hemoptysis

Hemoptysis , or the expectoration of blood, originating from below the vocal cords,
can range from blood-streaking of sputum to the presence of gross blood in the
absence of any accompanying sputum.
Bronchitis, bronchogenic carcinoma, and bronchiectasis are the most common
causes of hemoptysis
massive hemoptysis: is reserved for bleeding that is potentially acutely lifethreatening; often ranging from more than 100 to more than 600 mL of blood over
a 24 hour period
Three etiologies accounted for 90 percent of the cases of massive hemoptysis:
tuberculosis, bronchiectasis, and lung abscess

EVALUATION OF HEMOPTYSIS

history and physical examination,

the initial important study for evaluating the patient with hemoptysis is the chest radiograph.
o Abnormal findings may be range from neoplasm to focal infection (tuberculosis,
aspergilloma) to mitral stenosis.
measurement of hematocrit (to assess the magnitude and chronicity of bleeding),
urinalysis and renal function (in those circumstances in which a pulmonary-renal syndrome
such as Goodpasture's syndrome or granulomatosis with polyangiitis (Wegeners) might be
responsible for bleeding),
coagulation profile (to exclude thrombocytopenia or another coagulopathy as a contributing
factor).
Adequacy of oxygenation is assessed with pulse oximetry or arterial blood gas analysis.
Evaluation for pulmonary embolism should be considered in patients with risk factors for
pulmonary embolism and abnormal gas transfer.

Further evaluation is next directed toward confirming the suspected diagnosis if the history,
physical examination, or any of the above studies suggests a particular cause for the
hemoptysis.

Fiberoptic bronchoscopy is a useful procedure, often allowing localization of the site of

hemoptysis and visualization of endobronchial pathology causing the bleeding.

flexible bronchoscopy: its role in patients with normal chest radiographs, to rule out
endobronchial malignancy that is radiographically silent
high-resolution CT scanning (HRCT)

Treatment
Airway:
o

HOB > 45; lean to side of bleeding (if known).

If intubation necessary, large bore ETT & consider placing ETT in

unaffected lung. Double-lumen ETT if skilled operator.

Definitive management: Minor hemoptysis can usually be

managed conservatively,
o

but if massive requires bronchoscopy or IR embolization,

surgical resection if all else fails

Disposition
Healthy, minimal bleeding: Get CXR; if negative: Home, outpt f/u
High-risk pt, minor bleeding: Get CT, consider admit for
observation, bronchoscopy

Massive: ICU, consult pulmonology, interventional radiology,

thoracic surgery

Related topics

Differential diagnosis of ANCA

c-ANCA (anti-PR3): Wegeners granulomatosis, Churg-Strauss, microscopic polyangiitis
p-ANCA (anti-MPO): microscopic polyangiitis, Churg-Strauss,Wegeners granulomatosis,
drug-induced vasculitis, nonvasculitic rheumatic diseases

Wegeners granulomatosis
Necrotizing granulomatous inflammatory disease with systemic vasculitis, particularly
involving the upper and lower respiratory tract, and kidney
Can occur at any age, but incidence in young and middle-aged adults

 Clinical manifestations
pulmonary (90%) upper: sinusitis, otitis (rare in adults), rhinitis, nasal mucosal ulceration,
saddlenose deformity
lower: pleurisy, pulmonary infiltrate, nodules, hemorrhage, hemoptysis
renal (80%): hematuria, RPGN (pauci-immune)
ocular (50%): episcleritis, uveitis, & proptosis from orbital granulomas, corneal ulcer
neurologic: cranial and peripheral neuropathies, mononeuritis multiplex
hematologic: incidence DVT/PE (20) when disease active
Dx studies:
90% ANCA (8095% c-ANCA, remainder p-ANCA)
CXR or CT nodules, infiltrates, cavities; sinus CT sinusitis
BUN & Cr, proteinuria, hematuria; sediment w/ RBC casts, dysmorphic RBCs
biopsy necrotizing granulomatous inflammation of arterioles, capillaries, veins

Classification criteria (2 of 4 criteria

1 . nasal or oral inflammation: oral ulcers, purulent or bloody nasal discharge
2. CXR showing nodules, fixed infiltrates, or cavities
3. microscopic hematuria or urinary red cell casts
4. granulomatous inflammation on biopsy

Treatment
Induction: cyclophosphamide PO (2 mg/kg/d 36 mo or pulse 1 5 mg/kg/d q23 wk)&
prednisone (1 2 mg/kg/d taper over 61 8 mo)..RPGN: consider adding plasma
exchange to regimen
Maintenance: MTX or AZA for 2 y
for mild disease MTX/prednisone may be adequate for induction
disease relapses: match aggressive disease with aggressive Rx as needed
ANCA w/o clinical evidence of flare should not prompt Rx TMP-SMX may prevent
upper airway disease relapse incited by respiratory infections