Hemoptysis

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Chapter 24

Hemoptysis

Perspective

Epidemiology

Hemoptysis is defined as the expectoration of blood from the respiratory tract below the vocal cords. Most cases seen in the emergency department (ED) are mild episodes of small-volume hemoptysis, typically consisting of either blood-tinged sputum or minute amounts of frank blood and are most commonly caused by bronchitis. Although hemoptysis is commonly seen in the ED, only 1 to 5% of hemoptysis patients have massive or life-threatening hemorrhage (generally accepted as 100 to 600 mL of blood loss in any 24-hour period), which can result in hemodynamic instability, shock, or impaired alveolar gas exchange and has a mortality rate approaching 80%.

Large, contemporary series of patients with massive hemoptysis are lacking, and most causative data originate from small, often rural, studies in which tuberculosis (TB) and bronchiectasis are responsible for the majority of cases.1 In developed nations, cancer, cystic fibrosis, arteriovenous malformations, and postprocedural complications play more prominent roles. Pediatric hemoptysis is rare but can be caused by infection, congenital heart disease, cystic fibrosis, or bleeding from a preexisting tracheostomy.2

Pathophysiology

Trace hemoptysis typically originates from tracheobronchial capillaries that are disrupted by vigorous coughing or minor bronchial infections. Conversely, massive hemoptysis nearly always involves disruption of bronchial or pulmonary arteries, the two sets of vessels that constitute the lung’s dual blood supply. Bronchial arteries, which are direct branches from the thoracic aorta, are responsible for supplying oxygenated blood to lung parenchyma, and disruption of these vessels from arteritis, trauma, bronchiectasis or malignant erosion can result in sudden and profound hemorrhage. Although small in caliber, the bronchial circulation is a high-pressure system and the culprit in nearly 90% of the cases of massive hemoptysis requiring embolization. Pulmonary arteries, although transmitting large volumes of blood, do so at much lower pressures and, unless affected centrally, are less likely to cause massive hemoptysis.

Nearly all causes of hemoptysis have a common mechanism—vascular disruption within the trachea, bronchi, small-caliber airways, or lung parenchyma. Modes of vessel injury include acute and chronic inflammation (from bronchitis and arteritis), local infection (especially lung abscesses, TB, and aspergillosis), trauma, malignant invasion, infarction following a pulmonary embolus, and fistula formation (specifically aortobronchial fistulae).

Bronchiectasis, a chronic necrotizing infection resulting in bronchial wall inflammation and dilation, is one of the most common causes of massive hemoptysis. As tissue destruction and remodeling occur, rupture of nearby bronchial vessels can result in bleeding. Bronchiectasis can complicate chronic airway obstruction, necrotizing pneumonia, TB, or cystic fibrosis. Broncholithiasis, the formation of calcified endobronchial lesions following a wide array of granulomatous infections, is an uncommon problem with a similar propensity to erode nearby vessels. Hemorrhage control often requires surgical intervention.3–5

Iatrogenic hemoptysis complicates 2 to 10% of all endobronchial procedures, especially percutaneous lung biopsies.6,7 Diffuse alveolar hemorrhage can be seen with autoimmune vasculitides such as Wegener’s granulomatosis, systemic lupus erythematosus, and Goodpasture’s syndrome. An uncommon cause of hemoptysis occurs when ectopic endometrial tissue within the lung results in monthly catamenial episodes of bleeding.8 Less common causes include pulmonary hereditary telangiectasias and hydatidiform infections. Any episode of hemoptysis can be exacerbated by coagulopathy and thrombocytopenia.

Diagnostic Approach

Differential Considerations

For a patient with apparent hemoptysis, two other potential sources of bleeding should be investigated. Nasal, oral, or hypopharyngeal bleeding sometimes contaminates the tracheobronchial tree, mimicking true hemoptysis. The clinician should closely inspect the nasopharynx and oral cavity to exclude this possibility. Gastric or proximal duodenal bleeding can similarly mimic hemoptysis, and differentiating a gastrointestinal (GI) source of bleeding is especially important because further evaluation and management of these two pathologies follow divergent pathways. Usually differentiation can be done by the patient and physician working together to differentiate coughing from vomiting. In unclear cases, inspection and pH testing may help to distinguish GI from tracheobronchial hemorrhage. Unless an active, brisk upper GI hemorrhage is present, the acidification of blood in the stomach results in fragmentation and darkening, producing specks of brown or black material often referred to as coffee-ground emesis. Pulmonary blood appears bright red or as only slightly darker clots and is alkaline.

Rapid Assessment and Stabilization

Although hemodynamic instability can occur as a result of hemorrhage, the most lethal sequela of massive hemoptysis is hypoxia, which results from the ventilation-perfusion mismatch that follows submersion of the small airways and alveoli with blood.

As a mitigating maneuver in patients with a known lateralizing source of bleeding, the “lung-down” position can be employed. For this position the patient is turned such that the bleeding lung is more dependent, promoting continued protection and ventilation of the unaffected lung and improved oxygenation. If intubation is required, a large diameter (8.0) endotracheal tube should be used to facilitate emergent fiberoptic bronchoscopy. In selected cases of confirmed left-sided bleeding, a single-lumen right-mainstem intubation often can be successfully performed through advancement of the tube in the neutral position or use of a 90-degree rotational technique, during which the tube is rotated 90 degrees in the direction of desired placement and advanced until resistance is met.9 Left-mainstem intubations are more difficult but may be attempted when the bleeding site is the right lung and simple lung-down positioning is not sufficient to stabilize the patient’s airway and oxygenation.

When these measures fail or the hemoptysis is life-threatening, anesthesia consultation is sought for consideration of placement of a double-lumen endotracheal tubes for lung isolation. The correct positioning of blindly placed double-lumen tubes is difficult and requires confirmation by auscultation and fiberoptic bronchoscopy, both of which have are severely impaired by massive hemoptysis. Complications of double-lumen tubes include unilateral and bilateral pneumothoraces, pneumomediastinum, carinal rupture, lobar collapse, and tube malposition.10

Pivotal Findings

History

Although patient reports of bleeding severity can be inaccurate, an estimate of the rate, volume, and appearance of expectorated blood should be obtained. Additional pertinent history includes prior episodes of hemoptysis or parenchymal pulmonary disorders, including bronchiectasis, recurrent pneumonia, chronic obstructive pulmonary disease, bronchitis, TB, and fungal infection. Inflammatory disorders that secondarily involve the lungs or pulmonary vasculature include Wegener’s granulomatosis, Goodpasture’s syndrome, and systemic lupus erythematosus, and a history of these should be elicited. Any risk factors for platelet dysfunction, thrombocytopenia, and coagulopathy should be noted, as should, conversely, any hypercoagulable states that might contribute to venous thromboembolic disease.

Primary or metastatic cancer can cause hemoptysis by erosion into pulmonary and bronchial vessels. Recent percutaneous or transbronchial procedures can cause immediate or delayed postprocedural bleeding, and any recent history of trauma should also be noted. A pertinent travel history to areas in which TB or pulmonary paragonimiasis is endemic is crucial.

Physical Examination

After a primary survey and stabilization, a targeted examination may suggest the location and cause of bleeding but does so in less than 50% of cases.11 Focal adventitious breath sounds may indicate pneumonia or pulmonary abscess. A new heart murmur, especially in a febrile patient, may reflect endocarditis causing septic pulmonary emboli. Symptoms and signs of deep venous thrombosis should suggest pulmonary embolism. Ecchymoses and petechiae can indicate coagulopathy and thrombocytopenia, respectively.

Ancillary Testing

Initial laboratory studies include a complete blood count, coagulation tests, and a type and screen or crossmatch. Renal function tests should be performed if vasculitis is suggested or contrast computed tomography (CT) is planned. Plain chest radiography screens for causes of hemoptysis (including infection and malignancy), although its sensitivity is poor. A prospective study of 184 consecutive patients with varying degrees of hemoptysis revealed that more than 40% of patients with a normal chest radiograph had positive findings on chest CT.12

In patients with massive hemoptysis, plain films may localize the site of hemorrhage in as many as 80% of patients; however, high-resolution multidetector CT of the chest is the principle diagnostic test for investigating both bronchial and nonbronchial causes of massive hemoptysis.13 A chest CT scan should be obtained in the high-risk patient (smokers, oncology patients) or in any patient with moderate to severe bleeding even if the initial chest radiograph is normal. CT localization of hemorrhage can expedite bronchoscopic evaluation and guide subsequent interventional procedures.

CT is diagnostically comparable to conventional angiography but less invasive and more rapidly available. Angiography is the first-line study when the cause of the hemoptysis is known (e.g., malignancy) and angiography-assisted embolization therapy is contemplated.14–16

Diagnostic Algorithm

Differential Diagnosis

Potential causes of hemoptysis vary and include systemic illnesses as well as pulmonary parenchymal diseases. Box 24-1 includes the most common causes.

BOX 24-1   Differential Diagnosis

Hemoptysis

Management

Since the advent of high-resolution CT, radiologic evaluation has had an integral role in the evaluation and treatment of patients with hemoptysis. The challenge to the emergency physician is to rapidly assess the need for airway control before radiographic evaluation and hemodynamic stabilization. Unless the initial chest radiograph is diagnostic or the patient is hemodynamically unstable, a chest CT should be obtained. Further management decisions should be guided by the CT results and made in conjunction with pulmonary and thoracic surgery consultants (Fig. 24-1).

Bronchoscopy

Early bronchoscopy facilitates both localization of bleeding and therapeutic intervention. Balloon and topical hemostatic tamponade, thermocoagulation, and injection of vasoactive agents can all effectively control arterial bleeding. Optimal timing for bronchoscopy remains conjectural; although stable patients with mild to moderate bleeding may benefit from early bronchoscopy, in unstable patients or those with brisk hemorrhage, bronchoscopy may facilitate airway management but is less likely to control bleeding.

Chest CT is as diagnostically accurate as bronchoscopy in locating bleeding peripheral vessels not accessible by a flexible bronchoscope.17 Chest CT can be used to identify the site of bleeding to determine whether angiography is indicated. There may be little added benefit to bronchoscopy before interventional angiography if the bleeding source has already been accurately identified on CT.18

Disposition

Healthy patients with blood-streaked sputum or intermittent small-volume hemoptysis that has resolved and who have normal vital signs do not require imaging beyond plain chest radiography and can be discharged. Follow-up should be arranged for a few days to a week later if symptoms persist, or sooner (including return to the ED) if symptoms are worsening. High-risk patients with minor hemoptysis and all patients with moderate or large amounts of hemoptysis should undergo emergent chest CT scan. There is little value in obtaining a plain chest radiograph before CT, and a plain x-ray film should not be obtained if chest CT is planned regardless of the findings on the plain film. Brief hospitalization or admission to an observation unit for bronchoscopy should be considered. All patients with massive hemoptysis require admission to an intensive care unit and expedited multidisciplinary treatment involving the emergency physician, pulmonologist, and thoracic surgeon.

References

1. Reechaipichitkul, W, Latong, S. Etiology and treatment outcomes of massive hemoptysis. Southeast Asian J Trop Med Public Health. 2005;36:2.

2. Batra, PS, Holinger, LD. Etiology and management of pediatric hemoptysis. Arch Otolaryngol Head Neck Surg. 2001;127:377.

3. Minami, H, Sano, I, Matsuo, S. Broncholithiasis managed by surgical resection. Gen Thorac Cardiovasc Surg. 2007;55:138.

4. Reza, B, Ziaollah, H. Surgical management of TB broncholithiasis with hemoptysis: Experience with five operated cases. Ann Thorac Cardiovasc Surg. 2007;13:185.

5. Potaris, K, Miller, DL, Trastek, VF. Role of surgical resection in broncholithiasis. Ann Thorac Surg. 2000;70:248.

6. Wescott, JL. Percutaneous transthoracic needle biopsy. Radiology. 1988;169:593.

7. Cordasco, EM, Jr., Mehta, AC, Ahmad, M. Bronchoscopically induced bleeding: A summary of nine years’ Cleveland Clinic experience and review of the literature. Chest. 1991;100:1141.

8. Augoulea, A, Lambrinoudaki, I, Christodoulakos, G. Thoracic endometriosis syndrome. Respiration. 2008;75:113.

9. Bair, AE, Doherty, MJ, Harper, R, Albertson, TE. An evaluation of a blind rotational technique for selective mainstem intubation. Acad Emerg Med. 2004;11:1105.

10. Sucato, DJ, Girgis, M. Bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema following intubation with a double-lumen endotracheal tube for thoracoscopic anterior spinal release and fusion in a patient with idiopathic scoliosis. J Spinal Disord Tech. 2002;15:133.

11. Haro Estarriol, M, et al. Utility of history, physical examination and radiography in the localization of bleeding in patients with hemoptysis. An Med Interna. 2002;19:289.

12. Tsoumakidai, M, et al. A prospective analysis of 184 cases of hemoptysis: Diagnostic impact of chest x-ray, computed tomography, bronchoscopy. Respiration. 2006;73:808.

13. Khalil, A, et al. Severe hemoptysis of pulmonary arterial origin: Signs and role of multidetector row CT angiography. Chest. 2008;133:212.

14. Remy-Jardin, M, et al. Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: Comparison with conventional angiography. Radiology. 2004;233:741.

15. Yoon, YC, et al. Hemoptysis: Bronchial and nonbronchial systemic arteries at 16-detector row CT. Radiology. 2005;234:292.

16. Yoon, W, et al. Massive hemoptysis: Prediction of nonbronchial systemic arterial supply with chest CT. Radiology. 2003;227:232.

17. Revel, MP, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol. 2002;179:1217.

18. Hsiao, EI, Kirsch, CM, Kagawa, FT. Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. AJR Am J Roentgenol. 2001;177:861.

19. Swanson, KL, et al. Bronchial artery embolization: Experience with 54 patients. Chest. 2001;121:789.

20. Osaki, S, et al. Prognosis of bronchial artery embolization in the management of hemoptysis. Respiration. 2000;67:412.

21. Poyanli, A, et al. Endovascular therapy in the management of moderate and massive haemoptysis. Br J Radiol. 2007;80:331.

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