Hemoptysis

Hemoptysis is the expectoration of blood from the lower respiratory tract. It most commonly occurs as a result of a pulmonary infection; tuberculosis is the leading cause of hemoptysis worldwide. While lung cancer is the second most frequent cause of hemoptysis, bleeding from the respiratory tract only occurs in a minority of these patients. Typically, management of hemoptysis begins with the identification of the bleeding site using imaging or bronchoscopy. Definitive diagnostic evaluation is then guided by the location and appearance of the hemorrhagic site, patient symptoms, and patient risk factors for lung cancer. Treatment is directed at the underlying cause. Oral or inhaled tranexamic acid may be used for symptomatic relief. A minority of patients may present with massive hemoptysis, which can be life-threatening if not controlled emergently. In these patients, management begins with securing the airway and protecting the functioning lung. Bedside bronchoscopy and/or bronchial artery embolization are then used to control the hemorrhage. Definitive diagnosis and treatment follow respiratory and hemodynamic stabilization.

• Hemoptysis: expectoration of blood from the lower respiratory tract
• Diffuse alveolar hemorrhage (DAH): hemorrhage arising from the pulmonary microcirculation (e.g., alveolar capillaries, arterioles, and/or venules) that manifests clinically with hypoxemia, alveolar infiltrates on imaging, and possible hemoptysis. ^[1][2][3][4]

• Hemoptysis is the presenting symptom in 0.1% of outpatient visits and hospitalizations. ^[5][6]

Epidemiological data refers to the US, unless otherwise specified.

Source of bleeding ^[2][7][8][9]

• Bronchial arteries (90% of cases)
• Pulmonary arteries (5% of cases)
• Systemic arteries (5% of cases)
• Diffuse alveolar hemorrhage (0.2% of cases) ^[2]

Overview of common etiologies

Diffuse alveolar hemorrhage is most commonly a result of immune-mediated vasculitis or connective tissue disease. Other causes include congestive heart failure, infection, coagulopathy, and trauma. ^[1]

Approach ^[7][8]

See detailed further management of ”Nonmassive hemoptysis” and ”Massive and/or life-threatening hemoptysis” in their dedicated sections.

• All patients: Initially assume that even a small volume of hemoptysis is life-threatening until proven otherwise.
  • Perform an ABCDE survey, while clinically distinguishing hemoptysis from pseudohemoptysis.
  • Obtain portable CXR and other initial studies for hemoptysis.
  • Determine the severity of the hemoptysis (see “Severity assessment”).
  • Identify and treat the underlying cause.
• Massive and/or life-threatening hemoptysis
  • Begin acute stabilization and urgently consult pulmonology or thoracic surgery.
  • Localize bleeding based on stability.
    • Persistently unstable patients: Proceed directly to bronchoscopy and bronchoscopic hemostasis.
    • Stabilized patients: Obtain CT chest and consider subsequent bronchoscopy.
  • Evaluate for definitive therapy: e.g., bronchial artery embolization (BAE) or surgery.
• Nonmassive hemoptysis
  • Manage conservatively.
  • Obtain further diagnostics as directed by clinical suspicion, initial CXR, and patient risk factors.

In cases of massive hemoptysis, stabilize the patient before obtaining further diagnostic studies.

Management priorities are resuscitation, protecting the nondiseased lung, and establishing respiratory and hemodynamic stability. Fatal hypoxia due to impaired gas exchange typically occurs before a hemodynamic change resulting from blood loss. ^[7][14]

Severity assessment ^[7]

• Estimate volume and speed of blood loss: See “Massive hemoptysis” and “Nonmassive hemoptysis.”
• Evaluate the effect of hemoptysis on airway patency, gas exchange, and hemodynamics: See “Life-threatening hemoptysis” and “Nonmassive hemoptysis.”
• Identify any red flags for hemoptysis.

Nonmassive hemoptysis requires respiratory and hemodynamic stability, a low volume and speed of blood loss, and no red flags for hemoptysis. Assume all other types of hemoptysis to be potentially life-threatening or have a high risk of progression to massive hemoptysis.

Red flags for hemoptysis ^[15]

The presence of any red flag feature is associated with an increased risk of mortality and the potential for rapid patient deterioration. ^[15]

• Need for mechanical ventilation on admission
• History of:
  • Cancer
  • Pulmonary aspergillosis
  • Chronic alcohol use disorder
• Pulmonary artery involvement
• CXR findings show involvement of more than one quadrant.

Hemoptysis due to diffuse alveolar hemorrhage is frequently severe and life-threatening. ^[1]

Disposition

• Admit all patients with massive hemoptysis and life-threatening hemoptysis to hospital.
• Select patients with nonmassive hemoptysis may be managed as outpatients after initial workup and observation.
• Consider ICU admission for patients with any of the following: ^[5]
  • High-risk lesions (e.g., aspergilloma, pulmonary artery involvement)
  • Evidence of respiratory compromise
  • Evidence of hemodynamic compromise
  • Chronic cardiac or pulmonary disease
  • Need for continuing anticoagulation

Approach

• Perform initial studies, including CXR and basic laboratory studies.
• Locate the site of bleeding.
  • Massive hemoptysis
    • Unstable patients: Proceed directly to bronchoscopy (accurately determines the site of bleeding and allows for hemostatic treatment).
    • Stable patients: Obtain CT chest with or without subsequent bronchoscopy.
  • Nonmassive hemoptysis: Initial CXR findings direct further studies
• Continue with further investigations for the underlying cause once the patient is clinically stable.

Initial studies for hemoptysis

• Imaging
  • CXR (PA and lateral): preferred initial study ^[14][16]
  • Potential findings include: ^[14]
    • Air space opacity secondary to bleeding
    • Evidence of underlying masses, pneumonia, cavitary lesions, or chronic lung disease
• Laboratory studies ^[5]
  • Type and screen for potential blood transfusion
  • Arterial blood gas to assess for respiratory compromise
  • Studies to assess for complications and determine the underlying etiology ^[5]
    • CBC
    • BMP
    • Liver chemistries
    • Coagulation panel
    • Inflammatory markers (e.g., CRP and procalcitonin)
    • Sputum cultures

Chest x-ray is mandatory in all patients with hemoptysis as it may quickly indicate the location and underlying cause of the bleeding.

Studies to locate the source of bleeding

• CT chest with IV contrast ^[5]
  • Indications (see also “Nonmassive hemoptysis”)
    • Planned bronchial artery embolization
    • Abnormal CXR
    • Recurrence of hemoptysis after conservative management
    • Patients with an elevated risk of cancer ^[9][16]
  • Potential findings ^[17]
    • Localized ground glass or alveolar opacities
    • Extravasation of contrast, vessel enlargement or tortuosity, hypervascularity, and arteriovenous malformations ^[12]
    • Evidence of tumor, infection, or other underlying cause
• Bronchoscopy
  • Indications
    • All unstable patients: to facilitate simultaneous diagnosis and management of bleeding
    • Evaluation of suspicious lesions on imaging, including biopsy
    • To obtain samples for further studies via bronchoalveolar lavage
  • Potential findings
    • Fresh blood and clots in airways
    • Underlying tumor, angiomas, mucosal irritation
    • Findings suggestive of DAH ^[1]
      • Sustained or increased concentration of blood on serial aliquots of bronchial lavage
      • ≥ 20% hemosiderin-laden macrophages in bronchial lavage fluid
  • Next steps: See “Bronchoscopic hemostasis.”
• Angiography: CTA chest or selective catheter angiography may be indicated to help guide BAE, depending on the bleeding source identified on CT chest.

Bronchoscopy can accurately determine the site of bleeding but is much less sensitive than chest CT at determining the underlying cause of the hemoptysis. A combination of both studies is often required for optimal management. ^[18]

Workup for underlying causes

Consider further investigations as directed by clinical suspicion of underlying conditions. See “Etiology of hemoptysis”. ^[5][19]

• CT imaging: e.g., CTPA for PE or other pulmonary arterial abnormalities, CT chest/abdomen/pelvis for malignancy screening
• Laboratory studies
  • Microbiological: e.g., blood or sputum cultures for pneumonia, AFB smear microscopy for TB,
  • Immunological: e.g., anti-GBM antibodies for Goodpasture syndrome, c-ANCA for granulomatosis with polyangiitis, ANAs for SLE.
• Tests of cardiac and pulmonary function: e.g., echocardiography and CHF and valvular heart disease, spirometry for COPD

Priorities for management are acute stabilization followed by definitive bleeding control. The underlying cause can be investigated and treated once patients have been stabilized.

Description

• Massive hemoptysis
  • A frequently used term with no universal definition
  • Commonly described using blood loss parameters, e.g., 100–1000 mL/24 hours or > 100 mL/hour ^[12]
  • Occurs in 5–15% of patients presenting with hemoptysis. ^[5][20]
• Life-threatening hemoptysis consists of any volume of expectorated blood that causes any of the following: ^[21]
  • Airway compromise
  • Impaired gas exchange
  • Hemodynamic instability

The effects of hemoptysis on a patient's airway patency, oxygenation, ventilation, and hemodynamic status are more important predictors of outcome and need for intervention than the absolute value or rate of blood loss. ^[7]

Acute stabilization

Follow ABCDE approach with simultaneous assessment and management.

Airway management and respiratory support

• Secure the airway if signs of airway compromise are present, ideally via intubation with a large ETT (internal diameter ≥ 8.5 mm). ^[7][12]
• Begin supplemental oxygen or mechanical ventilation as needed.
• Consider lung isolation: the physical separation of the bleeding lung from lung still participating in gas exchange.
  • Initial step: Place the patient in the lateral decubitus position with the bleeding side down.
  • Definitive isolation (under bronchoscopy guidance): Options include deliberate mainstem bronchus intubation of the nonbleeding lung or a bronchial blocker (Fogarty catheter). ^[7]

Avoid using a double-lumen endotracheal tube in the management of massive hemoptysis: The small lumen diameter impedes passage of a flexible bronchoscope and effective removal of large blood clots! ^[7]

Immediate hemodynamic support

• Establish large-bore IV access and obtain type and screen and crossmatch for blood products
• Start fluid resuscitation and begin emergency blood transfusion as indicated.

Basic hemostatic measures

• Reverse anticoagulants.
• Consider the use of a hemostatic agent.
  • First line: tranexamic acid (TXA)
    • Has been shown to reduce mortality, interventional procedures, and length of hospital stay. ^{[20][22][23][24]}
    • Can be administered systemically, orally, or by nebulization. ^[22][25]
  • Consider desmopressin in patients with severe renal impairment. ^[26][27]

Bronchoscopic hemostasis ^[7]

Basic hemostatic measures alone rarely control the bleeding in massive hemoptysis; patients typically require local therapy via bronchoscopy.

• First-line modality: flexible fiberoptic bronchoscopy
• Alternative modality: rigid bronchoscopy
• Advanced hemostatic methods
  • Topical therapy with any or a combination of the following:
    • Cold saline lavage ^[7][12][28]
    • Vasoconstrictive agents (e.g., epinephrine) or antidiuretic hormone derivatives ^[7][20]
    • TXA ^[20]
    • Oxidized regenerated cellulose ^[12]
  • Thermal ablation ^[7]
  • Physical tamponade of the bleeding site ^[10]

Flexible fiberoptic bronchoscopy is the initial procedure of choice for the diagnosis and treatment of massive hemoptysis in an unstable patient. ^[7]

Definitive therapy

To prevent a recurrence, the majority of patients who have experienced massive hemoptysis undergo either bronchial artery embolization or surgery.

Bronchial artery embolization (BAE) ^[29]

• BAE is the preferred treatment method for most patients with massive hemoptysis.
• Bleeding sites or high-risk vascular abnormalities are detected on CTA or thoracic angiography.
• Embolic material or coils are introduced to the suspected area under fluoroscopic guidance. ^[8][14]

BAE should be performed as soon as the patient has been stabilized. ^[8][30]

Because the aortic origins of the spinal arteries and the bronchial arteries are in close proximity, spinal arteries may be inadvertently occluded during BAE. Therefore, be alert for new neurological symptoms in patients who have recently undergone BAE. ^[8]

Surgery ^[8][12]

• Ideally, surgery is only performed once hemostasis has been achieved via other methods because of the high mortality rate in actively bleeding patients. ^[12]
• Emergency surgical intervention typically involves lobectomy or pneumonectomy.
• Indications for surgery
  • Iatrogenic pulmonary artery rupture or pulmonary artery aneurysm (e.g., Rasmussen aneurysm)
  • Hemoptysis secondary to chest trauma
  • Ongoing massive hemoptysis after attempted BAE
  • Patients with hemoptysis secondary to aspergilloma, TB, or resectable lung tumor that is considered to have a high rebleeding risk

Management of diffuse alveolar hemorrhage ^[1][31]

• Acute stabilization and basic hemostasis measures as for other types of hemoptysis.
• Consider mechanical ventilation with high PEEP.
• If the etiology is immune-mediated, consult a specialist and consider immune suppression (e.g., high-dose corticosteroids, rituximab) and/or plasmapheresis.

Acute management checklist for massive and/or life-threatening hemoptysis

• Perform ABCDE survey.
• Place the patient in lateral decubitus position with the bleeding side down.
• Establish a secure airway with an 8.5-mm ID endotracheal tube if air exchange is compromised.
• Obtain urgent pulmonary medicine consult.
• Secure IV access and start resuscitation with fluid or blood products.
• Obtain x-ray chest.
• Send initial studies for hemoptysis.
• Reverse known anticoagulants.
• Consider TXA.

Description ^[5][7]

Nonmassive hemoptysis has no universal definition. Commonly described parameters include all of the following:

• < 100 mL of blood volume lost ^[5]
• No signs of respiratory distress or hemodynamic instability
• No other red flags for hemoptysis

Initial approach

• Rule out pseudohemoptysis.
• Examine for signs of infectious disease.
• Identify features of elevated cancer risk, i.e., age > 40 years, smoking history ≥ 30 pack years, or hemoptysis volume ≥ 30 mL.
• Review CXR and other initial diagnostics for hemoptysis to determine further management.

Treat any patients who develop signs of hemodynamic instability, respiratory compromise, or red flags for hemoptysis as life-threatening hemoptysis!

Symptomatic therapy

• In 90% of cases, hemoptysis resolves with treatment of the underlying cause. ^[7]
• If the symptoms of hemoptysis are distressing for the patient, consider TXA. ^[22][25]

Management of underlying causes ^[5]

• For patients with new opacity or signs of infection on CXR:
  • Prescribe oral antibiotics (see “Pneumonia treatment”).
  • Repeat CXR in 6–8 weeks; Consider conservative management for opacities that resolve on follow-up.
• Obtain CT chest with IV contrast for patients with:
  • CXR showing a mass or evidence of lung disease (e.g., COPD).
  • Any of the following despite normal findings or new opacity on initial CXR:
    • Elevated cancer risk
    • Recurrent hemoptysis at any time
    • Persistent opacity on follow-up CXR
• Consult pulmonology and consider bronchoscopy for patients with:
  • A mass or evidence of lung disease on imaging
  • Recurrent hemoptysis at any time
  • Elevated cancer risk despite normal imaging ^[9]

Even after extensive evaluation, up to 50% of patients with nonmassive hemoptysis have no definitive diagnosis. Though the likelihood of underlying malignancy is rare, educate patients on the symptoms of lung cancer and arrange regular follow-up for those with an elevated risk. ^[11]

Acute management checklist for nonmassive hemoptysis

• Verify patient is stable, oxygenating well, and that the bleeding is not clinically significant.
• Verify that bleeding is from the lower respiratory tract.
• Obtain x-ray chest.
• Obtain initial laboratory studies for hemoptysis, including cultures.
• Determine the patient's cancer risk based on history and volume of hemoptysis.
• CT chest if indicated by x-ray chest findings and cancer risk.
• Pulmonary consultation for abnormal imaging, abnormal laboratory studies, or recurrent bleeding
• Investigate and treat underlying causes.

• Pseudohemoptysis: expectorated blood arising from the upper respiratory tract, oropharynx, or gastrointestinal tract

The differential diagnoses listed here are not exhaustive.

• Mortality rates vary greatly according to the underlying cause and severity of the hemoptysis.
• Massive hemoptysis is associated with a mortality rate of 6.5–38%. ^[8][12]