Haemoptysis

Haemoptysis refers to coughing out blood. Generally, it appears bright red in colour as opposed to blood from the gastrointestinal tract which appears dark red. It is considered an alarming sign of a serious underlying aetiology.

Terminology

Massive haemoptysis is referred to as expectoration of > 100-600 mL of blood over a 24 hour period ⁶.

Pathology

In 90% of cases, the source of bleeding is the bronchial artery. In the remainder of cases, either the pulmonary artery or another non-bronchial artery (e.g. intercostal, internal thoracic) is the source of bleeding. 

Aetiology

The following are the most common causes:

• bronchogenic carcinoma
• bronchitis
• bronchiectasis
  • cystic fibrosis
• tuberculosis
• aspergilloma
• pneumococcal pneumonia
• pulmonary metastasis
• pulmonary contusion
• pulmonary thromboembolism
• mitral stenosis
• iatrogenic during catheter manipulation of pulmonary artery

Other causes:

• foreign body
• airway trauma
• lung abscess
• Goodpasture syndrome
• granulomatosis with polyangiitis
• tracheal invasion, e.g. from thyroid cancer

Rarer causes:

• arteriovenous malformation
• pulmonary endometriosis
• systemic coagulopathy
• anticoagulants

Treatment and prognosis

Approach to haemoptysis

This approach can be followed for small amounts of blood or streaks of blood in sputum. The underlying cause can be life-threatening; however, it is not an emergency.

Bronchoscopy followed by a contrast-enhanced CT scan must be carried out to detect the cause. The above-mentioned common causes and certain uncommon and rare causes must be kept in mind.

Approach to massive haemoptysis

• examine the patient to rule out a non-pulmonary cause of bleeding, such as from the upper airway or gastrointestinal tract
• confirm and localise the site of bleed with bronchoscopy
• CT imaging may help in characterisations of lesions if time permits
  • CT arterial angiogram of the thoracic aorta should be considered in certain scenarios, particularly in patients with known cystic fibrosis 
    • provides definitions of the bronchial arteries anatomy and recruited aortobronchial collaterals ⁸
• arteriographyDSA angiography will help localise the vessels involved and also enable embolisation
• after stabilisation of the patient, further imaging can be carried out and appropriate measures are taken to prevent rebleed