Hemoptysis, the coughing up of blood from the respiratory tract, is a symptom that can range from mild and self-limiting to severe and life-threatening. A systematic and professional approach is crucial for accurate diagnosis, risk stratification, and effective management.
Definition of Hemoptysis
Hemoptysis is defined as the expectoration of blood or blood-tinged sputum originating from the lower respiratory tract (larynx, trachea, bronchi, or lungs). It is a symptom, not a diagnosis, indicating underlying pathology within the airways or pulmonary parenchyma. The amount of blood can vary significantly, from streaks of blood in sputum to large volumes of frank blood.
Differentiation of Hemoptysis from Gastrointestinal and Nasopharyngeal Bleeding
It is critical to distinguish hemoptysis from other sources of bleeding that might present similarly, primarily hematemesis (vomiting blood from the GI tract) and bleeding from the upper respiratory or nasopharyngeal passages. Careful history taking and physical examination are essential.
- Hemoptysis Characteristics:
- Blood is typically bright red and frothy due to mixing with air and surfactant.
- Often preceded or accompanied by coughing, tickling in the throat, or a burning sensation in the chest.
- May contain pus or mucus.
- Usually alkaline pH due to the respiratory tract pH.
- Blood is generally cleared with subsequent coughs.
- Associated symptoms may include dyspnea, chest pain, fever, or weight loss depending on the underlying cause.
- Hematemesis Characteristics (from GI Tract):
- Blood is typically dark red or coffee-ground in appearance due to exposure to gastric acid.
- Often mixed with food particles.
- Usually preceded by nausea or vomiting.
- May be accompanied by epigastric pain or symptoms of dyspepsia.
- Usually acidic pH due to gastric acid.
- Followed by feelings of nausea or a sensation of stomach emptying.
- Nasopharyngeal Bleeding Characteristics (from Upper Respiratory Tract):
- Blood can be swallowed and subsequently coughed up or vomited, leading to confusion.
- Often originates from nosebleeds (epistaxis) or oral/pharyngeal lesions.
- History of nasal congestion, sneezing, sore throat, or recent trauma/procedures in the head and neck region.
- Physical examination of the nasal cavity, oral cavity, and pharynx may reveal the source.
- Blood may be bright red but is not typically frothy.
In cases where the source is unclear, observing the characteristics of the expectorated/vomited material, testing its pH with litmus paper (acidic for gastric, alkaline for respiratory), and reviewing associated symptoms are helpful. Endoscopy (esophagogastroduodenoscopy) or bronchoscopy may be required for definitive distinction if doubt persists.
Pathogenesis of Hemoptysis
Bleeding in the respiratory tract typically originates from either the bronchial circulation or the pulmonary circulation. Understanding these vascular systems is key to understanding pathogenesis.
- Bronchial Circulation: This system is part of the systemic circulation, supplying oxygenated blood to the airways (bronchi, bronchioles to the level of respiratory bronchioles), pleura, lymph nodes, and pulmonary vessels. The bronchial arteries originate from the aorta or intercostal arteries and carry blood at systemic pressure. Pathological processes affecting the airways or adjacent structures (e.g., inflammation, infection, cancer) often cause neovascularization and engorgement of the bronchial arteries. Because they are under high pressure, rupturing or erosion of these vessels is the most common cause of significant or massive hemoptysis (accounting for >90% of cases).
- Pulmonary Circulation: This low-pressure system carries deoxygenated blood from the right ventricle to the alveolar capillaries for gas exchange and returns oxygenated blood to the left atrium. Bleeding from the pulmonary circulation (e.g., from pulmonary capillaries or arterioles) usually results in lower volumes of hemoptysis and is often associated with parenchymal lung diseases affecting the alveoli or interstitial space (e.g., pneumonia, tuberculosis, pulmonary embolism with infarction, vasculitis like Goodpasture syndrome or granulomatosis with polyangiitis). However, some conditions affecting larger pulmonary vessels (e.g., AV malformations, aneurysms) can lead to significant bleeding.
Common mechanisms leading to breach of these vessels include:
- Inflammation and Infection: Chronic inflammation (e.g., bronchiectasis, chronic bronchitis, tuberculosis, fungal infections like aspergilloma) leads to hypertrophy and fragility of bronchial vessels. Acute infections (e.g., pneumonia, bronchitis) can cause mucosal hyperaemia and minor bleeding.
- Structural Abnormalities: Bronchiectasis (dilated airways with chronic inflammation) is a major cause of recurrent hemoptysis. Cavitary lesions (e.g., tuberculosis, fungal infections, cancer) can erode into vessels. Arteriovenous malformations or aneurysms (e.g., Rasmussen’s aneurysm in tuberculosis cavities) can rupture.
- Malignancy: Primary lung cancer or metastatic disease can invade and erode airways and vessels.
- Trauma: Chest trauma, foreign body aspiration, or iatrogenic causes (e.g., bronchoscopy with biopsy, lung biopsy, catheter procedures).
- Pulmonary Vascular Disease: Pulmonary embolism with infarction, pulmonary hypertension, vascular malformations, vasculitis.
- Cardiac Causes: Mitral stenosis (leading to elevated pulmonary capillary pressure).
- Coagulopathy: Bleeding disorders or anticoagulant use can exacerbate bleeding fromany source.
Classifications of Hemoptysis
Hemoptysis is most commonly classified based on the estimated volume of blood expectorated over a specific time period, as this strongly correlates with the risk of asphyxiation and dictates the urgency and approach to management.
- Non-Massive Hemoptysis (Mild to Moderate): This refers to expectorating smaller volumes of blood. There is no universally agreed-upon cutoff, but it generally ranges from <100 mL to <300-400 mL in 24 hours. While not immediately life-threatening due to asphyxiation risk, it still requires thorough investigation to identify the underlying cause and prevent recurrence or progression.
- Massive Hemoptysis (Severe or Life-Threatening): This involves expectoration of a large volume of blood over a short period. Again, definitions vary, but commonly cited thresholds include >100 mL, >200 mL, or >600 mL within 24 hours, or >150 mL per hour. Crucially, any amount of blood that threatens the airway due to rapid accumulation or impaired ability to clear secretions should be considered massive, regardless of the absolute volume. Massive hemoptysis is a medical emergency with high mortality, primarily due to airway obstruction and asphyxiation rather than hypovolemia.
Other classifications might include:
- Recurrent Hemoptysis: Repeated episodes over time.
- Chronic Hemoptysis: Persistent hemoptysis over an extended period.
However, the severity-based classification (massive vs. non-massive) is paramount for initial triage and management planning.
Approach to the Patient with Hemoptysis
A systematic approach is vital to ensure patient stability, identify the bleeding source, diagnose the underlying cause, and initiate appropriate treatment.
- Initial Assessment and Stabilization (ABCs):
- Assess Airway patency: Is the patient able to clear secretions? Is there evidence of airway obstruction?
- Assess Breathing adequacy: Respiratory rate, effort, oxygen saturation.
- Assess Circulation: Heart rate, blood pressure, signs of shock.
- Establish intravenous access and administer supplemental oxygen as needed.
- Position the patient appropriately (see management section).
- History Taking: A detailed history is crucial.
- Onset, duration, frequency, and approximate volume of blood expectorated.
- Characteristics of the blood (color, consistency, mixed with sputum/food).
- Associated symptoms: Cough (productive/dry), dyspnea, chest pain, fever, chills, night sweats, weight loss, fatigue, symptoms suggestive of GI or ENT bleeding, leg swelling (PE).
- Past medical history: Previous respiratory diseases (TB, bronchiectasis, COPD, asthma, pneumonia), cardiac disease (mitral stenosis), kidney disease, autoimmune disorders, malignancy, bleeding disorders.
- Medications: Anticoagulants, antiplatelets, NSAIDs.
- Smoking history, occupational or environmental exposures (e.g., silica, asbestos), recent travel (endemic areas for TB, fungi), family history of bleeding disorders or lung disease.
- Recent procedures or trauma.
- Physical Examination:
- General appearance: Distress, pallor, cyanosis.
- Vital signs: Heart rate, blood pressure, respiratory rate, temperature, oxygen saturation.
- ENT exam: Check nasal passages, oral cavity, and pharynx for potential bleeding sites.
- Chest exam: Auscultation for crackles, rhonchi, wheezes (location can sometimes localize the source), decreased breath sounds. Palpation and percussion.
- Cardiac exam: Murmurs (especially mitral stenosis).
- Extremity exam: Edema, signs of DVT.
- Skin exam: Rashes, petechiae, telangiectasias.
Diagnostic Work-up for Hemoptysis
The extent and urgency of the diagnostic work-up depend on the severity of hemoptysis and the clinical suspicion.
- Laboratory Tests:
- Complete Blood Count (CBC): Assess hemoglobin (detect anemia) and white blood cell count (suggest infection).
- Coagulation profile (PT/INR, PTT): Evaluate for bleeding disorders or monitor anticoagulant therapy.
- Electrolytes and Renal function tests: May be relevant depending on suspected cause (e.g., vasculitis affecting kidneys).
- Arterial Blood Gas (ABG): Assess gas exchange, especially in patients with dyspnea or massive hemoptysis.
- Type and Screen/Crossmatch: Essential in massive hemoptysis.
- Inflammatory markers (CRP, ESR): Non-specific indicators of inflammation.
- Sputum analysis: Gram stain, culture, AFB smear and culture, fungal stains and cultures, cytology (for suspected malignancy).
- Autoimmune serology (e.g., ANCA, anti-GBM antibodies): If vasculitis or Goodpasture syndrome is suspected.
- Imaging Studies:
- Chest X-ray (CXR): Often the initial imaging test. Can identify infiltrates, consolidation, masses, cavities, pleural effusions, or signs of pulmonary hypertension. However, it may be normal in up to 30% of cases, especially with mild hemoptysis from the airways.
- Computed Tomography (CT) Scan: Highly valuable, especially High-Resolution CT (HRCT). Provides detailed images of the airways, parenchyma, and vasculature. More sensitive than CXR for detecting bronchiectasis, subtle infiltrates, small nodules, cavities, and mediastinal/hilar abnormalities. Often helps localize the bleeding site and identify the underlying cause (e.g., tumor, bronchiectasis, aspergilloma).
- CT Angiography (CTA): If a vascular cause is suspected (e.g., pulmonary embolism, vascular malformation) or as part of pre-embolization planning to map the bronchial circulation.
- Bronchoscopy:
- Flexible Bronchoscopy: A cornerstone in the diagnostic work-up, especially for localizing the bleeding site in cases where imaging is inconclusive or multiple lesions are present. Allows direct visualization of the airways, identification of active bleeding, presence of clots, mucosal abnormalities, endobronchial lesions, or foreign bodies. Biopsies or washings can be obtained. In massive hemoptysis, urgent bronchoscopy is often performed to localize the source and guide management (e.g., tamponade, lavage).
- Rigid Bronchoscopy: May be preferred in massive hemoptysis for better airway control, suctioning of large clots, and potential therapeutic interventions (e.g., direct tamponade, laser therapy, foreign body removal), especially by experienced operators.
- Other Investigations:
- Echocardiogram: If mitral stenosis or other cardiac causes are suspected.
- Endoscopy (EGD): If hematemesis cannot be definitively ruled out.
Assessment of Severity of Hemoptysis (Massive & Non-Massive)
As highlighted in the classification section, correctly assessing severity is critical for determining the urgency of intervention and guiding the management strategy.
- Criteria for Massive Hemoptysis:
- Absolute volume: Commonly >100-600 mL in 24 hours (lower volumes are often used as the threshold for increased risk, e.g., >100 mL/24h or >150 mL/h). There is no single universally accepted volume threshold.
- Rate of bleeding: Rapid bleeding is more dangerous than slow bleeding.
- Impact on respiratory function: Any volume causing airway compromise, difficulty clearing secretions, significant dyspnea, hypoxemia, or hemodynamic instability should be treated as massive. This is often the most practical definition in clinical practice, as even smaller volumes can be life-threatening in patients with poor respiratory reserve or impaired cough reflex.
- Criteria for Non-Massive Hemoptysis:
- Smaller volumes of blood, typically <100-200 mL in 24 hours.
- Patient is hemodynamically stable.
- No immediate threat to the airway (patient is able to clear secretions effectively).
Assessment involves carefully quantifying the reported volume (acknowledging patient estimations can be imprecise), monitoring vital signs and oxygenation, and assessing the patient’s ability to protect their airway.
Management of Massive & Non-Massive Hemoptysis
Management strategies differ significantly based on the severity.
- Management of Massive Hemoptysis (Medical Emergency):
- Priority 1: Airway Protection and Stabilization:
- Secure the airway: Often requires intubation. A large-bore endotracheal tube allows for better suctioning. A double-lumen tube or bronchial blocker may be used to isolate the bleeding lung and protect the non-bleeding lung from aspiration.
- Positioning: Position the patient with the bleeding side down (if known) to minimize aspiration of blood into the contralateral lung.
- Resuscitation: Administer high-flow oxygen, secure IV access (large bore), fluid resuscitation, blood transfusion if needed (correct coagulopathy if present).
- Priority 2: Localization and Control of Bleeding:
- Urgent Bronchoscopy: Typically performed early to localize the bleeding source, remove blood clots (potentially using rigid bronchoscopy), and attempt immediate control measures (e.g., instillation of cold saline, vasoconstrictors like epinephrine, balloon tamponade, insertion of bronchial blockers).
- Imaging: Rapid CT angiography may be performed if patient is stable enough, to help localize the source and map bronchial arteries for embolization.
- Priority 3: Definitive Hemostasis:
- Bronchial Artery Embolization (BAE): This is the preferred first-line treatment for massive hemoptysis attributable to the bronchial circulation (the most common source). Interventional radiologists catheterize the offending bronchial artery(ies) and embolize them with particles or coils to occlude blood flow to the bleeding site. BAE is less invasive than surgery and has a high success rate in controlling bleeding acutely, though recurrence can occur.
- Surgery: Resection of the affected lung segment, lobe, or pneumonectomy may be necessary if BAE fails, the bleeding source is not amenable to embolization (e.g., pulmonary artery source, major vessel erosion), the underlying disease requires surgical management (e.g., localized aspergilloma, non-resectable tumor causing bleeding), or in cases of severe trauma not controllable by other means. Surgery for massive hemoptysis carries high morbidity and mortality and is reserved for selected cases, often after other options have been exhausted or are unsuitable.
- Medical Management: Antifibrinolytics (e.g., tranexamic acid) may be considered as an adjunct, but are rarely sufficient alone for massive bleeding. Treating underlying infections (e.g., antibiotics) is important but does not acutely stop massive bleeding.
- Priority 1: Airway Protection and Stabilization:
- Management of Non-Massive Hemoptysis:
- Diagnosis of Underlying Cause: The primary focus is on performing the comprehensive diagnostic work-up outlined above (history, physical, labs, imaging like CXR/CT, bronchoscopy if indicated by suspicion of malignancy, localized lesion, or failure of initial treatment).
- Treatment of Underlying Cause: Management is directed at the specific etiology identified.
- Infections: Antibiotics for pneumonia, bronchitis, or mycobacterial infections (TB). Antifungals for aspergilloma/fungal infections.
- Bronchiectasis: Management of exacerbations, airway clearance.
- Malignancy: Appropriate cancer therapy (surgery, chemotherapy, radiation).
- Coagulopathy: Reversal of anticoagulation, factor replacement.
- Vasculitis: Immunosuppression.
- Cardiac: Management of heart failure, valve disease.
- Symptomatic Treatment: Cough suppressants may be used if cough is exacerbating minor bleeding, but caution is needed as cough is protective for clearing the airway.
- Monitoring: Patients should be monitored for potential escalation in bleeding volume.
Conclusion
Hemoptysis is a significant symptom requiring prompt and systematic evaluation. Differentiating it from non-pulmonary bleeding is the crucial first step. Understanding the pathogenesis arising from the bronchial or pulmonary circulation guides diagnostic thinking. Classifying hemoptysis by severity dictates the urgency and nature of the initial response. A thorough history, physical examination, and appropriate diagnostic work-up involving laboratory tests, imaging (especially CT), and often bronchoscopy are essential to identify the source and underlying cause. Management is tailored to the severity, with massive hemoptysis demanding urgent airway protection and definitive bleeding control (often BAE or surgery), while non-massive hemoptysis focuses on diagnosing and treating the root cause to prevent recurrence and progression. A multidisciplinary approach involving pulmonologists, interventional radiologists, thoracic surgeons, and other specialists is often optimal for managing complex cases.
