Hemoptysis

Not to be confused with Hematemesis.

Hemoptysis or haemoptysis is the discharge of blood or blood-stained mucus through the mouth coming from the bronchi, larynx, trachea, or lungs. It does not necessarily involve coughing. In other words, it is the airway bleeding. This can occur with lung cancer, infections such as tuberculosis, bronchitis, or pneumonia, and certain cardiovascular conditions. Hemoptysis is considered massive at 300 mL (11 imp fl oz; 10 US fl oz). In such cases, there are always severe injuries. The primary danger comes from choking, rather than blood loss.^[1]

Hemoptysis
Other names	Haemoptysis, coughing up of blood
Lower left: Inflammation of the bronchus can bring about bloody mucus.
Pronunciation	/hɪˈmɒptɪsɪs/
Specialty	Pulmonology
Symptoms	Spitting blood or bloody sputum
Complications	Pulmonary aspiration, choking
Causes	bronchitis, lung cancer, certain infections
Differential diagnosis	epistaxis (combined with post-nasal drip)

Diagnosis

 

Diagnostic approach to solving the puzzle of hemoptysis.

• Past history, history of present illness, family history^[2]
  • history of tuberculosis, bronchiectasis, chronic bronchitis, mitral stenosis, etc.
  • history of cigarette smoking, occupational diseases by exposure to silica dust, etc.
• Blood
  • duration, frequency, amount
  • Amounts of blood: large amounts of blood, or is there blood-streaked sputum
  • Probable source of bleeding: Is the blood coughed up, or vomited?
• Bloody sputum
  • color, characters: blood-streaked, fresh blood, frothy pink, bloody gelatinous.
• Accompanying symptoms
  • fever, chest pain, coughing, purulent sputum, mucocutaneous bleeding, jaundice.
• Imaging examination
  • chest X-ray, CT scan and 3D reconstruction images or CT virtual bronchoscopy, bronchial angiography.
• Laboratory tests
  • blood test: WBC
  • Sputum: cells and bacterial examinations, sputum culture
• Bronchial fiber endoscopy^[3]

Differential diagnosis

The most common causes for hemoptysis in adults are chest infections such as bronchitis or pneumonia.^[1] In children, hemoptysis is commonly caused by the presence of a foreign body in the airway. Other common causes include lung cancers and tuberculosis. Less common causes include aspergilloma, bronchiectasis, coccidioidomycosis, pulmonary embolism, pneumonic plague, and cystic fibrosis. Rarer causes include hereditary hemorrhagic telangiectasia (HHT or Rendu-Osler-Weber syndrome), Goodpasture's syndrome, and granulomatosis with polyangiitis. A rare cause of hemoptysis in women is endometriosis, which leads to intermittent hemoptysis coinciding with menstrual periods in 7% of women with thoracic endometriosis syndrome.^[4] Hemoptysis may be exacerbated or even caused by overtreatment with anticoagulant drugs such as warfarin.^{[citation needed]}

Blood-laced mucus from the sinus or nose area can sometimes be misidentified as symptomatic of hemoptysis (such secretions can be a sign of nasal or sinus cancer, but also a sinus infection). Extensive non-respiratory injury can also cause one to cough up blood. Cardiac causes like congestive heart failure and mitral stenosis should be ruled out. The origin of blood can be identified by observing its color. Bright-red, foamy blood comes from the respiratory tract, whereas dark-red, coffee-colored blood comes from the gastrointestinal tract. Sometimes hemoptysis may be rust-colored.^{[citation needed]}

• Lung cancer, including both non-small cell lung carcinoma and small cell lung carcinoma.^[5][6]
• Sarcoidosis^[7]
• Aspergilloma^[8]
• Tuberculosis^[9]
• Histoplasmosis^[10]
• Pneumonia^[11]
• Pulmonary edema^[12][13]
• Endometriosis and thoracic endometriosis syndrome^[14]
• Foreign body aspiration and aspiration pneumonia^[15]
• Goodpasture's syndrome^[16]
• Microscopic polyangiitis^[17]
• Granulomatosis with polyangiitis^[18]
• Eosinophilic granulomatosis with polyangiitis^[19][20]
• Bronchitis^[21]
• Bronchiectasis^[21]
• Pulmonary embolism^[22]
• Anticoagulant use^[22]
• Trauma^[22]
• Lung abscess^[22]
• Mitral stenosis^[23]
• Tropical pulmonary eosinophilia^[24]
• Bleeding disorders^[25]
• Hughes-Stovin syndrome and other variants of Behçet's disease^[26]
• Pulmonary arteriovenous malformations

Massive hemoptysis and mortality

 

Hemoptysis

Although there are reports that the fatality rate is as high as 80%, the mortality rate for hospitalized hemoptysis patients is 9.4% (with n=28539), calculated from the data in the article by Kinoshita et al.^[27] This is probably the most reasonable figure considering the overwhelming number of cases.^{[citation needed]}

The general definition of massive hemoptysis is more than 200 ml within 24 hours, but there is a wide range in the literature (100-600 ml). Considering that the total volume of the tracheal and bronchial lumen is about 150 cc,^[28][29] it may be reasonable to define massive hemoptysis as 200 ml, which is a little more than 150 ml, in terms of setting the threshold for fatal hemoptysis. More than 400ml/day is not adequate for screening purposes.^{[citation needed]}

Treatment

Treatment depends on the underlying cause. Treatments include iced saline, and topical vasoconstrictors such as adrenaline or vasopressin. Tranexamic acid was proved to improve in-hospital mortality.^[27] Selective bronchial intubation can be used to collapse the lung that is bleeding. Also, endobronchial tamponade can be used.^[30] Laser photocoagulation can be used to stop bleeding during bronchoscopy. Angiography of bronchial arteries can be performed to locate the bleeding, and it can often be embolized.^[31] Bronchial artery embolization (BAE) is the first line treatment nowadays.^{[32][33][34][35][36]} Surgical option is usually the last resort and can involve removal of a lung lobe or removal of the entire lung. Cough suppressants can increase the risk of choking.^[1]

References

1. Sabatine MS (2014). Pocket medicine (Fifth ed.). [S.l.]: Aspen Publishers, Inc. ISBN 978-1451193787.
2. "Hemoptysis". The Lecturio Medical Concept Library. Retrieved 24 July 2021.
3. Richard F.LeBlond (2004). Diagnostics. US: McGraw-Hill Companies, Inc. ISBN 978-0-07-140923-0.
4. McCann MR, Schenk WB, Nassar A, Maimone S (September 2020). "Thoracic endometriosis presenting as a catamenial hemothorax with discordant video-assisted thoracoscopic surgery". Radiology Case Reports. 15 (9): 1419–1422. doi:10.1016/j.radcr.2020.05.064. PMC 7334551. PMID 32642009.
5. Google Health – Google
6. Google Health – Google
7. . Archived from the original on 2009-02-21. Retrieved 2010-02-05.
8. MedlinePlus Encyclopedia: Pulmonary aspergilloma
9. Google Health – Google
10. "Histoplasmosis Symptoms – Diseases and Conditions – Mayo Clinic". from the original on 2013-05-31. Retrieved 2010-02-05.
11. "Pneumonia". The Lecturio Medical Concept Library. 27 August 2020. Retrieved 1 July 2021.
12. Dorland's illustrated medical dictionary (32nd ed.). Saunders/Elsevier. 2 May 2011. p. 593. ISBN 9781416062578.
13. Ware LB, Matthay MA (December 2005). "Clinical practice. Acute pulmonary edema". N. Engl. J. Med. 353 (26): 2788–96. doi:10.1056/NEJMcp052699. PMID 16382065.
14. "Endometriosis". The Lecturio Medical Concept Library. Retrieved 25 July 2021.
15. "Foreign Body Aspiration". The Lecturio Medical Concept Library. Retrieved 25 July 2021.
16. Pediatric Goodpasture Syndrome at eMedicine
17. Altaie R, Ditizio F, Fahy GT (March 2005). "Microscopic polyangitis presenting with sub-acute reversible optic neuropathy". Eye (Lond). 19 (3): 363–5. doi:10.1038/sj.eye.6701479. hdl:10379/8830. PMID 15272290.
18. "Granulomatosis with Polyangiitis". www.mayoclinic.org. Mayo Foundation for Medical Education and Research. from the original on 22 December 2017. Retrieved 3 March 2018.
19. Adu, Emery & Madaio 2012, p. 125.
20. "What Is Churg–Strauss Syndrome?". WebMD. 30 January 2019. Retrieved 8 March 2020.
21. . Archived from the original on 2009-01-23. Retrieved 2010-02-05.
22. . Archived from the original on 2009-06-08. Retrieved 2010-02-05.
23. "Mitral Stenosis". The Lecturio Medical Concept Library. Retrieved 24 July 2021.
24. Jha, Suman K.; Karna, Bibek; Mahajan, Kunal (2020), "Tropical Pulmonary Eosinophilia", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 32491456, retrieved 2020-12-01
25. Hunt, Beverley J. (2014). "Bleeding and Coagulopathies in Critical Care". New England Journal of Medicine. 370 (9): 847–859. doi:10.1056/NEJMra1208626. ISSN 0028-4793. PMID 24571757.
26. Hughes, JP; Stovin, PG (January 1959). "Segmental pulmonary artery aneurysms with peripheral venous thrombosis". British Journal of Diseases of the Chest. 53 (1): 19–27. doi:10.1016/S0007-0971(59)80106-6. PMID 13618502.
27. Kinoshita T, Ohbe H, Matsui H, Fushimi K, Ogura H, Yasunaga H (November 2019). "Effect of tranexamic acid on mortality in patients with haemoptysis: a nationwide study". Critical Care. 23 (1): 347. doi:10.1186/s13054-019-2620-5. PMC 6836388. PMID 31694697.
28. Patwa A, Shah A (September 2015). "Anatomy and physiology of respiratory system relevant to anaesthesia". Indian Journal of Anaesthesia. 59 (9): 533–41. doi:10.4103/0019-5049.165849. PMC 4613399. PMID 26556911.
29. Davidson K, Shojaee S (January 2020). "Managing Massive Hemoptysis". Chest. 157 (1): 77–88. doi:10.1016/j.chest.2019.07.012. PMID 31374211. S2CID 199388328.
30. Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC (June 2005). "Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis". Chest. 127 (6): 2113–8. doi:10.1378/chest.127.6.2113. PMID 15947328.
31. Hanson C, Karlsson CA, Kämpe M, Lamberg K, Lindberg E, Boman LM, Stålenheim G (August 2004). Guidelines for treatment of acute lung diseases (Report). Uppsala Academic Hospital.
32. Woo S, Yoon CJ, Chung JW, Kang SG, Jae HJ, Kim HC, et al. (November 2013). "Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles". Radiology. 269 (2): 594–602. doi:10.1148/radiol.13130046. PMID 23801773. S2CID 21597160.
33. Ishikawa H, Hara M, Ryuge M, Takafuji J, Youmoto M, Akira M, et al. (February 2017). "Efficacy and safety of super selective bronchial artery coil embolisation for haemoptysis: a single-centre retrospective observational study". BMJ Open. 7 (2): e014805. doi:10.1136/bmjopen-2016-014805. PMC 5318547. PMID 28213604.
34. Ryuge M, Hara M, Hiroe T, Omachi N, Minomo S, Kitaguchi K, et al. (February 2019). "Mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation: a single-centre retrospective observational study". European Radiology. 29 (2): 707–715. doi:10.1007/s00330-018-5637-2. PMC 6302874. PMID 30054792.
35. Panda A, Bhalla AS, Goyal A (2017-07-07). "Bronchial artery embolization in hemoptysis: a systematic review". Diagnostic and Interventional Radiology. 23 (4): 307–317. doi:10.5152/dir.2017.16454. PMC 5508955. PMID 28703105.
36. Olsen KM, Manouchehr-Pour S, Donnelly EF, Henry TS, Berry MF, Boiselle PM, et al. (May 2020). "ACR Appropriateness Criteria® Hemoptysis". Journal of the American College of Radiology. 17 (5S): S148–S159. doi:10.1016/j.jacr.2020.01.043. PMID 32370959. S2CID 218520816.

Further reading

• Adu D, Emery P, Madaio M (2012). Rheumatology and the Kidney (2, illustrated ed.). Oxford University Press. ISBN 9780199579655.
• Corey R (1990). "Chapter 39: Hemoptysis". In Walker HK, Hall WD, Hurst JW (eds.). Clinical Methods: The History, Physical, and Laboratory Examinations. Boston: Butterworths. ISBN 978-0-409-90077-4. PMID 21250201.

External links