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Table of Contents
REVIEW ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 3  |  Page : 81-85

Approach to hemoptysis: A review


Department of Pulmonary Medicine, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Submission30-Jul-2021
Date of Acceptance02-Sep-2021
Date of Web Publication25-Nov-2021

Correspondence Address:
Dr. Saurabh Karmakar
Room No. 330, Pulmonary Medicine OPD, 3rd Floor, New OPD Building, All India Institute of Medical Sciences, Phulwari Sharif, Patna, Bihar 801505.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AMJM.AMJM_35_21

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  Abstract 

Hemoptysis is an important and alarming symptom with various etiologies. A thorough evaluation should be done by the clinician to identify the underlying pathology and site of bleeding, so that the appropriate treatment can be planned. In our review article, we describe the various etiologies of hemoptysis and define the approach to hemoptysis for the clinician and the relevant investigations. We performed literature searches in PubMed for keywords “Hemoptysis and Approach and Diagnosis” using Medical Subject Heading terms. The etiology of hemoptysis may sometimes be missed by an incomplete initial diagnosis; hence, the diagnostic work up should be exhaustive. Optimal diagnostic workup remains largely unclear. Through our review, we have described the causes of hemoptysis, provided an essential diagnostic pathway according to the accuracy of the investigations, and tried to fill the gaps regarding the subject.

Keywords: Approach, hemoptysis, pulmonary, tuberculosis


How to cite this article:
Karmakar S, Sharma P, Harishkumar A, Yadav R, Kumar M, Rai DK. Approach to hemoptysis: A review. Amrita J Med 2021;17:81-5

How to cite this URL:
Karmakar S, Sharma P, Harishkumar A, Yadav R, Kumar M, Rai DK. Approach to hemoptysis: A review. Amrita J Med [serial online] 2021 [cited 2021 Dec 9];17:81-5. Available from: https://www.ajmonline.org.in/text.asp?2021/17/3/81/331117




  Introduction Top


Hemoptysis is defined as the expectoration of blood from the lung airways or lung parenchyma. Hemoptysis is a common presenting symptom and is alarming to the patient and challenging to the physician. It occurs in approximately 10% of patients with chronic lung disease and has an annual incidence of approximately 0.1% in outpatients and 0.2% in inpatients.[1],[2] Hence, it is essential for family physicians/primary care physicians to be well versed in the evaluation and management of patients with hemoptysis. The differential diagnosis of hemoptysis is broad, and the frequency of possible etiologies depends on the clinical setting. Initially, family physician/primary care physician may be approached by a patient with hemoptysis. Thus the family physician/primary care physician assumes an onerous responsibility. Primary care physician has to identify the cause of hemoptysis and determine whether a specialist referral or inpatient admission is needed. Specialist referral is also indicated as diagnostic techniques may need performance and interpretation by specialty physicians. The family physician/primary care physician may also need to convince the necessary patient for diagnostic workup. Careful evaluation of the severity and status of the patient should be done as hemoptysis can lead to life-threatening complications.


  Clinical Features Top


The majority of cases of hemoptysis occur in adults (male: female ratio 2:1); only rarely are children affected.[3] True hemoptysis must be distinguished from pseudohemoptysis, where the blood originates from the upper gastrointestinal tract or the upper respiratory tract (mouth, nose, or throat). Careful history-taking and inspection of the nasopharynx should determine whether the bleeding originates from the respiratory tract (alkaline, bright red, foamy blood, associated with dyspnea and prodrome of tickling sensation in throat) or from the gastrointestinal tract (coffee ground appearance, acid pH, food particles, abdominal pain, and nausea).

The physician should quantify the amount of bleeding that has taken place, being as specific as possible (e.g. a teaspoon, a cupful) but patients may overestimate or underestimate the amount of bleeding.[4] Severity of hemoptysis has been arbitrarily divided into mild, moderate, or severe depending on the amount. It is “mild” if less than 30 mL of blood is expectorated per day or there is only streaking of blood in the sputum. Hemoptysis is “moderate” if between 30 and 200 mL/day is expectorated and “severe” if more than 200 mL/day is expectorated. “Massive hemoptysis” has been defined as blood loss of 200–600 mL or more within 48 h or as much that leads to hemodynamic disturbance.[5] The cryptogenic hemoptysis term denotes when source of bleeding cannot be identified.[6]

Because of the low volume of the tracheobronchial space (150–200 mL), a collection of blood can swiftly cause a serious problem with gas exchange.[1] Death, from asphyxia, can occur before detectable blood loss or the onset of hemorrhagic shock.[7]


  Differential Diagnosis Top


There are more than 100 causes of hemoptysis. The relative frequency of possible etiologies varies depending on the clinical setting. The causes of hemoptysis can be divided into five broad categories based on etiology: infective, neoplastic, vascular, autoimmune, and drug-related [Table 1] or four categories based on source [Table 2].
Table 1: Etiology of hemoptysis[8]

Click here to view
Table 2: Differential diagnosis based on source[9]

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  Cryptogenic Top


The most frequent cause worldwide is pulmonary tuberculosis.[10] Shankar et al.,[11] Shah et al.,[12] Singh and Tiwari,[13] and Bhalla et al.[14] in their studies found pulmonary tuberculosis (active/inactive) as the most common cause in India. Inactive tuberculosis is diagnosed on the basis of the previous history of tuberculosis and radiological features such as fibrocavitatory disease predominantly affecting upper lobes, in patients without systemic symptoms.


  Approach Top


The diagnostic assessment should aim to:

  • Differentiate among hematemesis, pseudohemoptysis, and hemoptysis,


  • Identify the site of bleeding,


  • Narrow the differential diagnosis through relevant investigations.


  • The physician should exclude the possibility of pseudohemoptysis and then narrow down the groups of causes for true hemoptysis. It is important to quantify the amount of blood loss and evaluate for any complications due to blood loss. This includes evaluation of signs and symptoms of anemia, searching for signs of hemodynamic compromise. The volume of blood expectorated is important not only in determining the cause but also in assessing the urgency for further diagnostic and therapeutic maneuvers. The patient’s vital signs should be measured and documented.

    Criteria for admission to the emergency department or referral to specialist are as[15],[16]:

    • (a) high risk of massive bleed;


    • (b) gas exchange abnormalities (respiratory rate >30 breaths/min, oxygen saturation <88% room air);


    • (c) hemodynamic instability;


    • (d) respiratory comorbidities;


    • (e) other comorbidities (e.g., ischemic heart disease, use of anticoagulants/antiplatelet agents).



      History and Physical Examination Top


    It should be noted whether this is the first episode of hemoptysis or whether it is a chronic and/or recurrent problem. The physician should ask for the type of expectoration. The patient may cough up bright red blood or blood clots (as in carcinoma of the lung, tuberculosis, pulmonary embolism); blood-streaked, purulent sputum (as in bronchitis, bronchiectasis, or pneumonia); blood-tinged, pink, frothy sputum (as in congestive heart failure); or foul smelling, bloody sputum (as in an anerobic lung abscess) [Table 3].
    Table 3: Important points of the history of hemoptysis

    Click here to view


    Red sputum that contains no blood is seen in a rare case of Serratia marcescens pneumonia with its red pigmentation, in glass sanders with sputum discolored by iron oxide, and in ruptured hepatic amebic liver abscess with its “anchovy sauce” sputum. Associated pulmonary symptoms such as chronic cough with sputum production, change in voice, shortness of breath on exertion, chest pain (especially of a pleuritic nature), and wheezing are also important in the evaluation. A history suggestive of asthma with hemoptysis and fleeting infiltrates on serial chest X-rays is suggestive of allergic bronchopulmonary aspergillosis.

  • Untreated active tuberculosis in the form of present history of constitutional symptoms and low grade evening rise in fever or a past history of treated tuberculosis, or extrapulmonary primary with metastasis to lung, increase the risk of hemoptysis.


  • A history of smoking in an elderly patient confers an increased risk of lung cancer.


  • A history of chronic copious mucopurulent sputum production with chronic lung disease is suggestive of bronchiectasis.


  • A history of dyspnea on exertion, orthopnea, or paroxysmal nocturnal dyspnea suggests presence of congestive heart failure or mitral stenosis.


  • Detailed medication history should be taken. The use of anticoagulation therapy may indicate coagulopathy.


  • A history of deep venous thrombosis and hypercoagulable state with inadequate anticoagulation suggest the possibility of pulmonary embolism as the source of hemoptysis.


  • Physical findings are uncommon but may help to establish the cause of hemoptysis.

  • The presence of ecchymoses and/or petechiae suggests hematological diseases such as thrombocytopenia.


  • The presence of clubbing may be associated with non-small-cell bronchogenic carcinoma, bronchiectasis, and chronic lung abscess.


  • A monophonic wheeze may be heard in cases of bronchial adenoma or endobronchial carcinomas that obstruct a bronchus.


  • The presence of a diastolic rumble, with an opening snap, loud S1, and loud P2 in the precordial examination, suggests the presence of mitral stenosis.


  • Other systemic findings such as arthralgias, synovitis, and/or nose deformity are clues to rheumatological causes such as granulomatosis with polyangiitis (formerly Wegener’s granulomatosis).


  • The specific characteristics of hemoptysis may be helpful in determining an etiology, such as whether the expectorated material consists of blood-tinged, purulent secretions; pink, frothy sputum; or pure blood. Information on specific triggers of the bleeding (e.g., recent inhalation exposures) as well as any previous episodes of hemoptysis, their duration, and resolution should be elicited during history-taking.

    Monthly hemoptysis in a woman suggests catamenial hemoptysis from pulmonary endometriosis. As diffuse alveolar hemorrhage can be part of a pulmonary-renal syndrome, workup of renal insufficiency is important. Mucocutaneous telangiectasias should raise the possibility of pulmonary arterial-venous malformations.

    The lungs have a dual blood supply: around 99% of perfusion is via the pulmonary arteries, and the remaining 1% is from the bronchial arteries.[17] About 90% of hemoptysis originates in the bronchial arteries, 5% in the pulmonary arteries, and 5% in non-bronchial systemic arteries.[18]


      Diagnosis Top


    If the hemoptysis is massive and life-threatening, the patient should be immediately transferred to a center with the necessary bronchoscopic, radiological/endovascular, intensive care, and surgical expertise.

    Following the initial assessment to determine any threat to the patient’s life, the main goals of the diagnostic work-up in hemoptysis are to identify the site and the cause of the bleeding.

    Laboratory tests may reveal the possible coagulopathic, immunological, or vasculitic causes. Chest radiography is recommended for all patients who present with hemoptysis.[19] It is a quick, readily available, and cheap modality that can assist in revealing any focal or diffuse parenchymal involvement as well as pleural abnormalities. The laterality of the bleeding and common causes such as pneumonia, lung abscess, malignant tumor, pulmonary tuberculosis (cavities), or heart defects leading to cardiomegaly (e.g., mitral stenosis) can often be detected without resorting to other imaging modalities. The sensitivity of conventional radiography is limited: the laterality of the bleeding is established in 33–82% of the cases, the cause in only 35–50%.[2]

    In a patient of massive hemoptysis and when the findings of chest radiography are unclear/doubtful, contrast-enhanced computed tomography (CECT) thorax CT angiography (thoracic/pulmonary) should be carried out and provides most of the information needed to identify the cause and site of the bleeding in hemoptysis.

    The advantages are:

  • Localization of the bleeding (correct identification of the lobe in 63–100% of cases);


  • Correct disclosure of the cause of hemoptysis in 60–77% of cases,[2],[20],[21] e.g.,
  • diffuse alveolar hemorrhage


  • bronchiectasis


  • malignant tumor


  • aspergilloma


  • pulmonary arteriovenous malformation, or


  • thoracic aortic or pulmonary artery aneurysm




  • For detection of endobronchial lesions, fiberoptic bronchoscopy (FOB) is the gold standard modality. FOB is helpful in localizing the bleeding source (sensitivity 73–93%).[2] If chest radiography or multislice CT does not localize the cause of hemoptysis, bronchoscopy should be performed.[1] Bronchoscopically visible sources of bleeding in the central airways are reliably detected. For bleeding in the periphery of the lungs, the diagnostic purpose of FOB is to roughly localize the source (right or left lung, lobe, segment) as an aid to the planning of treatment (bronchial artery embolization, surgery) and sampling (for microbiological, cytological, or histological examination). Multislice CT scan should be done first because it is a non-invasive technique and can supply useful information for the planning of FOB.[22],[23] Overall, the combination of multislice computed tomography and FOB yields the best results in the diagnosis of hemoptysis.


      Conclusion Top


    Hemoptysis is a common symptom in a family physician’s practice. It is also a worrying symptom and usually indicates some underlying lung pathology. Tuberculosis (active/inactive) still remains an important cause of hemoptysis in developing countries. No diagnostic modality is universally superior, and each case needs to be individually approached. A thorough initial evaluation should be done, and close interdisciplinary collaboration for diagnosis may be required among family physicians, pulmonologists, and radiologists.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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    Bhalla A, Pannu AK, Suri V. Etiology and outcome of moderate-to-massive hemoptysis: Experience from a tertiary care center of North India. Int J Mycobacteriol 2017;6:307-10.  Back to cited text no. 14
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      In this article
    Abstract
    Introduction
    Clinical Features
    Differential Dia...
    Cryptogenic
    Approach
    History and Phys...
    Diagnosis
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