Hemoptysis - Causes. Workup And Management

Definition and Pathophysiology
• Expectoration of blood or blood-streaked sputum
• Massive hemoptysis: ~>600 mL/24–48 h; gas exchange more important than blood loss
• Massive hemoptysis usually results from tortuous or invaded bronchial arteries

Etiology

1. Infections/Inflammation:

• Bronchitis - the most common cause of trivial hemoptysis
• Bronchiectasis 
• Cystic fibrosis
• Tuberculosis
• Aspergilloma
• Pneumonia
• Lung abscess

2. Neoplasms:

• Usually primary lung cancer
• sometimes metastases

3. Cardiovascular causes:

• Pulmonary embolism - can cause massive hemoptysis
• Pulmonary arterial rupture
• Congestive heart failure
• Mitral stenosis
• Trauma
• Foreign body
• Broncovascualr fistula

4. Other causes:

• Vasculitis (Wegener's Good pasture) 
• Anticoagulant drug therapy
• Cocaine
• Rarely lung endometriosis. 

Diagnostic workup

• Localize bleeding site

Rule out GI or ENT source by exam, history; may require endoscopy

Pulmonary source: determine whether unilateral or bilateral, localized or diffuse, parenchymal or airway by CXR or chest CT, bronchoscopy if necessary

• PT, PTT, CBC to rule out coagulopathy

• Sputum culture/stain for bacteria, fungi and AFB; cytology to r/o malignancy

• ANCA, anti-GBM, urinalysis to ✓ for vasculitis or pulmonary-renal syndrome

Treatment

• Mechanism of death is asphyxiation not exsanguination; maintain gas exchange, reverse coagulation and treat underlying condition; cough suppression . may ↑ risk of asphyxiation

• Massive hemoptysis: put bleeding side dependent; selectively intubate nl lung if needed 

- Angiography: diagnostic as well as therapeutic (vascular occlusion balloons or selective embolization  of bronchial artery) 

- Rigid bronchoscopy: allows more interventional options (electrocautery, laser) than flexible bronchoscopy. 

- Surgical resection