Hemoptysis

Basics

Description

  • Expectoration of blood originating from the tracheobronchial tree
  • Source of massive bleeding:
    • Bronchial arteries (90%), due to high pressure in the bronchial circulation
    • Pulmonary arteries (5%), more commonly causes small volume bleeding
    • Nonbronchial arteries (5%) including aorta, intercostal arteries, coronary arteries, thoracic, upper, and inferior phrenic arteries
  • Threshold of massive hemoptysis:
    • 100 mL to 1,000 mL in 24 hr
    • 100 mL/hr
    • >8 mL/kg/d
    • 200 mL/24 hr in children
  • Mortality:
    • Massive hemoptysis defined as >500 mL/24 hr: 38%
    • Trivial to moderate hemoptysis defined as <500 mL/24 hr: 4.5%
    • Malignancy and coagulopathy increase the risk of mortality

Etiology

  • Infectious (most common cause):
    • Acute or chronic bronchitis
    • Pneumonia
    • Necrotizing pneumonia or lung abscess (Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pneumoniae)
    • Tuberculosis
    • Viral (influenza, varicella)
    • Fungal (Aspergillus, Coccidioides, Histoplasma, Blastomyces)
    • Parasitic (Ascariasis, Amebiasis, Paragonimiasis, Echinococcus)
  • Neoplastic:
    • Squamous cell, small cell, carcinoid
    • Bronchogenic carcinoma
    • Metastatic disease
  • Pulmonary:
    • Bronchiectasis
    • Pulmonary embolism/infarction
    • Cystic fibrosis
    • Bronchopleural fistula
    • Sarcoidosis
  • Cardiac:
    • Mitral stenosis
    • Tricuspid endocarditis
    • Heart failure
  • Systemic disease:
    • Goodpasture syndrome
    • Systemic lupus erythematosus
    • Vasculitis (Wegener granulomatosis, Henoch–Schönlein purpura, Behçet disease)
  • Hematologic:
    • Coagulopathy
    • Thrombocytopenia
    • Platelet dysfunction
    • DIC
  • Vascular:
    • Pulmonary HTN
    • Arteriovenous malformation
    • Aortic aneurysm
    • Pulmonary artery aneurysm (Rasmussen aneurysm, mycotic, arteritis)
    • Aortobronchial fistula
  • Drugs/toxins:
    • Aspirin/antiplatelet therapy
    • Anticoagulants
    • Penicillamine, amiodarone, propylthiouracil, bevacizumab
    • Cocaine (“crack”) lung
    • Organic solvents
  • Trauma:
    • Tracheobronchial rupture
    • Pulmonary contusion
  • Iatrogenic:
    • Bronchoscopy/lung biopsy
    • Pulmonary artery or central venous catheterization
    • Transtracheal aspirate
  • Miscellaneous:
    • Foreign-body aspiration
    • Catamenial hemoptysis (pulmonary endometriosis)
    • Amyloidosis
    • Idiopathic or cryptogenic (between 5–30%, depending on patient population)

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