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Hemoptysis: Evaluation and Management

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.)
hemopty for the past two abdominal
sis four days. Associated examinations are
CME
This clinical content conforms to AAFP criteria for continuing medical
or five symptoms include unremarkable.
education (CME). See CME Quiz Questions on page 230. times per rhinorrhea,
year. congestion, and CASE 2
Author disclosure: No rel-evant financial affiliations. Massive subjec-tive fever. He
hemopty estimates the total A 74-year-old
sis amount of blood woman presents to
accounts loss to be less than 1 the emer-gency

H emoptysis is defined as the expectoration of blood


from the lung parenchyma or airways. The volume of blood
for a
minority
of cases
(5% to
tablespoon. The
medical history is
unremarkable. He
has never used
department after
coughing up blood.
She brings a
container with
produced 15%).5 tobacco and has not approximately 100
recently trav-eled, mL of blood-tinged
has traditionally been used to differentiate between lost weight, or had sputum produced
nonmassive and massive hemopty-sis; the cutoff value night sweats. over the past 24
ranges from 100 to 600 mL of blood produced in a 24-hour Illustrat
ive hours. She reports
period.1,2 For the purposes of this article, expectoration of Vital signs are that she has had
more than 200 mL of blood per 24 hours is considered Cases
within normal similar episodes in
massive hemoptysis.3 Because of the practical difficulties of limits, and the the past, which were
CASE 1
quantifying the volume of expectorated blood, others have patient appears to diagnosed as
proposed the term life-threatening hemop-tysis to indicate breathe comfortably, bronchitis, and that
hemoptysis accompanied by measurable parameters, such as A 46-
other than the symptoms
abnormal gas exchange and hemodynamic instability, for year-old
intermittent cough. resolved within a few
patients in need of urgent resuscitation and treatment. 4,5 man
No blood is days of ini-tiating
presents
produced in the oral antibiotic
A study of 762,325 patients in a primary care database with a
clinic. Pulmonary therapy. Her medical
evaluated the incidence of hemoptysis as a presenting cough
exami-nation history is significant
6 that has
symptom in the outpatient setting. Hemoptysis occurred demonstrates for Sjögren
produced
in 4,812 patients in a six-year period, for an incidence of normal breath syndrome,
blood-
approximately one case per 1,000 patients per year. Thus, sounds. Nasal, bronchiectasis, and
streaked
a typi-cal primary care physician could expect to oropharyngeal, microcytic anemia.
sputum
encounter patients with the chief presenting symptom of cardiovascular, and She
FebruaryDo e◆AmericanVolumeFamily91 www.aafp.wwworg/afp.aafp.Co FamilyAmericanPhysiciansFamily.ForthePhysicianprivate,noncom 243-mercial use
wnloaded15 ,NumberPhysician4 website pyright.org/afp©2015 American of one individual user of the website. All other rights reserved. Contact
,from2015th at Academy of copyrights@aafp.org for copyright questions and/or permission requests.
Hemoptysis

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.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence,
usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1. Differential Diagnosis of Hemoptysis


Malingering Broncholithiasis
Mycetoma (“fungus ball”)
Primary vascular source Airway trauma
Idiopathic pulmonary hemosiderosis
Arteriovenous malformation Pulmonary embolism Pulmonary Foreign body
parenchymal Wegener granulomatosis
source Miscellaneous and rare causes
Elevated pulmonary venous pressure Pulmonary artery rupture Tracheobronchial Lupus pneumonitis
Pseudohemoptysis source Systemic coagulopathy or thrombolytic
Tuberculosis Goodpasture syndrome
Upper airway source Gastrointestinal source Bronchiectasis agents
Pneumonia
Neoplasm Catamenial hemoptysis (pulmonary
Serratia marcescens (gram-negative bacterium that produces a red pigment Lung abscess
that may be mistaken for blood)
Bronchitis
Lung contusion endometriosis)
permission from Braunwald E, Kasper DL, et al., eds. Harrison’s
Weinberger SE, Lipson Prin-ciples of Internal Medicine. 17th ed. New
NOTE: Diagnoses listed in approximate order of Adapted DA. Cough and York, NY: McGraw-Hill; 2008:227.
frequency. with hemoptysis. In: Fauci AS,
Altho Nasal exami- hy. Pulmonary 1
1 ), and the asthma,
ugh nation relative chronic
the demonstrates frequency of obstructive
has a 50 pack-year smoking respir normal mucosa
history and quit smoking five atory examination reveals diffuse possible pulmonary
without etiolo-gies disease,
years ago. She does not drink rate is epistaxis. inspiratory rales. Cardio-
varies malignancy,
alcohol. She has lost 40 lb (18increa Oropharyngeal vascular examination is and
significantly
kg) over the past 12 months. sed, examination normal except for bronchiectasi
the reveals normal tachycardia. Abdominal depending on
the clinical s are the
Vital signs at the time of patien dentition and examination is
unremarkable. set-ting. In most
presentation include a tem- t does mucosa
not without signs outpatient common
perature of 99°F (37.2°C),
blood pressure of 146/73 mm appear of bleeding or Differential Diagnosis primary care, diagnoses in
Hg, heart rate of 127 beats per to be ulceration. The acute patients with
minute, respiratory rate of 36 in neck is supple respiratory hemoptysis.6
The differential diagnosis of tract In
breaths per minute, and oxygen distres and without
saturation of 83% in room air. s. lymphadenopat hemoptysis is broad (Table infections, comparison,
a study of patients with hemo ptysis in a
244 American Physician www.aafp.o Number 4 ◆ February 15,
  Family rg/afp 2015
Volume 91,
Hemoptysis
Table 2. Etiologies of Hemoptysis

in Outpatient and Inpatient Settings

Etiology
Frequency (%) The likelihood of tuberculosis infection associated with
hemoptysis varies throughout the world. Tuberculosis
accounts for 7% to 85% of cases of massive hemoptysis,
with the lowest incidence in the United States and high-est
Outpatient (U.K. Primary Care Cohort)6
incidence in South Africa.5 Pulmonary tuberculosis should
be suspected in patients with respiratory symptoms and
Acute respiratory tract infection
64
possible tuberculosis exposure, younger age, weight loss,
Asthma and radiographic findings of cavitation, upper lobe
10 infiltrates, or miliary pattern.8 Approximately 6% to 7% of
Chronic obstructive pulmonary disease
8
tuberculosis cases in the United States occur in home-less
Unknown persons,9 and the rate of tuberculosis in persons born
8 outside the United States is 12 times that of U.S.-born per-
Lung cancer
6 sons.10 Uncommon but well-known causes of hemoptysis
Bronchiectasis include pulmonary embolism, pulmonary endometriosis,
2 Goodpasture syndrome, and foreign body aspiration.
Pulmonary embolism
1
Tuberculosis History and Physical Examination
0.4
Bleeding disorder
0.3 The initial history should focus on determining the
Pulmonary edema anatomic origin of bleeding. Once sources of bleed-ing
0.2
Mitral valve stenosis other than the lower respiratory tract have been excluded
0.1 (Table 32,11), specific etiologies can be consid-ered
Aspergillosis
0.04 (Table 4).
Inpatient (Israel Inpatient Cohort)7
Physical examination should begin with determina-tion of
Bronchiectasis cardiopulmonary status and the need for resusci-tation.12
20
Lung cancer
Criteria for admission to the intensive care unit or for
19 referral to a specialty center for expedited evalua-tion are
Bronchitis available (Table 5).13 Hemodynamic instability, abnormal
18
gas exchange, cardiopulmonary comorbidi-ties, and lesions
Pneumonia
16 at high risk of massive bleeding warrant inpatient
Unknown evaluation. A scoring system based on a retro-spective
8 analysis of 1,087 patients with hemoptysis can identify
Congestive heart failure
4
patients at risk of in-hospital mortality and assist
Hemorrhagic diathesis
4
Tuberculosis
1
Other
10

Information from references 6 and 7.

tertiary referral center showed that bronchiectasis, lung


cancer, bronchitis, and pneumonia account for more than
70% of inpatient diagnoses (Table 2).6,7 A likely
explanation for the difference is that bronchiectasis and
lung cancer are more likely to produce massive hemop-
tysis and lead to hospitalization.
antibiotics, mechanical

Table 3. Differentiating
a red pigment that may
Features of Serratia marcescens ventilation
Pseudohemoptysis Previous hospitalization,
Normal
No red blood cells in sputum;
Etiology (gram-negative
Historical findings use of broad-spectrum be mistaken for blood)
Physical examination findings
Confirmatory test or procedure
positive culture
bacterium that produces

gums, epistaxis, little of the tongue, esopha oscopy if


nose, gogastr etiology
Upper gastrointestinal blood, nausea, nasopharynx, o- is not
vomiting, source or no cough oropharynx, or duoden apparent
Coffee
hypopharynx oscopy,
ground appearance
barium
gastrointestinal swallo
Epigastric tenderness, signs of chronic liver
disease disease (e.g., palmar erythema, spider angiomas, Acidic blood pH, w
tract source
ascites, peripheral edema) blood mixed with
(not bubbly food particles,
Upper respiratory Nasop
or frothy), darker blood in nasogas-
tract Bleeding Gingivitis; telangiectasias; ulceration; varices tric aspiration, haryng
Information from references 2 and 11.

February 15, 2015 ◆ Volume w w.aaf /afp American Family Physician


91, Number 4 w p.org 245
Hemoptysis
in na
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a Adap
ted
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from
s Farto
t ukh
M,
o Khos
r hnoo
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Parro
t A, et
o al.
f Early
pre-
dictio
m n of
i in-
hospi
n tal
i morta
m lity of
patie
a nts
l with
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ptysis
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o defini
d ng
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e
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r ptysis
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o Respi
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u 2012;
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t :111.
i
o
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,

n
o
r
m
a
l
2
Evaluation
of
Nonmassi
ve
Hemoptysi
s

Hemoptysis

History and
physical
examination
Rule out
pseudohemoptysis
and hematemesis
Chest radiography

Normal (Figure 2)
Infiltrate

Mass

Other parenchymal
disease
Antibiotics

Chest CT

Chest CT
Resolution
No resolution
Bronchoscopy;

No specific
diagnosis
Specific diagnosis

consultation with
pulmonologist

Repeat chest
radiography
Chest CT;
consultation

Futher evaluation

in six to eight
weeks
with pulmonologist
or treatment
based

on diagnosis
Normal

Abnormal

(Figure 2)
Chest CT

Figure 1.
Algorithm for
the evaluation
of nonmassive
hemoptysis.
(CT =
computed
tomography.)

Information from
references 3 and
15.
Manageme
nt of
Nonmassiv
e
Hemoptysi
s in
Patients
with
Normal
Radiograp
hic
Findings

Normal findings
on chest
radiography
o
r

C
No risk of o
cancer;
history not
suggestive
of lower
respiratory
tract
infection

Observe
for two to
six weeks

No risk of
cancer;
history
Risk
factors for
cancer

suggestive
of lower

respiratory
tract
infection
antibiotics
t ation
a from
Cessa refere
tion of nces 3
bleedi and
ng 15.
Recurr
ence
of
hemop
tysis

Chest
compu
ted
tomogr
aphy;
consid
er

N
o

consul

Feb
rua
ry
15,
201
5◆
Vol
ume
91,
Nu
mbe
r4
ww
w.aa
fp.o
rg/a
fp
Am
eric
an
Fa
mily
Phy
sici
an
24
7
Hemoptysis

raphy or a noncontrasted study if the patient is aller-

Table 7. American College of Radiology

gic to contrast media.15-17 The ACR makes the same

Appropriateness Criteria for Imaging

evaluation recommendation for patients with at least

in Patients with Hemoptysis

30 mL of hemoptysis who are not at increased risk of

malignancy.15 The ACR recommends that patients

Initial evaluation of patients with hemoptysis should include

with cryptogenic hemoptysis (negative findings on CT

chest radiography
and bronchoscopy) be followed for three years, but it

In patients at high risk of malignancy with normal findings on

does not
make specific recommendations regarding

chest radiography, CT, and bronchoscopy:

follow-up chest CT, bronchoscopy, or other imaging

Observation for three years may be considered

over that period. Instead, surveillance should be based

Radiography and CT should be performed at follow-up based

on patient risk factors and clinical course.15

on the patient’s risk factors

Bronchoscopy may be performed in addition to imaging


Patients with infiltrate detected on chest radiogra-

during the observation period

phy and historical findings consistent with pneumonia

CT should be used for initial evaluation in patients at high

should receive appropriate antibiotic therapy and repeat

risk of malignancy or with suspicious findings on chest

chest radiography in six to eight weeks. Resolution of

radiography

hemoptysis and chest infiltrate indicates that acute lower

CT should be considered in current or former smokers who have

respiratory tract infection was the cause. If hemoptysis

normal findings on chest radiography

Massive hemoptysis can be treated with surgery or

or infiltrate persists, CT should be performed to evalu-

percutaneous embolization; multidetector CT before


ate for more serious disease. A mass warrants further CT

embolization or surgery can define the source of hemoptysis;

evaluation for malignancy.16

percutaneous embolization may be used initially to halt the

hemorrhage before definitive surgery

CASE 2: MASSIVE HEMOPTYSIS

CT = computed tomography.

This patient has signs of hemodynamic instability

Information from reference 15.

(tachycardia) and abnormal gas exchange (tachypnea

and hypoxia), which warrant inpatient management. For


patients with massive hemoptysis, consulta-

tion with a pulmonologist and admission

to the intensive care unit are usually war-

Table 8. Suggested Initial Tests in Patients

ranted.4,12,13,18 Resuscitation focusing on the

with Massive Hemoptysis

airway, breathing, and circulation should be


Test
Indications

performed before diagnostic testing. Table 8

outlines suggested initial studies in the eval-

Blood typing and cross-


For patients with hemodynamic instability

uation of patients with massive hemoptysis.

match
from blood loss or those in whom a

Chest radiography may provide clues

complete blood count reveals anemia that

about the etiology, as well as guide fur-

warrants transfusion

ther resuscitation and evaluation. Once


Chest radiography
For all patients with hemoptysis; may help

the bleeding site has been determined, the

localize bleeding and identify etiology;

patient should be placed in the lateral decu-

provides images for later comparison to

evaluate resolution of disease

bitus position with the affected lung down

Coagulation studies
Reasonable to obtain in patients with a history

to prevent pooling of blood in the unaf-

of coagulopathy or current anticoagulant use

fected bronchial system. Rapid bleeding

Complete blood count


Reasonable to obtain in all patients with
warrants immediate airway control with

hemoptysis to rule out thrombocytopenia

rigid bronchoscopy or endotracheal intu-

and to evaluate for anemia and/or

microcytosis indicative of chronic blood loss

bation.5 Flexible bronchoscopy is less effec-

or malignancy

tive in maintaining a patent airway, but can

Renal function testing


Should be obtained before imaging with

provide useful diagnostic information. For

contrast media and in patients with

stable patients with no identifiable lesion on


suspected vasculitis

chest radiography or bronchoscopy, chest

Sputum testing (Gram stain,


Should be obtained if massive hemoptysis or

CT angiography and/or bronchial artery

acid-fast bacilli smear,


an infectious etiology is suspected

fungal cultures, cytology)

arteriography with or without embolization


should be performed to guide treatment.

Volume 91, Number 4 ◆ February 15, 2015


248  American Family Physician www.aafp.org/afp
Hemoptysis
identif
icatio
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with
Dete bleedi
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