Haemoptysis

Introduction

Haemoptysis is the expectoration of blood, sometimes mixed with saliva or sputum, from the lungs or tracheobronchial tree.

There are many causes for haemoptysis (see below), however no cause is identifiable in around 30% of cases. A thorough history and exam should help to identify underlying causes.

Most patients present with small volume haemoptysis (< 20ml per 24 hours) and tend to be stable on presentation. A small percentage (~2%) present with massive haemoptysis which can quickly result in respiratory or cardiovascular compromise. Massive haemoptysis has a mortality rate of up to 80% and is defined as expectoration of a volume of blood that is significant enough to be life threatening by virtue of airway obstruction or blood loss. The most common causes of massive haemoptysis are lung malignancies and chronic inflammatory conditions such as TB, bronchiectasis and pulmonary abscesses.

Causes of Haemoptysis

It is important to differentiate haemoptysis from haematemesis, oral bleeding or nasopharyngeal bleeding i.e. that the blood was coughed up by the patient and is not from an other sources.

 

Pulmonary

  • Infection

    • Pneumonia

    • Tuberculosis

    • Lung Abscess

    • Bronchiectasis including cystic fibrosis

  • Neoplasm (primary or metastatic)

  • PE with pulmonary infarction

  • Trauma, foreign body

  • Connective Tissue Disease

  • Arteriovenous malformation

Extra Pulmonary

  • Oral e.g. dental, nasal or tongue bleeding

  • Pharyngeal e.g. Tonsillitis

  • GI Bleed

  • Cardiac

    • Acute pulmonary oedema/CCF

    • Mitral stenosis

  • Vascular e.g. aortic dissection

  • Bleeding disorders

  • Drugs e.g. Cocaine

Clinical Features

 

Symptoms

  • Infectious symptoms

    • cough, fever

  • Pain (often pleuritic)

  • Fatigue

  • Weight loss

  • Night sweats

  • Symptoms to suggest extrapulmonary causes e.g. recent vomiting, sore throat

Signs

  • May have nil of note to find on exam

  • Signs of airway obstruction

    • resp distress, stridor, gurgling respirations, hypoxia, cyanosis

  • Signs of shock

    • hypotension, tachycardia, altered conscious state, peripherally shut down

  • Respiratory signs

    • hypoxia, clubbing, tachypnoea, wheeze, crackles

  • Signs of systemic illness

    • pallor, cachexia

  • Signs of extra-pulmonary cause e.g. cardiac, abdominal, oropharyngeal signs.

Clinical Investigations

 
Bedside.jpg

Bedside

  • Arterial Blood Gas (if Hypoxic)

    • ?Respiratory Failure. Hb, Lactate, BM, Electrolytes

  • ECG

    • Cardiac cause for symptoms

 
bloods%2B%252B%2Bpod.jpg

Laboratory

  • FBC, CRP, blood culture if ?sepsis or infectious cause

  • Group and Hold/Crossmatch in severe cases

  • Coagulation screen

  • U&E,

  • Bone profile + LFTs

    • may show abnormalities in some malignancies

  • Sputum culture (If concerns regarding infection including TB) + Urinary antigens if ? pneumonia

    • not routinely done in ED but may be organised by admitting team.

Screenshot 2021-02-24 at 15.41.16.png

Radiology

  • CXR

    • May identify an underlying cause. 20-30% will have normal CXR

  • CT

    • CT Thorax with contrast screening test of choice for ? malignancy, ? AVM, ? abscess. Further investigations may be needed to confirm diagnosis e.g. biopsy. IV contrast can demonstrate is there is active bleeding

    • CTPA if ? PE.

 

Bronchoscopy

  • Investigation of choice in cases where an abnormality of the bronchial tree is suspected

  • Direct visualisation and biopsy

  • In cases of massive haemoptysis therapeutic interventions can be done under direct vision via bronchoscopy as outline below.

Management & Disposition

 

Initial Resuscitation

Massive Haemoptysis

  • Resuscitation as required, following ABCs

    • nurse the patient lying on their side with the bleeding lung (if known) down, or in trendelenberg position

  • Airway compromise can occur quickly in massive haemoptysis

    • Suctioning & Oxygen as required for Sats >94%

    • Early intubation with large bore ETT if airway concerns.

      • consider double lumen tube if skilled operator and aware what side the lung pathology is

  • Declare CODE RED and commence warmed IV blood products if evidence of cardiovascular collapse

Specific Treatment

Massive Haemoptysis

  • Treatment depends on the patient and the source of bleeding

    • in those patients with advanced lung cancer invasive treatments may not be in their best interests.

  • Topical adrenaline or endobronchial balloon tamponade at bronchoscopy with respiratory physicians

  • Bronchial artery embolization with interventional radiology

  • Ongoing bleeding may warrant thoracotomy +/- partial or complete lobectomy with cardiothoracic surgeons.

Mild/Moderate Haemoptysis

  • Seek and treat underlying cause is generally only treatment required

    • e.g. antibiotics for infection, treat CCF etc

Disposition

  • Mild haemoptysis can usually be discharged from the ED with outpatient follow up

    • very important to have tight follow up. e.g. Rapid Access Lung Clinic if any possibility of underlying malignancy

  • Moderate haemoptysis should be admitted for inpatient work up and treatment of underlying pathology.

  • Massive haemoptysis patients if they survive initial insult will require ongoing airway and ventilatory management in ICU

References

  1. Cham G ,Cameron P. et al. Chapter 6.8 Haemoptysis. Textbook of Adult Emergency Medicine. 4th Edition

  2. Dixon J, Cline D. et al. Chapter 33 Haemoptysis. Tintinalli's Emergency Medicine Manual, 7th Edition

  3. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8524

This blog was written by Dr Robert Evans and was last updated in February 2021

 Before you go have another look at the case and see if any of your answers have changed and if so how?