Therefore, the presence or absence of hemoptysis alone has no significant effect on the likelihood of pulmonary embolism. Idiopathic hemoptysis is a diagnosis of exclusion.
In 7 to 34 percent of patients with hemoptysis, no identifiable cause can be found after careful evaluation. The major cause of hemoptysis in children is lower respiratory tract infection. The second most common cause is foreign body aspiration, with most cases occurring in children younger than four years. Another important cause is bronchiectasis, which often is secondary to cystic fibrosis.
Primary pulmonary tuberculosis is a rare cause estimated to occur in less than 1 percent of cases. Blunt-force trauma may result in hemoptysis secondary to pulmonary contusion and hemorrhage. Bleeding caused by suffocation, deliberate or accidental, also should be considered. Historic clues are useful for differentiating hemoptysis from hematemesis Table 2 4 , 17 , Patient history also can help identify the anatomic site of bleeding, differentiate between hemoptysis and pseudohemoptysis, and narrow the differential diagnosis Table 3 4 , 5 , 17 , Factors such as age, nutrition status, and comorbid conditions can assist in the diagnosis and management of hemoptysis.
Information from references 4 , 17 , and Dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, frothy pink sputum. Upper respiratory infection, acute sinusitis, acute bronchitis, pneumonia, lung abscess. History of chronic lung disease, recurrent lower respiratory track infection, cough with copious purulent sputum.
Nausea, vomiting, melena, alcoholism, chronic use of nonsteroidal anti-inflammatory drugs. Tuberculosis, parasites e. Information from references 4 , 5 , 17 , and Once true hemoptysis is suspected, the investigation should focus on the respiratory system. Blood from the lower bronchial tree typically induces cough, whereas a history of epistaxis or expectorating without cough would be consistent with an upper respiratory source but does not exclude a lower tract site.
Bleeding is difficult to quantify clinically. Patients may find it difficult to discern whether they are throwing up, coughing, or spitting out bloody material. The amount of blood loss usually is overestimated by patients and physicians, but an attempt to determine the volume and rate of blood loss should be made. Methods of determination include observing as the patient coughs and the use of a graduated container. Blood-streaked sputum deserves the same diagnostic consideration as blood alone.
The amount or frequency of bleeding does not correlate with the diagnosis or incidence of cancer. It is helpful to determine whether there have been previous episodes of hemoptysis and what diagnostic assessments have been done.
Mild hemoptysis recurring sporadically over a few years is common in smokers who have chronic bronchitis punctuated with superimposed acute bronchitis. Because smoking is an important risk factor, these patients are at higher risk for lung cancer. Environmental exposure to asbestos, arsenic, chromium, nickel, and certain ethers increases risk for hemoptysis. Bronchial adenomas, although malignant, are slow growing and may present with occasional bleeding over many years. Malignancy in general, especially adenocarcinomas, can induce a hypercoagulable state, thereby increasing the risk for a pulmonary embolism.
A history of chronic, purulent sputum production and frequent pneumonias, including tuberculosis, may represent bronchiectasis. Association of hemoptysis with menses i. A travel history may be helpful. Tuberculosis is endemic in many parts of the world, and parasitic etiologies should be considered. Historic clues often will narrow the differential diagnosis and help focus the physical examination Table 4 4 , 5 , Examining the expectoration may help localize the source of bleeding.
Constitutional signs such as cachexia and level of patient distress also should be noted. The skin and mucous membranes should be inspected for cyanosis, pallor, ecchymoses, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa.
Primary lung cancer, bronchiectasis, lung abscess, severe chronic lung disease, secondary lung metastases. Fever, tachypnea, hypoxia, hypertrophied accessory respiratory muscles, barrel chest, intercostal retractions, pursed lip breathing, rhonchi, wheezing, tympani to percussion, distant heart sounds.
Gingival thickening, mulberry gingivitis, saddle nose, nasal septum perforation. Tachycardia, tachypnea, hypoxia, jugulovenous distention, S3 gallop, decreased lung sounds, bilateral rales, dullness to percussion in lower lung fields. Congestive heart failure caused by left ventricular dysfunction or severe mitral valve stenosis.
Tachypnea, tachycardia, dyspnea, fixed split S2, pleural friction rub, unilateral leg pain and edema. Information from 4 , 5 , and The examination for lymph node enlargement should include the neck, supraclavicular region, and axillae. The cardiovascular examination includes an evaluation for jugular venous distention, abnormal heart sounds, and edema. The physician should check the chest and lungs for signs of consolidation, wheezing, rales, and trauma. The abdominal examination should focus on signs of hepatic congestion or masses, with an inspection of the extremities for signs of edema, cyanosis, or clubbing.
Figure 1 5 presents an algorithm for the evaluation of nonmassive hemoptysis. After a careful history and examination, a chest radiograph should be obtained Table 5 4 , If a diagnosis remains unclear, further imaging with chest computed tomography CT or direct visualization with bronchoscopy often is indicated.
In high-risk patients with a normal chest radiograph, fiberoptic bronchoscopy should be considered to rule out malignancy. Risk factors that increase the likelihood of finding lung cancer on bronchoscopy include male sex, older than 40 years, a smoking history of more than 40 pack-years, and duration of hemoptysis for more than one week. Cough and hemoptysis. New York: McGraw-Hill, Information from 4 and Fiberoptic bronchoscopy is preferred if neoplasia is suspected; it is diagnostic for central endobronchial disease and allows for direct visualization of the bleeding site.
It also permits tissue biopsy, bronchial lavage, or brushings for pathologic diagnosis. Fiberoptic bronchoscopy also can provide direct therapy in cases of continued bleeding. Rigid bronchoscopy is the preferred tool for cases of massive bleeding because of its greater suctioning and airway maintenance capabilities.
High-resolution CT has become increasingly useful in the initial evaluation of hemoptysis and is preferred if parenchymal disease is suspected. Its complementary use with bronchoscopy gives a greater positive yield of pathology 12 , 27 , 28 and is useful for excluding malignancy in high-risk patients.
Patients with recurrent or unexplained hemoptysis may need additional laboratory evaluation to establish a diagnosis Table 6 5 , Elevated cell count and differential shifts may be present in upper and lower respiratory tract infections.
Elevated in infection, autoimmune disorders e. Information from references 5 and The overall goals of management of the patient with hemoptysis are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause.
During a BAE, a special dye is injected into your arteries so they show up clearly on X-rays. Then, using X-ray scans as a guide, the source of the bleeding is located and injected with tiny particles, around the size of a grain of sand, that will help clog the vessel up and stop the bleeding. Page last reviewed: 27 July Next review due: 27 July Most often, the lesions are bronchiectasis, infections pneumonia, tuberculosis, fungal , or lung tumors.
However, conventional techniques may be insufficient in some cases, such as in patients with arteriovenous malformations 4. In addition, this multidetector CT could substitute bronchoscopy as the first-line method for the evaluation of patients with hemoptysis 5.
In case there are more suspicious areas in the radiological examination, fiberoptic bronchoscopy can be used as a guide to identify the focus of hemoptysis. Nonmassive hemoptysis can be managed by conservative treatment options such as treatment of the infection or the inflammatory disease according to the underlying pathology, and the outcome may be satisfactory in most of the cases 6.
Stabilization of coagulation by medical measures is another method to stop the bleeding. In this article, we would like to share our experience of our approach toward three different patients with hemoptysis. The first case was a patient with a first-time experience of a massive hemoptysis who underwent an emergency video-assisted thoracoscopic surgery VATS resection within 1 hour after her admission.
The second case was an elective candidate of VATS resection. The third patient was managed with bronchial embolization. There is no description about parasitic causes of hemoptysis such as Echinococcus granulosus as one of the common reasons for hemoptysis; thus, its incidence can increase according to endemicity of the geographical area 7.
Although surgery is the preferred method, pharmacotherapy benzimidazoles may also be useful in selected patients. Indications for medical therapy include smaller cysts, and patients with contraindication for surgery could be described as those with poor surgical risk, multiorgan disease, multiple cysts, recurrent cysts, and intraoperative spillage of hydatid fluid 8.
This case was a year-old female patient who was hospitalized with a first-time experience of a massive hemoptysis, and the volume of bleeding was approximately 0. An emergency chest CT demonstrated lesions compatible with lung pathology of cystic nature Figure 1.
Fiberoptic bronchoscopy was performed in the operating room under general anesthesia, and we observed that fresh coagulum was obstructing the right lower lobe orifice. We did not want to draw the coagulum and cause more bleeding and hence intubated the patient with a left endobronchial intubation tube and started unilateral lung isolation and ventilation.
Videothoracoscopic surgery was performed via three ports. The artery and vein of the lower lobe and the bronchus were stapled, and lower lobectomy was performed.
Pathology revealed a perforated hydatid cyst with erosion of pulmonary artery on the interlobar level. The duration of stay in the hospital was 4 days, and the patient was discharged without complications. She was prescribed albendazole treatment. During her 3-year follow-up examinations, she did not develop any cysts.
These subjects may suffer considerable worsening of gaseous exchange even for smaller quantities of blood. Mortality is generally more the result of airway compromise with asphyxiation, rather than exsanguination. Haemoptysis may derive from a variety of very different conditions, such as infections, pulmonary diseases, neoplastic conditions, cardiovascular alterations, vasculitis, traumatic events, haematological derangements, and iatrogenic or drug-induced events see Box The relative importance of different causes of haemoptysis has changed over time.
For centuries, haemoptysis was considered virtually pathognomonic for pulmonary tuberculosis. During the course of the last century, however, effective antimycobacterial treatment and the rise in prevalence of cigarette smoking have changed the epidemiology of haemoptysis. Box Haemoptysis is more likely to occur, and may manifest earlier in p. Among mycobacteria, haemoptysis is mainly related to Mycobacterium tuberculosis , with few reports on the involvement of non-tuberculous mycobacteria.
Haemoptysis may be the result of active tuberculosis, generally with small and chronic bouts of blood, although massive haemoptysis has also been described in this context.
Inactive mycobacterial disease may be associated with bleeding arising from post-tuberculous thick-walled cavities or bronchiectasis. Rarely, peri-bronchial calcified lymph node may erode into or distort an adjacent bronchus. Aspergilloma is a mycotic colonization of a pre-existing lung cavity or cyst. Post-tuberculous cavities or idiopathic pulmonary fibrosis cavities are examples of pre-existing lung disease conditions that may be prone to fungal colonization.
Aspergillus fumigatus and Aspergillus niger are the most commonly encountered species. The reported incidence of haemoptysis in patients with aspergilloma ranges from 54 to Invasive pulmonary aspergillosis in immunocompromised subjects is also associated with haemoptysis events, although rarely fatal.
Cystic fibrosis, usually in the context of extensive bronchiectasis, has become an increasingly common aetiology of haemoptysis, probably due to the longer survival of affected patients into adulthood. Necrotizing pneumonia, lung abscess, and lung gangrene caused by bacteria, such as Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae , other Streptococcus spp. The event of pulmonary artery rupture during pulmonary artery catheterization PAC is relatively rare with an incidence of 0.
Rupture may be due either to the catheter tip being directed into the vessel wall, or to catheter migration to a smaller calibre branch and subsequent rupturing during balloon inflation.
Pulmonary hypertension is reported as the underlying cause of haemoptysis in 0. Conversely, in patients with Eisenmenger syndrome, haemoptysis is a more common finding. In female patients with thoracic endometriosis haemoptysis represents an early clinical manifestation, occurring at an earlier age, whereas pneumothorax tends to manifest in more advanced disease.
Diffuse alveolar haemorrhage is a rare cause of haemoptysis associated with disruption of the alveolar—capillary barrier. It should be suspected in case of haemoptysis, anaemia and bilateral infiltrates on the chest radiograph. The infiltrates are the result of distal inhalation of blood.
Infectious processes, such as leptospirosis, malaria, and cytomegalovirus infection may present alveolar haemorrhage. A number of drugs are also associated with diffuse alveolar haemorrhage, such as propylthiouracil, carbimazole, and crack cocaine [ 13 ]. In a sizable number of cases, even after extensive diagnostic work-up, a definitive cause for haemoptosyis is not found.
These cases are termed as cryptogentic haemoptysis. Most of these studies have, however, not systematically used CT evaluation on all patients. Wider availability and technical developments in CT imaging will likely result in reduced prevalence of unknown origin cases of haemoptysis in the future. The lungs are furnished with a dual blood supply, the bronchial arteries and the pulmonary arteries. The bronchial arteries are a high-pressure circulation system.
They have a variable anatomy in terms of origin and branching distribution.
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