Hemoptysis: Causes and Types

Hemoptysis

• Hemoptysis is the expectoration of blood, which can occur in the form of blood-streaked, blood-tinged, or frank hemoptysis.
• Two types of hemoptysis:
  • True hemoptysis: Bleeding originating from below the vocal cords.
  • False or spurious hemoptysis: Bleeding originating from above the vocal cords.

Etiology

• Larynx disorders:
  • Laryngitis
  • Foreign body
  • Tumors
  • Ulcers
• Tracho-Bronchial disorders:
  • Acute infections
  • Chronic bronchitis
  • Violent coughing
  • Inhaled foreign body
  • Bronchiectasis
  • Bronchogenic carcinoma
• Pulmonary disorders:
  • Infections (Pulmonary TB, Massive pulmonary embolism, Lung abscess, Trauma, Pneumonia)
  • Pulmonary haemosiderosis
  • Aspergilloma
  • Pulmonary A-V malformation
  • Diffuse alveolar hemorrhage (caused by Vasculitis, Systemic lupus erythematosus, Anti-glomerular basement membrane disease)
• Cardiovascular disorders:
  • Acute left heart failure
  • Pulmonary oedema
  • Mitral stenosis
  • Severe hypertension
• Hematologic disease, anticoagulants, endometriosis

Differential Diagnosis

• Hemoptysis vs. Hematemesis:
  • Causes: Pulmonary or cardiac vs. Digestive system
  • Previous symptoms: Cough, chest tightness vs. Nausea, vomiting
  • Spit up: Cough up vs. Vomited
  • Color: Bright red & frothy vs. Dark red
  • Mixture: Sputum, frothy vs. Gastric contents
  • pH: Alkaline vs. Acidic
  • Tarry stools: - or + vs. +

Approach and Clinical Assessment

• History:
  • Determine bleeding source (respiratory tract or alternative source)
  • Previous hemoptysis episodes and cigarette smoking
  • Fever and chills (indicators of acute infection)
  • Recent inhalation of illicit drugs and other toxins
  • Drug history (anticoagulants) and DVT
• Amount:
  • Estimated quantity of expectorated blood influences urgency of evaluation and treatment
  • Varies from blood-stained sputum to several hundred ml pure blood
  • Mild: <100 ml/day, Moderate: 100-500 ml/day, Severe: >500 ml/day or 100-500 ml/time
• Character:
  • Blood-stained: Blood + sputum (acute inflammatory conditions and bronchogenic carcinoma)
  • Blood-streaked: Streaks of blood in sputum (pulmonary TB, chronic bronchitis, pulmonary infarction)
  • Frank blood: Pulmonary TB, bronchiectasis, tumors
• Physical examination:
  • Assessment of nares for epistaxis
  • Evaluation of heart and lungs
  • Lower limb edema (congestive heart failure or deep-vein thrombosis with pulmonary embolism)
  • Clubbing (lung cancer or bronchiectasis)
  • Vital signs and oxygen saturation (hemodynamic stability and respiratory compromise)

Investigations

• Radiographic evaluation:
  • Chest x-ray
  • Chest CT (bronchiectasis, pneumonia, lung cancer)
  • CT angiography (pulmonary embolism and location of bleeding)
• Laboratory studies:
  • Complete blood count and coagulation studies
  • Electrolytes, renal function, and urinalysis
  • Arterial blood gas
  • ANCA, anti-GBM, and ANA (diffuse alveolar hemorrhage)
  • Sputum (Gram's stain and routine culture, AFB smear and culture)
• Bronchoscopy
• Bronchography
• Cardiac investigations: ECG & echocardiography

Treatment

• Airway:
  • Clear and secure
  • Put on a face mask if maintaining airway or intubating
  • Ensure nearby high flow suction
• Breathing:
  • Provide O2 to maintain saturation at 94-98%
  • Massive hemoptysis may require endotracheal intubation and mechanical ventilation
• Circulation:
  • Insert large bore IV cannula
  • Give IV fluids/blood/clotting factors as clinically indicated
• Treatment of the cause (e.g., LVF, PE, infection, coagulopathy)
• If the source of bleeding is identified:
  • Isolate the bleeding lung with an endobronchial blocker or double-lumen endotracheal tube
  • Position the patient with the bleeding side down
  • Bronchial arterial embolization by angiography may be beneficial
  • Surgical resection can be considered as a last resort

Learn about hemoptysis, a condition characterized by coughing up blood, and its two types: true and false hemoptysis. Understand the various causes including larynx and tracho-bronchial disorders.