TOC | Pulm

HEMOPTYSIS                                                                                              REF:  Outlines in Clinical Medicine on Physicians' Online 2006 

Diff-Dx  |  Tests  |  Rx  
Differential Diagnosis:    

A. Inflammatory:

  • Bronchitis  (50% of hemoptysis)
  • Bronchiectasis (5%)
  • Pneumonia- necrotizing  (as Staphylococcal, viral, etc.)
  • Lung abscess
  • Tuberculosis of the lungs   
  • Fungal Infection: Histoplasmosis, Mucormycosis
  • Sarcoidosis , Wegener's Granulomatosis, Goodpasture's Syndrome

B. Pulmonary

  1. Pulmonary Embolism / Infarction
  2. Primary Lung Cancer (20% of hemoptysis cases)
    a.Small Cell Lung Cancer (SCLC)
    b.Non-Small Cell Lung Cancer
    c.Epithelioid Hemangioendothelioma [1]
  3. Other Neoplasm - Metastatic Disease, or bronchial adenoma
  4. Pulmonary hypertension
  5. Cystic fibrosis; Arteriovenous Malformation (AVM)
  6. Pulmonary vasculitis including Wegener's granulomatosis & Goodpasture's syndrome,
    pulmonary AV malformation, idiopathic pulmonary hemosiderosis, amyloid, etc.  
  7. Fistula Tract
  8. Trauma Foreign Body in the lungs & lung contusion
  9. Coughing up of "aspirated" oro-naso-pharyngo-laryngeal blood.
  10. Broncholithiasis

C. Cardiac

  1. Severe Mitral Stenosis ("Cardiac Apoplexy"); Left ventricular heart failure  
  2. Highly increased Pulmonary Venous Pressures
    a.Pulmonary Venous Congestion
    b.Acute Mitral Regurgitation
    c.Large Left Atrial Myxoma

D. Others

  1. Hemorrhagic diathesis including anticoagulant therapy                                  


Diff-Dx  |  Tests  |  Rx  
Diagnostic Tests:                            
  • Chest x-ray & Sputum study (Gram stain smear, culture, cytology)
  • Chest CT scan
  • Bronchoscopy
  • Pulomonary perfusion-ventilation scan
  • Pulmonary angiogram if indicated


Diff-Dx  |  Tests  |  Rx  
Treatment of Hemoptysis:        

*  Localization of bleeding site by bronchoscopy or pulmonary angiogram  

1.  Treat the identified underlying causes !!!   
     Position good lung up
      Cough suppression to prevent further coughing which likely inhibits hemostasis.
      Consider empirical antibiotics for lung infections

2.  Bronchoscopic Management of Massive Hemoptysis  
     -  Endotracheal Intubation with endotracheal tube of large caliber for airway control & acute respiratory distress
- to facilitate airway suctioning, ventilation, and bronchoscopy.  
Selective intubation of the mainstem bronchi can be used to emergently secure a blood-free airway in a patient with massive hemoptysis.
Double-lumen endotracheal tubes (DLTs) allow independent isolation of each mainstem bronchus.  However, there are problems with the use of DLTs in patients with massive hemoptysis. Placement requires expertise, and the DLT is difficult to secure in an unparalyzed patient.  

  • Repeated bronchoscopic suctioning
  • Iced saline irrigation
  • Bronchoscopic Infusions or instillation of topical Hemostatic or Vasoactive Drugs ( Materials)
    Bronchoscopic application of epinephrine 1:1000, 1 to 2 mL, to the bleeding site sometimes slows the bleeding.
    Fibrinogen-thrombin mixtures have been used in Japan with good success. Although commercial fibrinogen is not available in the United States for patient use, cryoprecipitate-thrombin or thrombin alone remains a theoretically beneficial alternative. Cold saline lavage through a rigid bronchoscope has also had reported success, although controlled trials have not been done.
  • Bronchoscopic tamponade  with Fogarty catheters or Baloon tamponade.
    - the balloon-tipped catheters to control massive hemoptysis.
    Swan-Ganz catheters can also be used for this purpose, but their short length requires they be carried on the exterior of the bronchoscope by a "bronchoscopic shuttle" technique to facilitate bronchoscope removal. With the balloon inflated, a less emergent decision regarding surgery can be made.
  • Tamponade with gauze or Gelfoam
  • Fibrin glue tamponade
  • Laser Photocoagulation (The Nd-YAG or argon laser)
    - is effective in controlling persistent hemoptysis from airway carcinomas in approximately 60% of patients.
    - Argon plasma coagulator
  • Electrocautery
  • A cryoprobe can be used via flexible bronchoscope to freeze and coagulate the bleeding lesion.
  • Isolation of bronchial tree (double-lumen endotracheal tube)
  • Bronchoscopic brachytherapy

3.  Selective Bronchial Artery Embolization (BAE)
     is useful in controlling most acutely bleeding patients yet carries a high incidence of recurrent bleeding in some patient subsets.  
     The most difficult part of the procedure is to identify the vessel(s) responsible for bleeding.

4.  SURGERY:  Thoractomy and resection of the most involved segments or lobes of the lung.

With any of these techniques, coagulation of the bleeding lesion is more important than resection of the lesion. If the bleeding is coming from distal bronchi or pulmonary parenchyma, the distal tip of the flexible bronchoscope is advanced as far as possible to tamponade the bronchus. This step alone may keep the blood from flooding other bronchi and permit slow coagulation of blood collected in the distal areas. Again, instillation of iced saline, 10 to 15 mL, through the bronchoscope may control the bleeding. Special bronchial-blockade balloon catheters are available to tamponade distal bronchi.

The greatest danger from hemoptysis is from asphyxiation rather than from exsanguination.
Bronchoscopic techniques are sometimes employed to control bleeding originating in the tracheobronchial tree or pulmonary parenchyma.  

Massive hemoptysis, defined as expectoration of more than 200 mL of blood in a 24-hour period, is seen in less than 5% of patients with hemoptysis. Treatment of significant hemoptysis begins with diagnostic bronchoscopy to localize the site of bleeding; the treatment approach is then selected.
Bronchoscopic techniques for management of massive hemoptysis are listed as above .

Death occurs by asphyxiation and can occur very suddenly.  
Small volumes of blood or blood clots suddenly placed into the central airways may necessitate endotracheal intubation even though the patient was speaking in full sentences the minute before. Unfortunately, the frustrating inability to know which patients will accelerate their hemoptysis suggests that all patients with hemoptysis of greater than 200 mL be admitted to an area of the hospital that can rapidly initiate airway support.

Major management issues are dependent on the rate of bleeding.
Patients with 600 mL of hemoptysis in less than 4 hours carry up to a 71% mortality rate vs. 22% and 5% if 600 mL of hemoptysis occurs in 4 to 16 hours and 16 to 48 hours, respectively. Therefore precise quantitation of bleeding requiring timed sputum containers at the beside is important.  Therapy for minor and moderate hemoptysis can usually proceed along diagnostic channels, whereas massive hemoptysis must first focus on patient resuscitation and stabilization .

When the Hemoptysis Stopped

  • Localization of bleeding site
  • Cough suppression to prevent further coughing which likely inhibits hemostasis.
  • Consider empirical antibiotics for lung infections
  • Diagnostic evaluation for underlying causes

REF: Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed., 2005


Diff-Dx  |  Tests  |  Rx  


REF: Ferri's Clinical Advisor: Instant Diagnosis and Treatment, 8th ed.,2006
REF: Mason: Murray & Nadel's Textbook of Respiratory Medicine, 4th ed., 2005  
Outlines in Clinical Medicine on Physicians' Online 2006 
Bone: Pulmonary & Critical Care Medicine, 1998