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Haemoptysis
Essentials
- 1
Most patients are stable and can be managed and investigated as outpatients.
- 2
It is essential to differentiate between haemoptysis, haematemesis and bleeding from the upper airway.
- 3
Chest x-ray is normal in 30% of patients with haemoptysis and misses 25% of malignancies.
- 4
High-resolution computed tomography is the investigation of choice if the chest x-ray cannot point to a cause of the bleeding.
- 5
Bronchoscopy is useful if haemoptysis is thought to be due to a lesion in the bronchial tree.
- 6
In 50% of cases, no cause for haemoptysis will be found.
- 7
The priorities in massive haemoptysis are the maintenance of ventilation, oxygenation, circulatory support and the identification and treatment of the source of bleeding.
- 8
If intubation is required, the choice of endotracheal tube type and location of placement will be challenging.
- 9
Embolization of bleeding vessels may provide temporary cessation of bleeding in emergencies, allowing time to stabilize patients prior to surgical procedures.
Introduction
Haemoptysis is the expectoration of blood from the lungs or tracheobronchial tree. Most patients who present with haemoptysis describe small amounts of blood mixed with sputum or saliva. Most patients are stable and can be managed as outpatients. Rarely, patients present with massive haemoptysis where respiratory and circulatory systems are severely compromised, and death by asphyxiation or exsanguination can be quite rapid. These patients require urgent skilful management of the airways and circulatory systems. A small blood clot may compromise ventilation by obstructing an airway just as effectively as a massive bleed that floods an entire lung.
Aetiology
The causes of haemoptysis are summarized in Table 6.8.1 . In up to 50% of cases no cause will be found.
Table 6.8.1
Causes and incidence of haemoptysis
From Ittrich H, Bockhorn M, Klose H, Simon M. The diagnosis and treatment of hemoptysis. Dtsch Arztebl Int . 2017;114(21):371–381.
| Common | Frequency (%) | |
|---|---|---|
| Idiopathic | 50 | |
| Infections | Bronchitis | 22 |
| Pneumonia | ||
| Lung abscess | ||
| Neoplasm | Bronchial carcinoma | 17 |
| Metastases | ||
| Bronchiectasis/cystic fibrosis | 7 | |
| Pulmonary oedema | 4.2 | |
| Uncommon | ||
| Iatrogenic | Anticoagulant therapy | 3.5 |
| Lung biopsy | ||
| Right heart catheterization | ||
| Post-pulmonary surgery | ||
| Tuberculosis | 2.7 | |
| Pulmonary embolism | 2.6 | |
| Apergillosis | 1.1 | |
| Benign bronchial tumours | 0.2 | |
| Vasculitides | 0.2 | |
| Rare | ||
| Vascular malformation | 0.2 | |
| Idiopathic pulmonary haemosiderosis | 0.1 | |
| Coagulopathies | ||
| Benign bronchial tumour | ||
| Septic embolism/endocarditis | ||
| Trauma | ||
| Foreign body | ||
Clinical features
Most patients (95%) with haemoptysis do not present with immediate life-threatening bleeding and can be managed as outpatients. Massive haemoptysis is any degree of haemoptysis that is immediately life-threatening (usually via respiratory compromise). Haemodynamic compromise is rare, as volumes required to threaten life by ventilatory impairment are as little as 200 mL of blood. Blood lost can also obstruct an airway.
Patients may have difficulty in differentiating between haemoptysis and haematemesis. Bronchial blood is usually coughed out, bright red, frothy and alkaline, whereas gastrointestinal blood is usually darker, may be mixed with food particles and is acidic. Haemoptysis must also be differentiated from nasopharyngeal bleeding, particularly epistaxis.
A targeted history and examination should first seek evidence of airway obstruction as well as respiratory or cardiovascular compromise and then elicit features of potential causes, from the most to the least common. Most patients will have no relevant findings, whereas others will have features of infection (fever, productive cough); possible neoplasm, tuberculosis (TB) and vasculitides (smoking history, other malignancy, chronic cough, weight loss, night sweats, clubbing); chronic or acute respiratory disease; cardiovascular disease and pulmonary embolism. History should also include recent procedures, anticoagulation, TB exposure, possible foreign bodies and past vasculitides. Assessment should aim to differentiate true haemoptysis from gastrointestinal or upper airway causes of bleeding.
Clinical investigations
The patient should be isolated during the course of assessment and management if pulmonary TB or other virulent airborne organisms are considered likely.
Chest x-ray
This is the first investigation to undertake. Between 20% and 30% of patients will have a normal chest x-ray. Chest x-ray may show new alveolar opacity identifying the location of the bleed. It may also show chronic lung disease or new pathology such as infection, masses, cavitation, pulmonary oedema or cardiomegaly. Note that in 25% of patients bleeding from a tumour, the tumour will not be identified on the chest x-ray.
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