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Lung cancer is a silent killer. Symptoms are present in only approximately 40% of patients in a population screened for lung cancer who have radiographic changes.1 Even in those patients with symptoms, these are usually nonspecific, and clues to the existence of an underlying lung cancer may be gleaned only from the patient's history. A history of long-standing cigarette smoking, age greater than 40 years, significant weight loss, and a chronic cough are clinical pointers worth noting.

Although some degree of hemoptysis may be the presenting complaint in 29% of patients with lung cancer, the degree of hemoptysis varies considerably.2 Most commonly, patients report a discrete episode of blood-streaked sputum at least once before seeing a physician. Often this is attributed to chronic bronchitis, especially in the face of a normal recent chest radiograph. Since a chest computed tomography (CT) scan has been shown to be much more sensitive for detecting underlying pulmonary lesions compared with a plain chest radiograph, a chest CT scan should be obtained in all patients with a history of hemoptysis.3

A more severe hemoptysis can be seen with the expectoration of clots after a vigorous coughing episode. It is surprising how many patients will continue to downplay the significance of more severe episodes of hemoptysis or fail to seek urgent medical attention. The expectoration of clots is not considered pathognomonic for lung cancer. Massive hemoptysis (by definition, >200 mL per day), although less common with lung cancer, can occur in up to 20% of patients in whom lung cancer is the cause.4 Furthermore, it has been reported to be fatal in up to 50% of patients with lung cancer and demands serious and immediate attention in a hospital setting.5

The single most common cause of streaky hemoptysis in the United States is acute bronchitis. The most common cause of the expectoration of clot or massive hemoptysis, however, is lung cancer, especially in patients older than 50 years who have a long-standing smoking history. Other causes of hemoptysis, which cannot be ignored, include tuberculosis, chronic bronchitis, bronchiectasis, pneumonia, pulmonary infarction, lung abscess, aspergilloma, arteriovenous malformation of the lung, mitral stenosis, and bronchial adenoma. Lung cancer should be ruled out before considering other causes.

General Principles

Massive hemoptysis must be considered a surgical emergency. The potential for imminent loss of life dictates attention first to preservation of the airway, breathing, and circulation (the ABCs of resuscitation). In the face of massive hemoptysis, the patient should be intubated with a single-lumen endotracheal tube (ET). A plain chest radiograph and urgent flexible bronchoscopy frequently can be used to determine which side of the airway is the source of bleeding. If the ET can be guided selectively into the contralateral airway, it can preserve the life of the patient, even if the ipsilateral airway completely fills with blood and ...

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