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Hemoptysis is coughing of blood that originates
from the respiratory tract below the level of the larynx. The causes
of hemoptysis vary from simple bronchitis to life-threatening pulmonary
embolism. Most causes are not life-threatening, but the symptoms
are quite frightening to patients. Hemoptysis is an “alarm” symptom
for possible lung cancer and requires investigation in older smokers
in whom the PPV for cancer is highest.1 Even with
careful evaluation, a cause is not identified in up to 25% of
cases.
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Priorities in the evaluation of hemoptysis are:
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- Ensuring adequate oxygenation and ventilation
- Confirming a pulmonary source of bleeding
- Attempting to identify the cause of hemoptysis through appropriate diagnostic
evaluation
- Appropriate disposition
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The true incidence of hemoptysis is unknown because many cases
are unreported. Causes of hemoptysis vary with when the data were
collected, types of investigations performed, and geographic demographics
of the population studied.2 Before the 1960s, most
cases of hemoptysis were caused by active tuberculosis (followed
by bronchiectasis, often from tuberculosis) and lung neoplasia.
In Western countries, bronchitis, pneumonia, and lung neoplasia
are now common causes of hemoptysis.3 In underdeveloped
countries, tuberculosis and bronchiectasis predominate.
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Table 66-1 lists disorders associated
with hemoptysis. Unusual causes of note for the ED include crack
cocaine inhalation–induced pulmonary hemorrhage,4 warfarin
(Coumadin) and glycoprotein IIb/IIIa inhibitor–induced
bleeding,5 hemoptysis from thrombolytics,6 catamenial
hemoptysis associated with menses (which can also cause pneumothorax),7 and postprocedure
complications of pulmonary artery catheterization,8 bronchoscopy,
or lung biopsy. Cardiovascular causes, such as congestive heart
failure and mitral stenosis, account for about 3% of cases.
Hemoptysis from trauma can be due to pulmonary contusion, airway
injury, or coagulopathy.9 When no cause for hemoptysis
is identified, a small number of patients may eventually develop
malignancy.10
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Hemoptysis has a 60:40 male predominance and occurs
in all age groups. Male gender, age >40 years old, and history of
smoking are risk factors for a neoplastic cause of hemoptysis.11 Hemoptysis
in children is rare and most often due to cystic fibrosis, foreign
body aspiration, congenital heart disease, infection (pneumonia,
tracheobronchitis), pulmonary-renal syndromes, child abuse (accidental
and deliberate suffocation), and tracheostomy complications.12
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