- Assure adequate oxygenation.
- Look for and correct coagulation abnormalities.
- For localized bleeding, bronchoscopy and/or computed tomography scanning can generally establish the region of the lung from which the bleeding is coming.
- Kidney or lung biopsy may be needed to establish the cause of diffuse bleeding.
- Treatment depends on cause, but bronchial arterial embolization should generally be considered prior to surgery.
Hemoptysis is defined as coughing of blood, and can be caused by numerous diseases and conditions (Table 41-1). Most series indicate that bronchiectasis is the most common cause, but the prevalence of any specific causal entity is a function of the time frame studied (with tuberculosis being more common in older series), and the nature of the population encountered (e.g., bronchiectasis in patients with cystic fibrosis, cancer in older smokers).
++ Table Graphic Jump Location Table 41–1. Causes of Hemoptysis and Pulmonary Hemorrhage ||Download (.pdf)
Table 41–1. Causes of Hemoptysis and Pulmonary Hemorrhage
- Localized bleeding
- Bacterial pneumonia (particularly Streptococcus pneumoniae and Klebsiella)
- Tuberculosis (particularly in the setting of cavitary disease)
- Fungal infections (particularly mycetomas from Aspergillus or Candida)
- Bronchiectasis (e.g., cystic fibrosis or immune deficiencies)
- Lung abscess
- Bronchogenic (i.e., squamous cell)
- Necrotizing parenchymal cancer (usually adenocarcinoma)
- Bronchial adenoma
- Cardiovascular problems
- Mitral stenosis
- Pulmonary vascular problems
- Pulmonary arteriovenous malformations (e.g., Rendu-OslerWeber syndrome)
- Pulmonary embolus with infarction
- Behçet syndrome
- Pulmonary artery catheterization with pulmonary arterial rupture
- Sarcoidosis(usually from cavitary lesions with mycetoma)
- Ankylosing spondylitis
- Diffuse bleeding
- Drug- and chemical-induced
- D-penicillamine (rare, seen with prior treatment of Wilson disease)
- Trimellitic anhydride (encountered during manufacturing of plastics, paint, and epoxy resins)
- Blood dyscrasias
- Thrombotic thrombocytopenic purpura
- Antiphospholipid antibody syndrome
- Pulmonary-renal syndrome
- Goodpasture syndrome (anti–glomerular basement membrane antibody disease)
- Wegener granulomatosis
- Pauci-immune vasculitis
- Pulmonary capillaritis (with or without a connective tissue disease, pauci-immune vasculitis, lung transplant rejection, propylthiouracil, or the retinoic acid syndrome)
- Churg-Strauss syndrome
- Henoch-Schönlein purpura
- Necrotizing vasculitis
- Connective tissue diseases (i.e., systemic lupus erythematosus, rheumatoid arthritis, mixed connective tissue disease, or rarely scleroderma)
- Pulmonary veno-occlusive disease
Most patients with hemoptysis do not require intensive care. Those who do generally have either such rapid rates of bleeding that they are hemodynamically unstable, or they have life-threatening hypoxemia as a result of diffuse parenchymal hemorrhage or extensive aspiration of blood that originates from a localized source.
“Massive” hemoptysis has been variably defined as production of more than 300 to 600 mL of blood in 12 to 24 hours, depending on the study. Although this connotation is perhaps important from a descriptive standpoint, the distinction has little clinical utility, as it is difficult for patients to accurately quantify the volume of blood they are producing, and the volume of hemoptysis may vary considerably from hour to hour (or even from minute to minute). In addition, some patients with diffuse pulmonary hemorrhage can present with ...