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Hemoptysis (plural: hemoptyses) refers to coughing up of blood. Generally, it appears bright red in color as opposed to blood from the gastrointestinal tract which appears dark red. It is considered an alarming sign of a serious underlying etiology.
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A variety of clinical classification systems exist for hemoptysis which typically attempt to enumerate criteria defining severe, life-threatening cases of hemoptysis from those with mild, non-life threatening disease.
Massive hemoptysis is a term commonly used in the aforementioned, with definitions based upon criteria such as volume of blood expectorated per cough and/or rate of production, with some proposed systems additionally utilizing physiologic modifiers, such as 15:
more than 200 ml of expectorated blood produced over 24 hours
quantity may range between authors from 100 to 1000 mL 17
more an 150 ml per hour
more than 50 ml per hour with pre-existing respiratory disease
requirement for interventions such as
blood product transfusion
association with physiologic derangements such as hypoxemia
Those not meeting the defined criteria for e.g. massive are subsequently classified as "nonmassive" or another nomenclature specific equivalent.
Other roughly synonymous monikers (i.e. equivalent to massive) include "severe," "life-threatening," or "major" hemoptysis. Regardless of terminology, the majority of classification systems largely attempt to dichotomize patients into those with a high degree of mortality requiring rapid intervention and those with a lower degree of acuity and expected short term morbidity and mortality.
Infection and acute or chronic inflammation of the lower respiratory tract accounts for the majority of cases of hemoptysis; the most common entities include acute and chronic bronchitis, pneumonia, and pulmonary tuberculosis (TB). Malignancy is implicated in a significant percentage of cases, with primary bronchogenic carcinoma cited as the etiology in between 5 to 44% of patients 13.
Roughly 5–14% of patients will meet the variable criteria for "massive" or "life-threatening" hemoptysis, with a somewhat different epidemiology; the most common etiologies include bronchiectasis, TB, invasive fungal infections (e.g. mycetoma), necrotizing infections, and neoplasms 14. In highly endemic areas tuberculosis may account for up to 85% of cases 15.
In 90% of cases the bronchial arteries are the source of bleeding; as branches of the descending thoracic aorta they are subject to the systemic (i.e. high-pressure arterial) blood pressure 12. Other less common potential sources of bleeding include:
collateral vessels derived from a variety of adjacent mediastinal/thoracic vasculature 11 (e.g. subclavian artery, intercostal arteries, internal thoracic artery)
development may be promoted by a chronic inflammatory milieu in the respiratory tract (e.g. elaboration of VEGF)
pulmonary arterial branches
subject to relatively lower pressures than the those derived from systemic arterial vessels
The following are the most common causes:
blunt or penetrating thoracic trauma
pulmonary arterial catheterization associated vascular trauma
diagnostic or interventional bronchoscopic trauma
trans-tracheal interventions (e.g. diagnostic aspiration, anesthesia)
with septic pulmonary emboli
trimellitic anhydride 17
Treatment and prognosis
Approach to hemoptysis
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 hemoptysis
Optimal management involves a team of multiple specialties with important facets of the initial approach to stabilization, diagnosis and management including the following:
airway protection, optimization of oxygenation and ventilation, circulatory support with consideration of pharmacologic hemostatic adjuncts (e.g. coagulopathy reversal)
endotracheal intubation typically necessary
selective endobronchial intubation of the contralateral lung may be considered as well as dependent lateral decubitus positioning of the involved hemithorax 11
multi-disciplinary collaboration between relevant parties including interventional radiology, cardiothoracic surgery, critical care, and interventional pulmonology for diagnosis and source control
bronchoscopy (flexible or rigid) for identification of source, interventional modalities may be possible such as argon plasma coagulation, balloon tamponade or electrocautery
CT imaging may help in characterization 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
DSA angiography will help localize the vessels involved and also enable embolization
emergent surgical intervention may be required if the above modalities fail, or as indicated in selected cases
may include thoracotomy with e.g. emergent pneumonectomy, segmentectomy, lobectomy, omentopexy 16
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