Hemoptysis is the expectoration of blood from the lungs or tracheobronchial tree. Massive hemoptysis is defined as 100 mL of blood per 24 hours up to >1000 mL per 24 hours. Minor hemoptysis is defined as the production of smaller quantities of blood in a patient with no comorbid lung disease and stable vital signs. Hemoptysis results from the disruption of blood vessels within the bronchial circulation which supplies oxygenated blood to the bronchi, bronchioles, and lung parenchyma.
Hemoptysis may be the presenting symptom for many different diseases. Massive hemoptysis can often be life threatening. A careful history and physical can raise suspicion for the underlying diagnosis and guide the appropriate workup. The acute onset of fever, cough, and bloody sputum may indicate pneumonia or bronchitis. An indolent productive cough can indicate bronchitis or bronchiectasis. Dyspnea and pleuritic chest pain are potential indicators of pulmonary embolism, particularly in the presence of venous thromboembolic risk factors. Tuberculosis should be considered in the setting of fever, night sweats, and risk factors such as travel from endemic regions. Bronchogenic carcinoma may present with tobacco use, chronic weight loss, and a change in cough. Chronic dyspnea and minor hemoptysis may indicate mitral stenosis or alveolar hemorrhage syndromes (most commonly seen in patients with renal disease). Consider Goodpasture's syndrome in patients with hemoptysis, hematuria, and renal insufficiency.
The physical examination should begin with an assessment of airway, breathing, and circulation, with a focus on the vital signs. Common abnormal vital signs include fever and tachypnea. Tachypnea may be a sign of respiratory compromise with hypoxemia. Hypotension is an ominous sign, usually seen only in massive hemoptysis. The cardiac examination may reveal signs of valvular heart disease (e.g., the diastolic murmur of mitral stenosis). The nasal and oral cavities should be inspected carefully to help rule out an extrapulmonary source of bleeding (pseudohemoptysis).
DIAGNOSIS AND DIFFERENTIAL
A careful history and physical examination may suggest a diagnosis, although the cause of hemoptysis is undetermined in up to 30% of cases. Pulse oximetry and a chest x-ray (PA and lateral, if the patient's condition allows) are always indicated. Other tests that may be helpful include arterial blood gas, hemoglobin and hematocrit levels, platelet count, coagulation studies, urinalysis, and electrocardiogram. Chest CT should be considered if there is hemoptysis with an abnormal chest radiograph or if considering pulmonary embolism or carcinoma on the differential diagnosis. The long differential diagnosis list includes infectious, neoplastic, and cardiac etiologies. Infectious etiologies include bronchitis, bronchiectasis, bacterial pneumonia, tuberculosis, fungal pneumonia, and lung abscess. Neoplastic etiologies include bronchogenic carcinoma and bronchial adenoma. Cardiogenic etiologies include mitral stenosis and left ventricular failure. Trauma, foreign body aspiration, pulmonary embolism (hemoptysis is one of the Wells criteria), primary pulmonary hypertension, pulmonary vasculitis, and bleeding diathesis, and coagulopathies secondary to medications are other potential causes.
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