Hemoptysis

Hemoptysis is defined as the expectoration of blood originating in the lower respiratory tract. Hemoptysis is a consequence of another disease process and can be classified as either life threatening or non-life threatening. Only 5%–15% of patients with hemoptysis have life-threatening bleeding. However, hemoptysis can result in significant morbidity and mortality due to both drowning (reduced gas exchange as the lungs fill with blood) and hemorrhagic shock. The most common causes of hemoptysis include bronchiectasis, lung cancer, tuberculosis, and aspergillosis. Diagnosis involves chest imaging and bronchoscopy. In cases of life-threatening bleeding, treatment is initially directed at stabilizing the patient and, if bleeding is ongoing, hemostasis can often be achieved with minimally invasive techniques (e.g., arterial embolization).

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Overview

Definition and classification

Hemoptysis is defined as the expectoration of blood originating in the lower respiratory tract. Hemoptysis is a consequence of another disease process and can be classified as either life threatening or non-life threatening.

  • Life-threatening hemoptysis:
    • Also referred to as major or massive hemoptysis
    • May result in significant:
      • Airway obstruction
      • Decrease in gas exchange
      • Hemodynamic instability
    • Definitions vary, but typically defined as > 100–200 mL of expectorated blood over 24 hours.
  • Non–life-threatening hemoptysis:
    • Also referred to as minor hemoptysis
    • Clinically irrelevant levels of bleeding (the bleeding itself is not life threatening)
    • May be a warning sign for more severe disease (e.g., lung cancer)
  • Pseudohemoptysis: expectorated blood from the upper respiratory tract and/or upper GI tract (i.e., hematemesis), which can mimic hemoptysis

Epidemiology

  • Life-threatening hemoptysis:
    • Uncommon
    • Estimated at 5%–15% of patients with hemoptysis
  • Non–life-threatening hemoptysis:
    • 85%–95% of patients with hemoptysis 
    • Many of the etiologies causing life-threatening hemoptysis commonly present with non–life-threatening hemoptysis.
  • In an observational study:
    • > 500 mL/24 hours in 2% of patients
    • 20–500 mL/24 hours in 30% of patients

Etiology

Table: Causes of hemoptysis
Airway disease
  • Bronchitis*: acute bronchitis, exacerbation of chronic bronchitis
  • Cystic fibrosis (CF)-related bronchiectasis**
  • Foreign body aspiration
Neoplasms
  • Malignant bronchial neoplasm:
    • Bronchogenic carcinoma**
    • Endobronchial metastatic carcinoma (most commonly from melanoma or breast/colon/renal cell carcinoma)
    • Kaposi sarcoma in AIDS
  • Benign bronchial neoplasm:
    • Hemangioma
    • Adenoma
Infections
  • Fungal infection**:
    • Aspergillus sp. (aspergillosis)**
    • Mycetoma**
  • Bacterial infection:
    • Mycobacterium tuberculosis (tuberculosis)**
    • Bacillus anthracis (anthrax)
    • Leptospira sp. (leptospirosis)
    • Yersinia pestis (plague)
    • Francisella tularensis (tularemia)
  • Viral infection:
    • Herpes simplex
    • Dengue virus
    • Ebola virus
  • Parasitic infection:
    • Paragonimus westermani
    • Strongyloides
  • Necrotizing pneumonia
  • Lung abscess
Other pulmonary parenchymal disease
  • Rheumatic disease:
    • Goodpasture disease (anti-glomerular basement membrane disease)
    • Granulomatosis with polyangiitis
    • Antiphospholipid antibody syndrome
    • Systemic lupus erythematosus (SLE)
  • Genetic defects of collagen (e.g., Ehlers-Danlos syndrome)
  • Endometriosis with intrathoracic implants
Pulmonary vascular disease
  • Conditions resulting in elevated pulmonary capillary pressure:
    • Congestive heart failure (CHF)
    • Mitral stenosis
  • Pulmonary embolism (PE)
  • Pulmonary arteriovenous malformation (AVM)
  • Bronchovascular fistula
  • Arterial aneurysm
Bleeding disorders
  • Anticoagulation and antiplatelet medication
  • Disseminated intravascular coagulation (DIC)
  • Platelet dysfunction (e.g., renal failure)
  • Thrombocytopenia (e.g., ITP, TTP, HUS)
  • Von Willebrand’s disease
Trauma
  • Blunt or penetrating traumas
  • Iatrogenic trauma
Other
  • Amyloidosis
  • E-cigarette or vaping-associated lung injury (EVALI)
  • Cocaine use
  • Cryptogenic hemoptysis (hemoptysis with no apparent cause; the majority are smokers)
*Most common cause of non–life-threatening hemoptysis
**Most common causes of life-threatening and non–life-threatening hemoptysis (no etiologies cause only life-threatening hemoptysis)
ITP: Immune thrombocytopenic purpura
TTP: Thrombotic thrombocytopenic purpura
HUS: Hemolytic uremic syndrome

Pathophysiology

The blood supply to the lungs involves both pulmonary and systemic circulation.

Non–life-threatening hemoptysis

Non–life-threatening hemoptysis usually arises from bleeding in pulmonary circulation.

Pulmonary artery: 

  • Part of the pulmonary circulation
  • Arises from the right ventricle
  • Carries deoxygenated blood from the heart to the lungs for gas exchange
  • A low-pressure system → bleeding from the vessels is generally non-life threatening

Life-threatening hemoptysis

Life-threatening hemoptysis usually arises from bleeding in bronchial artery circulation.

Bronchial arteries: 

  • Part of the systemic circulation
  • Arises from the aorta and intercostal arteries
  • Carries oxygenated blood to the conducting airways (e.g., bronchi), lymph nodes, and visceral pleura
  • Terminates at the level of the bronchioles where the blood moves through capillaries and into the systemic venous circulation
  • A relatively high-pressure system → bleeding from the vessels can result in life-threatening bleeding

Pathophysiology of life-threatening hemoptysis:

  • Drowning: blood fills the alveoli and small airways → prevents gas exchange 
  • Significant bleeding can result in hemorrhagic/hypovolemic shock

Clinical Presentation

Clinical presentation depends on the underlying etiology.

Common findings:

  • Cough
  • Blood is foamy and mixed with mucus → from the lungs

Findings suggestive of infectious etiologies:

  • Blood-tinged sputum 
  • Fever

Findings with life-threatening bleeding:

  • Larger volumes of bleeding
  • Hypotension
  • Respiratory distress: hypoxemia, tachypnea
  • Tachycardia
  • Severe pallor

Findings suggestive of pseudohemoptysis:

  • Expelled gross blood without mucus or sputum
  • Blood is typically expelled without a cough. 
  • Hemoptysis onset after vomiting
  • Nasal blood
  • Visible nasal or oral telangiectasias

Other signs and symptoms specific to the underlying etiology may be present (e.g., unilateral lower extremity edema may suggest deep vein thrombosis (DVT) indicative of PE).

Diagnosis

Laboratory studies

  • CBC: 
    • To assess the chronicity and magnitude of blood loss
    • WBC may suggest infection
  • Coagulation profile: to exclude bleeding disorders as contributing factors
  • Complete metabolic panel:
    • To assess renal function and screen for pulmonary-renal syndromes (e.g., Goodpasture syndrome, granulomatosis with polyangiitis)
    • To assess liver function
  • Sputum culture
  • TB testing:
    • Tuberculin skin test with purified protein derivative (PPD)
    • Interferon-gamma release assay (IGRA) with antigens against Mycobacterium tuberculosis (M. tuberculosis)
    • Acid-fast bacilli smear and culture
    • Chest imaging (see below)
  • Serologic testing for specific antibodies (if rheumatic disease suspected)

Imaging

  • Chest X-ray:
    • Best initial test
    • Findings may include:
      • Masses or large pulmonary nodules → suggestive of cancer
      • Apical cavities, calcified nodules, or round infiltrates → tuberculosis
      • Pulmonary edema → CHF or mitral stenosis
      • Consolidation → pneumonia
      • Multiple rib fractures → trauma
      • Foreign body
      • Hemo/pneumothorax
      • Normal findings (does not exclude life-threatening conditions)
  • Chest CT:
    • Obtain with and without contrast.
    • Purpose:
      • To localize the site of bleeding
      • To determine the underlying etiology
    • Indications:
      • All patients with life-threatening hemoptysis
      • Patients with an uncertain diagnosis after chest X-ray
    • Etiologies diagnosed by CT: 
      • Bronchiectasis
      • TB and aspergilloma
      • Lung cancer
      • Vascular disease: fistula, AVM, arterial aneurysm
  • Bronchoscopy:
    • Minimally invasive procedure using a scope to visualize the larger airways
    • Procedure of choice in most life-threatening hemoptysis
    • Perform within the 1st 12–24 hours of presentation.
    • Diagnostic purpose: 
      • To localize the site of bleeding
      • To determine the underlying etiology
    • Therapeutic purpose: 
      • To suction blood and thrombi and clear the airways
      • To stop the bleeding: electrocautery, laser therapy, epinephrine therapy, or balloon tamponade
  • Angiography:
    • Contrast is injected into the circulation to obtain real-time images.
    • Diagnostic purpose:
      • Identification of abnormal vascular structures
      • Actual visualization of the bleeding (contrast extravasation) is rare.
    • Therapeutic purpose: embolization
Bronchiectasis imaging

A chest radiograph demonstrating bronchiectasis

Image: “Bronchiectasis imaging” by Arinna’l. License: Public Domain

Management

Life-threatening hemoptysis

The 1st step in life-threatening hemoptysis is to stabilize the patient.

  • Address airway, breathing, and circulation (ABCs):
    • Airway: 
      • Ensure the airway is secure.
      • Intubation is likely required → use a large bore tube to allow for blood and thrombus extraction and diagnostic bronchoscopy
    • Breathing:
      • Provide appropriate ventilation. 
      • Suction blood to keep the airways clear.
      • Give high-flow oxygen to patients not requiring intubation.
      • Positioning: Place the patient in the decubitus position with the bleeding lung down to prevent aspiration into the unaffected lung.
    • Circulation:
      • Assess hemodynamic stability.
      • Insert 2 large-bore IV catheters.
      • Start fluid resuscitation.
      • Order a type and crossmatch → transfuse if clinically indicated
  • Perform bronchoscopy after initial stabilization:
    • Allows for deeper suctioning
    • Can treat identified sources of bleeding
    • Important in diagnosing the underlying etiology
  • Correct bleeding/clotting disorders:
    • Reverse anticoagulants if possible
    • Give platelets in severe thrombocytopenias.
  • Give tranexamic acid (an antifibrinolytic agent) to promote clotting.
  • Surgical/procedural interventions:
    • Indicated in severe or uncontrolled hemoptysis
    • May include:
      • Surgical resection of the bleeding area
      • Repair of penetrating trauma
      • Arterial embolization 

Non–life-threatening hemoptysis

Management is aimed at treating the underlying cause.

  • Antibiotics for infectious etiologies
  • Surgical treatment when appropriate:
    • Resection of neoplasms
    • Treatment of AVM, fistula, or aneurysm
    • Removal of aspirated foreign body
  • Observation is appropriate for idiopathic or cryptogenic hemoptysis (no cause is found). 
  • Smoking cessation: counseling, medications as appropriate

Differential Diagnosis

When a patient presents with hemoptysis, the following etiologies should be considered highest in the differential diagnosis:

  • Tuberculosis: an infectious bacterial disease caused by M. tuberculosis. The bacteria usually attack the lungs but can also damage other parts of the body.  Patients typically present with fever, hemoptysis, night sweats, and weight loss. The diagnosis is established with a tuberculin skin test, sputum culture, and lung imaging. The mainstay of management is antimycobacterial drugs. 
  • Aspergilloma: an opportunistic fungal infection caused by Aspergillus fumigatus. Aspergilloma develops in preexisting lung cavities, typically of immunocompromised patients. Hemoptysis is the most common symptom but patients may also present with cough or fever. Though less common, other types of aspergillosis (e.g., invasive aspergillosis or chronic necrotizing pulmonary aspergillosis) can also present with hemoptysis. Diagnosis involves a skin test, serologic test, sputum culture, and lung imaging. 
  • Bronchiectasis: a chronic inflammatory disease of the bronchial airways, resulting from a continuous cycle of inflammation, bronchial damage and dilation, impaired clearance of secretions, and recurrent infections. Hemoptysis due to bronchiectasis is especially common in patients with CF.  The diagnosis is made from characteristic radiographic findings such as bronchial wall thickening and luminal dilatation. Management aims to improve bronchial clearance and prevent infection. The condition is rarely curable.
  • Lung cancer: the malignant transformation of lung tissue. Lung cancer is the leading cause of cancer-related deaths in the United States and is closely associated with smoking. Symptoms include cough, dyspnea, weight loss, and hemoptysis. Diagnosis and staging are made by biopsy and imaging. Management is guided by the cancer stage and associated molecular profile. The disease carries a poor prognosis.
  • Left-sided congestive heart failure: the heart’s inability to supply the body with the cardiac output required to meet the body’s metabolic needs. Patients typically present with dyspnea on exertion and/or at rest, orthopnea, and peripheral edema. Hemoptysis may develop due to increased pulmonary capillary pressure resulting from left-sided ventricular failure. Diagnosis is confirmed with echocardiography. Treatment includes removing excess fluid and decreasing O2 demand on the heart. 
  • Pulmonary embolism: a potentially fatal condition commonly resulting from intravascular obstruction of the main pulmonary artery (or a branch) by a thrombus. Air, cholesterol, fat, and amniotic fluid can also cause PE. Because a thrombotic PE commonly arises from a leg DVT, patients may present with unilateral lower extremity edema and/or calf pain. The diagnosis is usually made from a chest CT. Management includes stabilization of the patient and anticoagulation in patients with thrombotic PE.  
  • Acute bronchitis: an infection of the mucous membrane of the bronchi without evidence of pneumonia. Acute bronchitis is usually viral (approximately 95% of all cases), but atypical bacteria if from a bacterial infection. Diagnosis is clinical, though a chest X-ray may be useful to rule out pneumonia. Patients typically present with a cough, fever, and possibly small amounts of non–life-threatening hemoptysis. Treatment is typically supportive since most cases are viral and do not require antibiotics.
  • Chronic bronchitis: lung disease and form of chronic obstructive pulmonary disease (COPD) characterized by airflow limitation resulting from chronic airway inflammation. Chronic bronchitis is closely associated with smoking. Hemoptysis may occur during an acute flare but otherwise is uncommon. Patients typically present with progressive dyspnea, a chronic productive cough, peripheral edema, and cyanosis (“blue bloater”). Diagnosis involves pulmonary function testing and chest X-ray. Management includes smoking cessation, bronchodilators, and O2 therapy.

References

  1. Ong, Z. Y., Chai, H. Z., How, C. H., Koh, J., & Low, T. B. (2016). A simplified approach to haemoptysis. Singapore medical journal, 57(8), 415–418. https://doi.org/10.11622/smedj.2016130
  2. Ingar, D & Weinberger, S (2021) Etiology of hemoptysis. In G. Finlay and H. Hollingsworth (Ed.), UpToDate. Retrieved April 7, 2021, from https://www.uptodate.com/contents/etiology-of-hemoptysis
  3. Ingar, D.H. and Erhan Dincer, H. (2021). Evaluation and management of life-threatening hemoptysis. In Finlay, G., and Hollingsworth, H. (Eds.), UpToDate. Retrieved April 12, 2021, from https://www.uptodate.com/contents/evaluation-and-management-of-life-threatening-hemoptysis
  4. Kassutto, S.M., and Weinberger, S.E. (2019). Evaluation of nonlife-threatening hemoptysis in adults. In Hollingsworth, H., and Finlay, G. (Eds.), UpToDate. Retrieved April 12, 2021, from https://www.uptodate.com/contents/evaluation-of-nonlife-threatening-hemoptysis-in-adults
  5. Herchline, T.E. (2020). Tuberculosis (TB). In Bronze, M.S. (Ed.), Medscape. Retrieved April 12, 2021, from https://emedicine.medscape.com/article/230802-overview

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