Hemoptysis is the expectoration of blood that originates below the vocal cords. It is commonly classified as trivial, mild, or massive the latter defined as more than 200 – 600 ml in 24 hours. Massive hemoptysis can be usefully defined as any amount that is hemodynamically significant or threatens ventilation.
The lungs are supplied with a dual circulation. The pulmonary arteries arise from the right ventricle to supply the pulmonary parenchyma in a low – pressure circuit.
The causes of hemoptysis can be classified anatomically. Blood may arise from the airways in COPD, bronchiectasis and bronchogenic carcinoma; from the pulmonary vasculature in left ventricular failure, mitral stenosis, pulmonary embolism, pulmonary arterial hypertension, and arteriovenous malformations.
Blood-tinged sputum in the setting of an upper respiratory tract infection in an otherwise healthy, young nonsmoker does not warrant an extensive diagnostic evaluation if the hemoptysis subsidies with a resolution of the infection.
Elevated pulse, hypotension, and decreased oxygen saturation suggest large-volume hemorrhage that warrants emergent evaluation and stabilization. The nares and oropharynx should be carefully inspected to identify a potential upper airway source of bleeding.
Diagnostic evaluation includes a chest radiograph and complete blood count. Kidney function tests, urinalysis and coagulation studies are appropriate in specific circumstances.
Nearly all of these patients are smokers over the age of 40 and most will have had symptoms for more than 1 week. High-resolution chest CT scan compliments Bronchoscopy reveals endobronchial cancer in 3 -6% of patients with hemoptysis who have a normal chest radiograph.
Treatment for hemoptysis depends on the cause and the amount of bleeding. Infrequent, mild hemoptysis usually does not require specific, immediate treatment, but it should always be thoroughly investigated in case the underlying disorder is life threatening. There is no way to predict whether a patient with mild hemoptysis will experience massive, life-threatening hemoptysis, so it is very important that the underlying cause be determined and treated.
Massive, or major, hemoptysis is a medical emergency. Death can result, usually from asphyxiation (impaired gas exchange in the lungs, leading to a lack of oxygen and excess of carbon dioxide in the body). In massive hemoptysis, steps are usually taken to localize the source of the bleeding, control the bleeding, and assure that the patient is able to breathe.
When to Refer
Patients should be referred to a pulmonologist when bronchoscopic evaluation of the lower respiratory tract is required.
Patients should be referred to an otolaryngologist when an upper respiratory tract bleeding source is identified.
When to Admit
To stabilize bleeding process in patients at risk for or experiencing massive hemoptysis.
To correct disordered coagulation .
To stabilize gas exchange.