Hemoptysis

Hemoptysis 

Hemoptysis refers to expectoration of blood originating from the lower respiratory tract (below the glottis).

Classification

Pathophysiology

1. Vascular sources

• Bronchial circulation (90%) — systemic high-pressure system from thoracic aorta.
• Pulmonary circulation (10%) — low-pressure system, but involvement in vasculitis, AV malformations, or trauma.

2. Mechanisms

• Erosion or rupture of bronchial artery due to chronic inflammation or neoplasm.
• Neovascularization with fragile vessels (e.g., bronchiectasis, TB).
• Alveolar capillary leakage (e.g., diffuse alveolar hemorrhage).

 Common Causes of Hemoptysis

1. Infectious

• Tuberculosis (active or sequelae) – cavitary lesions erode bronchial vessels.
• Bronchiectasis – chronic suppurative infection with fragile neovascularity.
• Lung abscess, necrotizing pneumonia, or fungal infections (Aspergilloma).

2. Inflammatory / Autoimmune

• Goodpasture’s syndrome (anti-GBM disease)
• Granulomatosis with polyangiitis (Wegener’s)
• Microscopic polyangiitis
• SLE, Behçet’s disease

3. Neoplastic

• Bronchogenic carcinoma – central tumors may erode vessels.
• Metastatic lesions – especially choriocarcinoma, renal cell carcinoma.

4. Cardiovascular

• Mitral stenosis – pulmonary venous hypertension → rupture of bronchial veins.
• Pulmonary embolism / infarction
• AV malformations, aneurysm of pulmonary artery (Rasmussen’s aneurysm)

5. Iatrogenic / Traumatic

• Bronchoscopy, biopsy, tracheostomy, catheter-induced injury, or mechanical ventilation.
• Any posttracheotomy bleeding occurring 3 days to 6 weeks after insertion should be considered a tracheoarterial fistula until proven otherwise

6. Coagulopathy / Drugs

• Anticoagulants, antiplatelet therapy, DIC, thrombocytopenia.

7. Idiopathic

• Up to 30% of cases — particularly in smokers and chronic bronchitics.

• Most common cause worldwide: Tuberculosis
• Most common cause in developed countries: Bronchiectasis
• Most common cause of death: Asphyxiation when bleeding from hemoptysis is greater than 150 mL/hour.(anatomical dead space=150 ml)
• Definitive treatment for massive hemoptysis: Bronchial artery embolization
• DAH hallmark on BAL: Hemosiderin-laden macrophages
• Rasmussen’s aneurysm: Pulmonary artery aneurysm adjacent to TB cavity

Differential Diagnosis — “Pseudohemoptysis”

Clinical Evaluation

1. HISTORY 

 Bleeding pattern

• Amount ≠ severity
• Assess:
• Frequency, timing, duration
• Recurrent over months–years → Bronchiectasis
• Daily small-volume for weeks → Bronchogenic carcinoma (late feature)
• Catamenial → Pulmonary endometriosis
• With exertion/sexual activity → Pulmonary congestion

Age-related causes

• Young (<30 yrs):
• Acute tracheobronchitis
• Congenital heart/lung disease
• Cystic fibrosis
• Blood dyscrasia
• Trauma
• Pneumonia
• Any age:
• Pneumonia + hemoptysis >24 hr despite treatment →
  ➜ Suspect endobronchial lesion / coagulopathy

 Travel & exposure history

• Endemic infections:
• USA → Coccidioidomycosis, Histoplasmosis
• East Asia → Paragonimiasis, Ascariasis
• Africa/South America → Schistosomiasis
• Occupational:
• Trimellitic anhydride → Pulmonary hemorrhage
• Isocyanates → Respiratory failure + hemoptysis

 Associated respiratory symptoms

• Chronic sputum → Chronic bronchitis / Bronchiectasis / Cystic fibrosis
• Orthopnea + PND → Pulmonary venous congestion

 Drug & thrombosis history

• Anticoagulants:
• Overdose → Bleeding
• Subtherapeutic → Recurrent thrombosis
• Always consider Pulmonary embolism if:
• DVT risk (Virchow triad)

 Procedure-related causes

• Balloon catheter → Pulmonary artery rupture
• Tracheostomy:
• Tracheoarterial fistula (48h–3 weeks, can be late)
• Sentinel bleed (34–50%)
• Early bleed (<48h) → poor hemostasis
• ET tube → Suction trauma (esp. with coagulopathy)

 Systemic disease clues

• Diffuse Alveolar Hemorrhage (DAH):
• May NOT have hemoptysis
• Symptoms: dyspnea, fever, cough
• Triad (Upper airway + lung + renal):
• ➜ Granulomatosis with polyangiitis
• SLE:
• Pulmonary hemorrhage anytime (even initial)
• Goodpasture syndrome:
• Young males
• Associations:
• Influenza
• Hydrocarbon inhalation
• Penicillamine

 Special situations

• Stem cell transplant:
• DAH during marrow recovery
• High mortality (64–100%)

2. PHYSICAL EXAMINATION

 Skin & mucosa

• Telangiectasia → Hereditary hemorrhagic telangiectasia
• Petechiae/ecchymosis → Hematologic disorder

 Airway clues

• Pulsation in tracheostomy → Tracheoarterial fistula
• Suction trauma signs

 Chest examination

• Unilateral wheeze/rales → Local lesion (tumor, adenoma)
• Diffuse crackles →
• Pulmonary congestion
• DAH

 Pulmonary embolism signs

• Tachypnea
• Phlebitis
• Pleural friction rub

 Trauma

• Evidence of recent/old chest trauma

 Investigations

1. Initial For All Patients

• CBC(infection, hematologic disorder, or chronic blood loss), renal and liver function, coagulation profile(hematologic disorde), ABG.
• Chest X-ray(posteroanterior and lateral films) – localize lesion (cavity, mass, infiltrate, consolidation).
• Sputum for AFB, cytology, Gram/fungal stain.
• ECG(cardiovascular disorder)
• Urine Analysis(may reveal hematuria and suggest the presence of a systemic disease associated with diffuse parenchymal disease (eg, pulmonary renal hemorrhage syndrome due to SLE, Goodpasturesyndrome, ANCA-associated vasculitides such as GPA and microscopic polyangiitis [MPA])

2. Advanced

• CT chest (HRCT or CECT) —first line if patient is stable, best for localization, detecting bronchiectasis, malignancy, aspergilloma, PE.
• Addition of IV contrast with performance of MDCTA can further enhance the ability of CT to further localize the source of bleeding
• Bronchoscopy (Flexible or Rigid)
• Diagnostic & therapeutic.
• Allows localization, suctioning, tamponade, instillation of vasoconstrictors or iced saline.
• first line if patient is unstable

Flexible bronchoscopy

• Instrument of choice for most lower respiratory tract diagnoses

 Rigid bronchoscopy

• Preferred in massive, uncontrolled hemoptysis
• Advantages:
• Better airway patency maintenance
• Allows simultaneous ventilation + suction

Timing 

• Best results when done:
• During active bleeding OR
• Within 24 hours of bleeding

When bronchoscopy is NOT required

• Stable chronic bronchitis with:
• Single episode of blood streaking
• Age < 40 years
• Duration < 1 week
• Low suspicion of malignancy
• Associated acute tracheobronchitis exacerbation
• Previously documented bleeding site on recent bronchoscopy
• Acute lower respiratory tract infection
• Obvious cardiovascular causes:
• Congestive heart failure
• Pulmonary embolism

3. Specific(Depending on History ,physical examination ,initial tests)

• Autoimmune panel: ANA, ANCA, anti-GBM.
• Urinalysis: red cells, casts (DAH).
• Echocardiography: evaluate mitral stenosis, cardiac causes.

 Management 

1. Immediate Priorities (ABCDE)

• Airway protection – main cause of death is asphyxiation, not exsanguination.
• Intubate with large-bore single-lumen ETT (>8.5 mm) for bronchoscopy access.
• Selective mainstem intubation of non-bleeding lung if bleeding side known.
• Can use bronchial blocker,double-lumen endotracheal tube
• Place the patient with the bleeding side down
• Other traumatic respiratory adjunctive therapies, such as chest physiotherapy and postural drainage, should be avoided.
• Breathing: supplemental oxygen, mechanical ventilation if required.
• Circulation: IV access, fluids, transfusion for anemia/shock.

2. Localization of Bleeding

• CT chest followed by bronchoscopy — often both needed.
• If site identified, position patient bleeding side down (dependent position).

3. Specific Therapy

 a. Medical Measures

• Stop anticoagulants, correct coagulopathy (FFP, PCC, platelets).
• Tranexamic acid – 500–1000 mg IV or via nebulization; may reduce bleeding duration.
• Cold saline lavage, topical epinephrine (1:20,000) via bronchoscope.
• Treat underlying cause — antibiotics, antituberculars, immunosuppressants.
• Mild or moderate hemoptysis can often be managed by conservative treatment of the underlying pathology (e.g., treatment of the infection or anti-inflammatory measures).
• There are no data showing that patients with hemoptysis due to pulmonary embolism bleed more with anticoagulation; therefore, do not initially withhold treatment or undertreat these patients with nonmassive hemoptysis. 

 b. Bronchoscopic Interventions

• Balloon tamponade, fibrin glue, topical hemostatics.
• Rigid bronchoscopy preferred in massive cases (better suction, airway control).

 c. Definitive Therapies

• Bronchial Artery Embolization (BAE):
• First-line definitive therapy for massive hemoptysis.
• Success: 70–90%, recurrence 10–30%.
• Embolic agents: PVA particles, coils, glue.
• Avoid spinal artery embolization (paraplegia risk).
• Surgical Resection:
• Indicated when embolization fails or if resectable localized lesion (aspergilloma, tumor, destroyed lobe).
• High mortality if done emergently; prefer elective once stabilized.

REFERENCES

• Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. Dtsch Arztebl Int. 2017 Jun 5;114(21):371-381. doi: 10.3238/arztebl.2017.0371. PMID: 28625277; PMCID: PMC5478790.
• Shee B, Anjum F, Sharma S, et al. Pulmonary Hemorrhage. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538278/
• Chapter 175- Managing Hemoptysis Irwin and Rippe’s Intensive Care Medicine