Chapter 33. Hemoptysis

Hemoptysis is the expectoration of blood from the lower respiratory tract. Massive hemoptysis, defined somewhat arbitrarily as a bleeding rate exceeding 600 mL per 24 hours, constitutes an emergency and requires prompt intervention to prevent asphyxiation from impaired gas exchange. Minor hemoptysis, the production of smaller quantities of blood (often mixed with mucus), is rarely life threatening but requires careful ED management.

Hemoptysis may be the presenting symptom for many different diseases. A careful history should focus on the presence of underlying lung disease or history of tobacco use. 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. Tuberculosis should be considered in the setting of fevers or night sweats. Bronchogenic carcinoma may present with 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).

The physical examination, which is usually not helpful in localizing the site of bleeding, is aimed at assessing the severity of the hemoptysis. The examination may also provide clues to the underlying disease process. Common 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 (eg, 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).

A careful history and physical examination may suggest a diagnosis. 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. 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 are other potential causes.

1. Supplemental oxygen should be administered as needed, to maintain adequate oxygenation.

2. Normal saline or lactated Ringer's solution should be administered initially for hypotension.

3. Blood should be typed and cross-matched if transfusion is necessary. Packed red blood cells should be transfused as needed.

4. Fresh frozen plasma (2 units) should be administered to patients with coagulopathies, including those taking warfarin; platelets should be given for thrombocytopenia (see Chapter 137 “Transfusion Therapy”).

5. Patients with ongoing massive hemoptysis may benefit from being placed in the decubitus position, with the bleeding lung in dependent position.

6. Hydrocodone (5 to 15 milligrams every 4 to 6 hours) or other opioids may provide some cough suppression.

7. Endotracheal intubation with a large diameter (8.0 mm) tube, which facilitates bronchoscopy, should be performed if there is respiratory failure or if the patient cannot clear blood or secretions from the airway.

8. Any patient with moderate to severe hemoptysis requires admission to the hospital, and strong consideration should be given to placement in the intensive care unit. Patients with mild hemoptysis who have conditions that predispose them to severe bleeding also should be considered for admission to an intensive care unit. The advice of a pulmonologist or thoracic surgeon is required for decisions as to whether bronchoscopy, computed tomography, or angiography for bronchial artery embolization might be needed. If the appropriate specialists are not available, the patient should be stabilized and then transferred to another facility.

9. Patients who are discharged home should be treated for several days with cough suppressants inhaled β-agonist bronchodilators as needed, and antibiotics if bacterial infection is thought to be the cause. Close follow-up is essential, particularly in those at high risk for neoplasm.