROACH
- DIAGNOSTIC MODALITIES
- History and physical examination
- Laboratory tests
- Computed tomography
- Radionuclide scanning
- Combined modalities
- SUMMARY AND RECOMMENDATIONS