Hemoptysis overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Life-threatening causes of hemoptysis include pulmonary embolism. Common causes of hemoptysis include bronchiectasis, acute respiratory tract infections, chronic obstructive pulmonary disease, bronchitis, pneumonia, lung cancer, tuberculosis, cystic fibrosis, and idiopathic. Less common causes of hemoptysis include ruptured aneurysms, lung abscess, aspergilloma, idiopathic pulmonary fibrosis, behçet's disease, aortobronchial fistula, pulmonary endometriosis, goodpasture syndrome, and foreign body aspiration.
Differentiating Hemoptysis from Other Diseases
Epidemiology and Demographics
The incidence of hemoptysis is approximately 100 per 100,000 individuals in the outpatient setting. There is no enough data on prevalence of hemoptysis. The mortality rate of patients with massive hemoptysis is approximately 50-100%, if left untreated. During 1995-2005, in-hospital mortality rate of massive hemoptysis was 0-15%. Patients of all age groups may develop hemoptysis. There is no racial predilection to hemoptysis. Hemoptysis affects men and women equally. Hemoptysis is a symptom that might affect everyone. Underlying causes of hemoptysis might be different in developed countries than in developing countries. In the United States, incidence of tuberculosis in patients with massive hemoptysis is 7%, while in south africa it is 85%.
Risk Factors
Common risk factors in the development of hemoptysis include cigarette smoking, chronic obstructive pulmonary disease, anticoagulant medications. Risk factors in the recurrence of hemoptysis include persistent residual mild bleeding following bronchial artery embolization, blood transfusion before the procedure, and aspergilloma. Less common risk factors in the development of hemoptysis include congestive heart failure and mitral regurgitation.
Screening
There is insufficient evidence to recommend routine screening for hemoptysis.
Natural History, Complications, and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Patients with hemoptysis may have a positive history of upper respiratory tract infection, gastrointestinal disease, exposure to patients with tuberculosis, bleeding disorders, medications (anticoagulants), and cigarette smoking. Common symptoms of hemoptysis include bloody sputum, chronic cough, shortness of breath, pleuritic chest pain, and wheezing. Less common symptoms of hemoptysis depends on the etiology include weight loss, change in cough, fatigue.
Physical Examination
Physical examination of patients with hemoptysis might be normal. However, patients might show different findings depend on underlying causes. Patients with hemoptysis usually appear anxious and depend on the severity of bleeding they might be critically ill. Patients with hemoptysis usually have abnormal vital signs indicating dehydration, other signs of mucosal bleeding, purulent bloody sputum, and abnormal lung exam indicating underlying pulmonary causes.
Laboratory Findings
Electrocardiogram
There are no electrocardiogram findings associated with hemoptysis. However, electrocardiogram might be abnormal with some of the underlying causes of hemoptysis.
X-ray
Chest x-ray is the first diagnostic modality that is used in a patient with hemoptysis. Chest x-ray might differentiate underlying causes of hemoptysis. Chest x-ray is usually used to compare with previous or later imagings in order to evaluate the progression and resolution of the underlying cause. However, chest x-ray might be completely normal in patients with hemoptysis.
Echocardiography and Ultrasound
There are no echocardiography/ultrasound findings associated with hemoptysis. However, echocardiography or ultrasound might be abnormal with some of the underlying causes of hemoptysis.
CT scan
MRI
Chest MRI may be helpful in the diagnosis of underlying causes of hemoptysis.
Other Imaging Findings
Other imaging findings may be helpful in the diagnosis of underlying causes of hemoptysis.
Other Diagnostic Studies
Treatment
Medical Therapy
Hemoptysis is a symptom that indicates an underlying pulmonary or extrapulmonary cause. Pharmacologic medical therapy depends on an underlying cause. However, the mainstay of treatment for massive hemoptysis is supportive and surgical therapy.
Surgery
Massive hemoptysis is a life-threatening condition and requires prompt intensive care. Surgery is indicated in patients with hemoptysis who are resistant to embolization. Interventional techniques are used to stop bleeding which include bronchial arterial embolization, different bronchoscopic strategies such as cold saline lavage, topical vasoconstrictor agents, balloon tamponade, endobronchial stent placement, endobronchial spigot, oxidized regenerated cellulose, N-Butyl cyanoacrylate glue, fibrinogenthrombin, tranexamic acid, laser photocoagulation, argon plasma coagulation, and electrocautery. Surgical techniques that are used for management of hemoptysis include pulmonary resection, lobectomy, and bilobectomy. Surgical techniques are definitely curative, effective for localized lesions. However, surgery has a mortality rate of 10-30%. Currently, bronchial arterial embolization considered as a first line therapy for both new and recurrent hemoptysis.
Primary Prevention
Effective measures for the primary prevention of hemoptysis include smoking cessation, avoiding air pollutants, and use of physical barriers such as masks and gown.
Secondary Prevention
There are no established measures for the secondary prevention of hemoptysis.