Diagnosis and management of hemoptysis

Abstract

Hemoptysis is the expectoration of blood that originates from the lower respiratory tract. It is usually a self-limiting event but in fewer than 5% of cases it may be massive, representing a life-threatening condition that warrants urgent investigations and treatment. This article aims to provide a comprehensive literature review on hemoptysis, analyzing its causes and pathophysiologic mechanisms, and providing details about anatomy and imaging of systemic bronchial and nonbronchial arteries responsible for hemoptysis. Strengths and limits of chest radiography, bronchoscopy, multidetector computed tomography (MDCT), MDCT angiography and digital subtraction angiography to assess the cause and lead the treatment of hemoptysis were reported, with particular emphasis on MDCT angiography. Treatment options for recurrent or massive hemoptysis were summarized, highlighting the predominant role of bronchial artery embolization. Finally, a guide was proposed for managing massive and nonmassive hemoptysis, according to the most recent medical literature.

Figure 1.

Four most frequent origins and branching types of the orthotopic bronchial arteries at the level of tracheal bifurcation as described by Cauldwell et al. (19). The right bronchial artery usually originates from the intercostobronchial trunk (ICBT), which arises from the medial aspect of the descending aorta and also provides at least one right intercostal artery. The left bronchial artery commonly comes from the anterior aspect of the descending aorta. Type 1 is characterized by one right bronchial artery originating from the ICBT and two left bronchial arteries. Type 2 has one right bronchial artery from the ICBT and one left bronchial artery. Type 3 has two right bronchial arteries, including one from the ICBT and the other originating separately from the aorta, and two left bronchial arteries. Type 4 has two right bronchial arteries, as type 3, and one left bronchial artery. Scheme modified with the permission by Emiliano Visconti, MD, from Yoon W, Kim JK, Kim YH, et al. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: A comprehensive review. RadiGraphics 2002;22:1395–1409.

Figure 2. a, b.

Flexible fiberoptic bronchoscopy (a) performed in a patient presenting with massive hemoptysis, showing the carina with active bleeding from an endoluminal lesion (arrow) located distally in the right main bronchus. Axial MDCT image at mediastinal window setting (b) demonstrates a soft tissue in the right hilum, abrupting into the lumen of distal main bronchus (arrow) and representing a squamous cell carcinoma. Right pleural effusion is also evident.

Figure 3. a–d.

Focal and diffuse pulmonary hemorrhage. Axial thin-section MDCT image at parenchymal window setting (a) shows a focal well-defined intra-alveolar ground-glass area located in the posterior segment of the right upper lobe in a smoker patient with hemoptysis, representing parenchymal hemorrhage. Oblique paracoronal reconstruction (b) depicts the continuity between the lung abnormality and the posterior segmental and subsegmental bronchi filled with intraluminal material, likely indicative of blood. Axial thin-section MDCT image at parenchymal window setting (c) demonstrates a right upper lobe non-small cell lung cancer surrounded by localized hazy ground-glass opacity, indicating pulmonary hemorrhage secondary to tumor bleeding. Diffuse pulmonary hemorrhage (d) in a patient with atrial fibrillo-flutter treated with oral anticoagulant drugs, appearing as bilateral parahilar ground-glass attenuation without distortion of the lung parenchyma, associated with mild centrilobular emphysema.

Figure 4. a, b.

Normal orthotopic right and left bronchial arteries. Oblique MIP images at mediastinal window setting show one right (a) and one left (b) bronchial artery arising from the medial aspect of the thoracic descending aorta at the level of tracheal bifurcation. The right bronchial artery (black arrow) courses below the carina towards the right main bronchus, while the left bronchial artery (white arrow) runs parallel to the left main bronchus.

Figure 5. a–d.

Hypertrophic orthotopic right and left bronchial arteries. Axial enhanced MDCT images at mediastinal window show right (a) and left (b) bronchial arteries as cluster of enhancing nodules below the aortic arch, behind the posterior wall of the main bronchi and in the aorto-pulmonary window (white arrows), connected with the descending aorta (a, black arrow). Three-dimensional volume rendering images (c, d) better depict on the right side (c) the presence of an intercostobronchial trunk that originates from the medial aspect of the descending aorta and has a cranial course before its bifurcation into one intercostal artery (white arrow) and one right bronchial artery (black arrow) with caudal course, and on the left side (d) the short and tortuous course of the left bronchial artery in the aorto-pulmonary window towards the left hilum (white arrow).

Figure 6. a, b.

Hypertrophic ectopic right bronchial artery. Oblique MIP image at mediastinal window (a) and 3D volume rendering image (b) show the ectopic origin of a hypertrophic right bronchial artery arising from the concavity of the aortic arch and running towards the right hilum (arrows).

Figure 7. a–c.

Hypertrophic nonbronchial arteries. Axial CT image at mediastinal window (a) of a 69-year-old woman with history of tuberculosis shows right upper lobe consolidation and enlarged and tortuous right upper intercostal artery (arrows) that courses along thickened pleura and goes towards the lesion. Coronal MIP image (b) detects a collateral hypertrophic nonbronchial vessel arising from the right intercostal artery that enters into the lung parenchyma with a vertical course (not parallel to the bronchi) and anastomoses with a pulmonary arterial branch (arrows). In the same patient, axial MIP reconstruction (c) demonstrates a hypertrophic nonbronchial arterial vessel originating from an enlarged right internal mammarian artery that enters into the lung parenchyma with a horizontal course and anastomoses with the arterial pulmonary system (arrows).

Figure 8.

Pulmonary arterial bleeding. Contrast-enhanced axial CT image shows a large squamous cell carcinoma with extensive necrotic component, infiltrating the arterial branch of the apical segment of the right lower lobe (arrow) and the intermediate bronchus in a 55-year-old woman.

Figure 9. a–c.

Oblique MIP image at mediastinal window setting (a) demonstrates a hypertrophic right bronchial artery (arrows) that supplies a pulmonary neuroendocrine mass in a 45-year-old man presenting with relapsing hemoptysis. Pre-embolization DSA (b) confirms the blood supply of the mass from the right bronchial artery (arrows). Postembolization image (c) shows the disappearance of lesion vascular supply (arrows). A subsequent resolution of hemoptysis was observed and eventually the patient underwent surgery.

Figure 10.

Flowchart for managing massive hemoptysis. CXR, chest radiography; MDCTA, multidetector computed tomography angiography; DSA, digital subtraction angiography.

Figure 11.

Flowchart for managing nonmassive hemoptysis. CXR, chest radiography; MDCTA, multidetector computed tomography angiography.