Hemoptysis

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 minor episodes of small-volume hemoptysis, typically consisting of either blood-tinged sputum or minute amounts of frank blood, most often associated with bronchitis. Although hemoptysis is commonly seen in the ED, only 1% to 5% of hemoptysis patients have massive or life-threatening hemorrhage. Many definitions exist, but massive hemoptysis is generally accepted as greater than 100 mL or greater than ½ cup of blood loss in any 24-hour period or a bleeding rate ≥100 mL/h, which may result in hemodynamic instability, shock, or impaired alveolar gas exchange and has a mortality rate approaching 80%. The average blood volume of the tracheopulmonary tree is 150 mL; therefore what might be considered small-volume bleeding from another location could be lethal when it occurs in the lungs. In patients admitted with hemoptysis to an intensive care unit (ICU), overall mortality is approximately 6.5%. Highest short-term mortality is found in patients with alcoholism, active cancer, aspergillosis, pulmonary artery involvement, multifocal pulmonary infiltrates, and need for mechanical ventilation at the time of admission.

Large, contemporary series of patients with massive hemoptysis are lacking. Previously, tuberculosis (TB), bronchiectasis, and lung abscesses were responsible for the majority of cases. Contemporary causes of hemoptysis, especially in developed nations, include cancer, cystic fibrosis, arteriovenous malformations, pneumonia, anticoagulant use, and postprocedural complications. Pediatric hemoptysis is rare but can be caused by infection, congenital heart disease, cystic fibrosis, or bleeding from a preexisting tracheostomy. Major causes of hemoptysis are listed in Box 20.1 .