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Snapshot
  • A 58-year-old man presents to an urgent care clinical after coughing up blood and experiencing shortness of breath. The patient reports that he has been coughing recently and decided to cut back on his cigarette use. He notes a 25-lb unintentional weight loss over the course of 6 months, along with night sweats and generalized malaise. On physical exam, the patient has blood in his sputum and no notable source of bleeding in his oropharynx. A chest radiograph is performed, which demonstrates a bronchial mass. (Lung cancer)
Introduction
  • Definition
    • expectoration of blood from the lower respiratory tract
      • hemoptysis is said to be massive when there is ≥ 500 mL of blood over 24 hours or ≥ 100 mL/hour 
  • Etiology
    • airway diseases
      • bronchitis
      • bronchogenic carcinoma
      • bronchiectasis
    • pulmonary parenchymal diseases
      • tuberculosis
      • abscess
    • rheumatic diseases
      • amyloid
      • anti-glomerular basement membrane disease (Goodpasture disease) 
        • treat with steroids, plasmapheresis, and cyclophosphamide for acute flares 
      • granulomatosis with polyangiitis (Wegener disease) and other vasculitides
      • systemic lupus erythematosus
    • pulmonary vascular diseases
      • pulmonary embolism 
      • pulmonary arteriovenous malformation
      • heart failure
    • coagulation disorders
      • disseminated intravascular coagulation
      • anticoagulant and antiplatelet medications
    • iatrogenic
      • bronchoscopy
    • other
      • cocaine use
      • catamenial hemoptysis due to thoracic endometriosis
  • Pathoanatomy
    • blood comes from 2 sources
      • pulmonary arteries
      • bronchial arteries (most common source of massive hemoptysis)
Presentation
  • Symptoms
    • hemoptysis
  • Physical exam
    • blood can range from a streak of blood to gross blood
Imaging
  • Chest radiograph
    • indication
      • initial imaging study in the evaluation of hemoptysis
  • CT of the chest
    • indication
      • considered in patients with an abnormal chest radiograph, risk factors for malignancy, or recurrent hemoptysis
        • risk factors for malignancy include
          • > 40 years of age
          • substantial smoking history
  • Bronchoscopy
    • indication
      • confirms hemoptysis and localizes the bleeding
Studies
  • Diagnostic approach
    • based on an extensive history and physical and chest imaging
      • it is important to differentiate hemoptysis from hematemesis or from the upper respiratory and gastrointestinal tract
    • laboratory testing is dependent on clinical suspicion
      • e.g., a patient comes from a tuberculosis-endemic region presenting with hemoptysis should get sputum acid-fast bacilli testing
Differential
  • Hematemesis
    • differentiating factors
      • source of bleeding is noted on endoscopy
Treatment
  • Conservative
    • patient positioning
      • indication
        • in cases of severe hemoptysis
        • position patient on the side of the involved lung and intubate the normal lung if necessary
          • e.g., if the source of the bleed is from the right lung, position the patient on the right side
  • Procedural
    • therapeutic bronchoscopy
      • indication
        • recommended in life-threatening cases
    • bronchovascular artery embolization
      • indication
        • first-line for massive, recurrent, or malignant hemoptysis
    • emergency thoracotomy 
      • indicated for massive hemoptysis that does not respond to initial measures (such as bronchoscopy)
Complications
  • Asphyxiation
  • Exsanguination

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