The Diagnosis and Treatment of Hemoptysis

Abstract

Background: Hemoptysis, i.e., the expectoration of blood from the lower airways, has an annual incidence of approximately 0.1% in ambulatory patients and 0.2% in inpatients. It is a potentially life-threatening medical emergency and carries a high mortality.

Methods: This review article is based on pertinent publications retrieved by a selective search in PubMed.

Results: Hemoptysis can be a sign of many different diseases. Its cause remains unknown in about half of all cases. Its more common recognized causes include infectious and inflammatory airway diseases (25.8%) and cancer (17.4%). Mild hemoptysis is self-limited in 90% of cases; massive hemoptysis carries a worse prognosis. In patients whose life is threatened by massive hemoptysis, adequate oxygenation must be achieved through the administration of oxygen, positioning of the patient with the bleeding side down (if known), and temporary intubation if necessary. A thorough diagnostic evaluation is needed to identify the underlying pathology, site of bleeding, and vascular anatomy, so that the appropriate treatment can be planned. The evaluation should include conventional chest x-rays in two planes, contrastenhanced multislice computerized tomography, and bronchoscopy. Hemostasis can be achieved at bronchoscopically accessible bleeding sites with interventionalbronchoscopic local treatment. Bronchial artery embolization is the first line of treatment for hemorrhage from the pulmonary periphery; it is performed to treat massive or recurrent hemoptysis or as a presurgical measure and provides successful hemostasis in 75-98% of cases. Surgery is indicated if bronchial artery embolization alone is not successful, or for special indications (traumatic or iatrogenic pulmonary/vascular injury, refractory asper gilloma).

Conclusion: The successful treatment of hemoptysis requires thorough diagnostic evaluation and close interdisciplinary collaboration among pulmonologists, radiologists, and thoracic surgeons.

Figure

Flow chart—The diagnosis and treatment of hemoptysis (+ = “clearly diagnostic,” i.e., the source of bleeding is precisely identified) CTA, Computed tomography angiography; MSCT, multislice computed tomography

eFigure 1

Chest radiography in mild hemoptysis with middle lobe densities from alveolar hemorrhages eCase 1 A 43-year-old man has mild hemoptysis as a result of previous recurrent episodes of pneumonia. Clinical examination shows a slight reduction in general status. Auscultation of the lungs reveals wet rales over the base of the right lung. A QuantiFERON test is negative. Chest radiography shows infiltrative densities in the right lower field in the presence of, for example, pneumonia or alveolar hemorrhage (efigure 1). Multislice computed tomography with CT angiography demonstrates spotty/confluent densities and bronchiectases in the middle lobe. Bronchoscopy shows small amounts of blood in the right main bronchus. Bronchial lavage with microscopy and polymerase chain reaction for Mycobacterium tuberculosis is negative, but Pseudomonas aeruginosa is found. The patient is treated with antibiotics according to the antibiogram. The symptoms have fully resolved by the time of discharge. Hemoptysis does not recur.

eFigure 2

Pathologically widened bronchial arteries (arrows) in cystic fibrosis: (a) contrast-enhanced multislice computed tomography with CT angiography; (b) digital subtraction angiography

eFigure 3

Bronchoscopic visualization of blood in the left main bronchus originating from the periphery of the left lower lobe