Académique Documents
Professionnel Documents
Culture Documents
JOHN SCOTT EARWOOD, MD, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
TIMOTHY DANIEL THOMPSON, MD, Mendoza Clinic, Fort Bliss, Texas
Hemoptysis is the expectoration of blood from the lung parenchyma or airways. The initial step in the evaluation
is determining the origin of bleeding. Pseudohemoptysis is identified through the history and physical
examination. In adults, acute respiratory tract infections (e.g., bronchitis, pneumonia), bronchiectasis, asthma,
chronic obstructive pulmonary disease, and malignancy are the most common causes. Tuberculosis is a major
cause of hemoptysis in endemic regions of the world. Although tuberculosis rates are low in the United States,
they are increased in persons who are homeless or who were born in other countries; consideration for testing
should be made on an individual basis. Hemodynamic instability, abnormal gas exchange, cardiopulmonary
comorbidities, and lesions at high risk of massive bleeding warrant inpatient evaluation. Chest radiography is
recommended as the initial diagnostic test for hemodynamically stable patients with hemoptysis. Further
evaluation with computed tomography with or without bronchoscopy is recommended in patients with massive
hemoptysis, those with abnormal radiographic findings, and those with risk factors for malignancy despite normal
radiographic findings. (Am Fam Physician. 2015;91(4):243-249. Copyright 2015 American Academy of Family
Physicians.)
H
CME This clinical content
emoptysis is defined as the Illustrative Cases
conforms to AAFP criteria CASE 1
for continuing medical expectoration of blood from the
education (CME). See lung parenchyma or airways. A 46-year-old man presents with a cough
CME Quiz Questions on The volume of blood produced that has produced blood-streaked sputum
page 230. has traditionally been used to differentiate for the past two days. Associated symptoms
Author disclosure: No rel- between nonmassive and massive hemopty- include rhinorrhea, congestion, and subjec-
evant financial affiliations. sis; the cutoff value ranges from 100 to 600 tive fever. He estimates the total amount of
mL of blood produced in a 24-hour blood loss to be less than 1 tablespoon. The
period.1,2 For the purposes of this article, medical history is unremarkable. He has
expectoration of more than 200 mL of never used tobacco and has not recently
blood per 24 hours is considered massive trav- eled, lost weight, or had night sweats.
hemoptysis.3 Because of the practical Vital signs are within normal limits, and
difficulties of quantifying the volume of the patient appears to breathe comfortably,
expectorated blood, others have proposed other than intermittent cough. No blood is
the term life-threatening hemop- tysis to produced in the clinic. Pulmonary exami-
indicate hemoptysis accompanied by nation demonstrates normal breath sounds.
measurable parameters, such as abnormal Nasal, oropharyngeal, cardiovascular, and
gas exchange and hemodynamic instability, abdominal examinations are unremarkable.
for patients in need of urgent resuscitation
and treatment.4,5 CASE 2
A study of 762,325 patients in a primary A 74-year-old woman presents to the emer-
care database evaluated the incidence of gency department after coughing up blood.
hemoptysis as a presenting symptom in the She brings a container with approximately
outpatient setting.6 Hemoptysis occurred 100 mL of blood-tinged sputum produced
in 4,812 patients in a six-year period, for over the past 24 hours. She reports that she
an incidence of approximately one case has had similar episodes in the past, which
per 1,000 patients per year. Thus, a typi- were diagnosed as bronchitis, and that the
cal primary care physician could expect to symptoms resolved within a few days of
encounter patients with the chief presenting ini- tiating oral antibiotic therapy. Her
symptom of hemoptysis four or five times medical history is significant for Sjgren
per year. Massive hemoptysis accounts for a syndrome, bronchiectasis, and microcytic
February 15, 2015 Volumeminority
91, Numberof4 cases (5% to 15%).
5
ww w.aa f p.org /af p anemia. She American Family Physician 243
Downloaded from the American Family Physician website at ww w.aafp.org /afp. Copyright 2015 American Academy of Family Physicians. For the private,
noncom- mercial use of one individual user of the website. All other rights reserved. Contact copyrights @ aafp.org for copyright questions and /or permission
requests.
Hemoptysis
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating Reference Comments
Chest radiography should be performed as part of the initial evaluation C 15 Recommendation from
of patients with hemoptysis. American College of
Radiology consensus guidelines
based on observational studies
CT is suggested for initial evaluation of patients at high risk of C 15 Recommendation from
malignancy who have suspicious findings on chest radiography. CT American College of Radiology
should be considered in patients with risk factors (e.g., 40 years or consensus guidelines based on
older, smoking history of at least 30 pack-years) who have negative or observational studies
nonlocalizing findings.
Patients with negative findings on chest radiography, CT, and C 15 Recommendation from
bronchoscopy (cryptogenic hemoptysis) have a low risk of malignancy American College of Radiology
and can be observed for three years. No specific recommendations consensus guidelines based on
can be made regarding chest CT or radiography during that interval, observational studies
but imaging should be based on risk factors. If hemoptysis recurs,
multidimensional CT angiography should be considered. Bronchoscopy
may also complement imaging during the observation period.
CT = computed tomography.
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to
ht tp:/ / ww w.aafp.org / afpsort.
has a 50 pack-year smoking history and quit smoking examination reveals diffuse inspiratory rales. Cardio-
five years ago. She does not drink alcohol. She has lost vascular examination is normal except for
tachycardia.
40 lb (18 kg) over the past 12 months. Abdominal examination is
unremarkable. Vital signs at the time of presentation include a tem-
perature of 99F (37.2C), blood pressure of 146/73 mm Differential
Diagnosis
Hg, heart rate of 127 beats per minute, respiratory rate of The differential diagnosis of hemoptysis is
broad
36 breaths per minute, and oxygen saturation of 83% in (Table 11), and the relative frequency of possible
etiolo- room air. Although the respiratory rate is increased, the gies varies significantly depending on the
clinical set- patient does not appear to be in distress. Nasal exami- ting. In outpatient primary care, acute
respiratory tract nation demonstrates normal mucosa without epistaxis. infections, asthma, chronic
244 American Family Physician ww w.aa f p.org /af p Volume 91, Number 4 February 15, 2015
Hemoptysis
Table 2. Etiologies of Hemoptysis
in Outpatient and Inpatient Settings
6
The likelihood of tuberculosis infection associated
Outpatient (U.K. Primary Care Cohort) with hemoptysis varies throughout the world.
Acute respiratory tract infection 64
Tuberculosis accounts for 7% to 85% of cases of
Asthma 10
massive hemoptysis, with the lowest incidence in the
Chronic obstructive pulmonary disease 8
Unknown 8
United States and high- est incidence in South Africa.5
Lung cancer 6
Pulmonary tuberculosis should be suspected in patients
Bronchiectasis 2 with respiratory symptoms and possible tuberculosis
Pulmonary embolism 1 exposure, younger age, weight loss, and radiographic
Tuberculosis 0.4 findings of cavitation, upper lobe infiltrates, or miliary
Bleeding disorder 0.3 pattern.8 Approximately 6% to 7% of tuberculosis cases
Pulmonary edema 0.2 in the United States occur in home- less persons,9 and
Mitral valve stenosis 0.1 the rate of tuberculosis in persons born outside the
Aspergillosis 0.04 United States is 12 times that of U.S.-born per- sons.10
Inpatient (Israel Inpatient Cohort)7 Uncommon but well-known causes of hemoptysis
Bronchiectasis 20 include pulmonary embolism, pulmonary
Lung cancer 19 endometriosis, Goodpasture syndrome, and foreign
Bronchitis 18 body aspiration.
Pneumonia 16
Unknown 8 History and Physical Examination
Congestive heart failure 4 The initial history should focus on determining the
Hemorrhagic diathesis 4 anatomic origin of bleeding. Once sources of bleed-
Tuberculosis 1 ing other than the lower respiratory tract have been
Other 10 excluded (Table 32,11), specific etiologies can be consid-
Information from references 6 and 7.
ered (Table 4).
Physical examination should begin with determina-
tion
or for of cardiopulmonary
referral status for
to a specialty center and the need
expedited for
evalua-
tertiary referral center showed that bronchiectasis, lung tion are available (Table 5).13 Hemodynamic
instability, cancer, bronchitis, and pneumonia account for more abnormal gas exchange, cardiopulmonary
comorbidi- than 70% of inpatient diagnoses (Table 2).6,7 A likely ties, and lesions at high risk of massive
bleeding warrant explanation for the difference is that bronchiectasis and inpatient evaluation. A scoring
system based on a retro- lung cancer are more likely to produce massive hemop- spective analysis of 1,087
patients with hemoptysis can tysis and lead to hospitalization. identify patients at risk of
in-hospital mortality and assist
February 15, 2015 Volume 91, Number ww w.aaf p.org /a f p American Family Physician
4 245245
Hemoptysis
Table 4. Historical Findings That Suggest Table 5. Indications for Admission to the
Etiology of Hemoptysis Intensive Care Unit or Referral to Specialty
Center in Patients with Hemoptysis
Finding Suggested etiology
Etiology with high risk of bleeding (e.g., aspergillosis, lesions
Anticoagulant use Coagulopathy
with pulmonary artery involvement)
Cough Bronchiectasis, COPD, foreign
Gas-exchange abnormalities (respiratory rate > 30 breaths per
body, pneumonia, tuberculosis
minute, oxygen saturation < 88% in room air, or need for
Fever Bronchitis, lung abscess, neoplasm, high-flow oxygen [> 8 L per minute] or mechanical ventilation)
pneumonia, pulmonary
Hemodynamic instability (hemoglobin < 8 g per dL [80 g per L]
embolism, tuberculosis
or a decrease of more than 2 g per dL [20 g per L] from
Heart disease (valvular or Congestive heart failure baseline, consumptive coagulopathy, or hypotension requiring
congestive heart failure) fluid bolus or vasopressors)
Immunosuppression Bronchitis, lung abscess, Massive hemoptysis (> 200 mL per 48 hours or > 50 mL per
pneumonia, tuberculosis episode in patients with chronic pulmonary disease)
Recent surgery or Pulmonary embolism Respiratory comorbidities (e.g., previous pneumonectomy,
immobilization chronic obstructive pulmonary disease, cystic fibrosis)
Smoking Bronchitis, COPD, neoplasia Other comorbidities (e.g., ischemic heart disease, need for
Sputum production Bronchiectasis, COPD, pneumonia, anticoagulation)
tuberculosis
Trauma Airway trauma, pulmonary Information from reference 13.
embolism
Weight loss COPD, neoplasia, tuberculosis
Mortality 1% 2% 6% 16%
34% 58% 79% 91%
February 15, 2015 Volume 91, Number ww w.aaf p.org /a f p American Family Physician
4 247247
Hemoptysis
Evaluation of Nonmassive Hemoptysis
History and physical examination
Normal Abnormal
(Figure 2)
Chest CT
Figure 1. Algorithm for the evaluation of nonmassive hemoptysis. (CT = computed tomography.)
Information from references 3 and 15.
No risk of cancer; history No risk of cancer; history Risk factors for cancer
not suggestive of lower suggestive of lower
respiratory tract infection respiratory tract infection
No further evaluation
Figure 2. Algorithm for the management of nonmassive hemoptysis in patients with normal findings on chest
radiography.
Information from references 3 and 15.
Hemoptysis
February 15, 2015 Volume 91, Number ww w.aaf p.org /a f p American Family Physician
4 249249
Hemoptysis
Sensitivity
REFERENCES
Detecting Identifying
1. Weinberger SE, Lipson DA. Cough and hemoptysis. In: Fauci AS,
Test bleeding site (%) etiology (%)
Braunwald E, Kasper DL, et al., eds. Harrisons Principles of Internal
Medicine. 17th ed. New York, NY: McGraw-Hill; 2008:225-228.
Bronchoscopy 73 to 93* 2.5 to 8
2. Spiro SG, Albert RK, Jett JR, eds. Clinical Respiratory Medicine: Expert
Chest radiography 33 to 82 35
Consult. 3rd ed. Philadelphia, Pa.: Mosby; 2008.
Computed tomography 70 to 88 60 to 77
3. Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am
Multidetector computed 100 (bronchial Not available Fam Physician. 2005;72(7):1253-1260.
tomography arteries)
4. Ibrahim WH. Massive haemoptysis: the definition should be revised. Eur
62 (nonbronchial Respir J. 2008;32(4):1131-1132.
systemic arteries)
5. Sakr L, Dutau H. Massive hemoptysis: an update on the role of
bronchos- copy in diagnosis and management. Respiration. 2010;80
*Site identification varies with bleeding rate; sensitivity (1):38-58.
decreases
significantly with lower bleeding rates.
5 6. Jones R, Charlton J, Latinovic R, Gulliford MC. Alarm symptoms and
identification of non-cancer diagnoses in primary care: cohort study.
Administration of contrast media is optimal to enhance the sys-
BMJ. 2009;339:b3094.
temic arteries. Imaging without contrast media may be performed in
patients with renal impairment or contrast allergy.14 7. Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: etiology,
evalu- ation, and outcome in a tertiary referral hospital. Chest.
Information from references 5 and 14. 1997;112(2):
440-444.
8. Solari L, Acuna-Villaorduna C, Soto A, et al. A clinical prediction rule for
Bronchial artery arteriography is usually reserved for pulmonary tuberculosis in emergency departments. Int J Tuberc Lung
cases in which embolization is planned, and is often Dis. 2008;12(6):619-624.
performed after CT angiography, which aids in 9. Haddad MB, Wilson TW, Ijaz K, Marks SM, Moore M. Tuberculo-
sis and homelessness in the United States, 1994-2003. JAMA.
localiza- tion of bleeding.15 Table 9 lists the
2005;
sensitivities of diag- nostic tests for hemoptysis.5,14 293 (22):2762-2766.
Data Sources: PubMed and OVID were searched using the key 10. Centers for Disease Control and Prevention. Trends in tuberculosis
terms hemoptysis, evaluation, management, and adult from 2005 to United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(11):181-
2014. 185.
The search included meta-analyses, randomized controlled trials, clinical 11. Irwin RS, Rippe JM, eds. Irwin and Rippes Intensive Care Medicine. 6th
trials, and reviews. Additional searches included the Cochrane Database ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2008.
of Systematic Reviews and the National Guideline Clearinghouse. Search 12. Corder R. Hemoptysis. Emerg Med Clin North Am. 2003;21(2):421-435.
dates: April 15, 2012, and September 3, 2014.
13. Fartoukh M. Severe haemoptysis: indications for triage and admission
The authors thank Jordan Mastrodonato, MS, certified medical to hospital or intensive care unit [in French]. Rev Mal Respir.
illustrator, for assistance with the preparation of the manuscript. 2010;
27(10):1243-1253.
The views expressed in this abstract /manuscript are those of the 14. Fartoukh M, Khoshnood B, Parrot A, et al. Early prediction of in-hospital
authors and do not reflect the official policy or position of the mortality of patients with hemoptysis: an approach to defining severe
Department of the Army, Department of Defense, or the U.S. hemoptysis. Respiration. 2012;83 (2):106-114.
government. 15. Ketai LH, Mohammed TL, Kirsch J, et al.; Expert Panel on Thoracic
The Authors Imaging. ACR appropriateness criteria hemoptysis. J Thorac Imaging.
JOHN SCOTT EARWOOD, MD, is a faculty physician and assistant professor 2014;29 (3):W19-W22.
in the Department of Family Medicine at the Dwight D. Eisenhower Army 16. Thirumaran M, Sundar R, Sutcliffe IM, Currie DC. Is investigation of
Medical Center Family Medicine Residency Program, Fort Gordon, Ga. patients with haemoptysis and normal chest radiograph justified? Tho-
rax. 2009;64 (10):854-856.
TIMOTHY DANIEL THOMPSON, MD, is the officer in charge of soldier care 17. Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer inci-
at Mendoza Clinic, Fort Bliss, Tex. dence in patients with hemoptysis of unknown origin. Chest.