Approach 2 PDF
Approach 2 PDF
Approach 2 PDF
haemoptysis
Overview 5
Aetiology 5
Emergencies 8
Urgent considerations 8
Diagnosis 10
Step-by-step diagnostic approach 10
Differential diagnosis overview 14
Differential diagnosis 16
Diagnostic guidelines 42
References 43
Images 48
Disclaimer 54
Summary
◊ Haemoptysis is the coughing of blood from a source below the glottis.[1] It can range from a small
amount of blood-streaked sputum to massive bleeding with life-threatening consequences due to
airway obstruction, hypoxaemia, and haemodynamic instability.
In one study of patients in a UK primary care database, the incidence of haemoptysis was found
to be 1 case in 1000 patients per year.[2] Massive haemoptysis occurs in around 5% to 15% of
patients presenting with haemoptysis as a chief presenting symptom.[3] The rate of bleeding has
been described as the most important factor determining mortality.[4]
◊ Massive haemoptysis :
Various definitions of massive haemoptysis exist. A common definition is the expectoration of blood
from a source below the glottis exceeding 600 mL of blood over a 24-hour period or 150 mL of blood
(which may flood the lung dead space) over a 1-hour period. Massive haemoptysis is a medical
emergency and should be addressed immediately. Initial priorities are stabilisation of the patient and
protection of the non-bleeding lung.
◊ Common causes :
Haemoptysis has numerous possible causes, including tracheobronchial, pulmonary parenchymal,
and pulmonary vascular diseases. In the primary care setting, major causes are acute and chronic
bronchitis, tuberculosis, lung cancer, pneumonia, and bronchiectasis.
◊ Vascular origin :
Clinical, radiological, and pathological evidence has demonstrated that the bronchial or systemic
circulation is responsible for most cases of haemoptysis.[7] However, the pulmonary circulation
has also been implicated, as is the case in catheter-induced pulmonary artery rupture, vasculitis,
pulmonary artery aneurysms due to collagen vascular disease, or hereditary haemorrhagic
telangiectasia.[8] [9]
Assessment of haemoptysis Overview
Aetiology
Acute and chronic bronchitis, and less commonly tuberculosis and bronchiectasis, have been reported
as major causes of haemoptysis.[10] [11] Malignancy is a common cause of massive or life-threatening
OVERVIEW
haemoptysis.[3]
The bronchial arteries are branches of the aorta or its tributaries, the intercostal arteries, and carry systemic
arterial pressures that perfuse the adjacent airways to the level of the terminal bronchioles. Bronchial arteries
supply the mediastinum, hilar lymph nodes, and visceral pleura.
The pulmonary artery is a low-pressure system, with normal systolic pressures ranging from 15 to 20
mmHg and diastolic pressures of 5 to 10 mmHg. These vessels supply the pulmonary parenchyma and the
respiratory bronchioles. The anastomotic connections between the bronchial circulation and the pulmonary
circulation contribute to physiological right-to-left shunt.[1]
Clinical, radiological, and pathological evidence has demonstrated that the systemic circulation (bronchial
arteries) is responsible for most cases of haemoptysis.[7] However, the pulmonary circulation has also
been implicated, as is the case in catheter-induced pulmonary artery rupture, vasculitis, pulmonary artery
aneurysms due to collagen vascular disease, necrotic pulmonary infection, or pulmonary arteriovenous
malformation as in hereditary haemorrhagic telangiectasia.[8] [9]
Infectious
Infection is one of the most common causes of haemoptysis.
• Pneumonia can cause haemoptysis by causing necrosis of adjacent bronchial vessels or local
mucosal ulceration.
• In chronic fibrotic tuberculosis, haemoptysis is caused by rupture of Rasmussen's aneurysms or
ectatic pulmonary arteries (with a weakened adventitia and media vessels) traversing the tuberculous
cavities.
• In bronchiectasis, chronic airway inflammation results in increased bronchial artery tortuosity, as
well as proliferation of the capillary beds and peribronchial vascular plexus. Recurrent inflammatory
destruction and healing lead to bronchopulmonary vascular anastomoses.[12] [13] [14]
• In lung abscess, the pathogenesis of haemoptysis is not entirely clear but may be due to progression
of local inflammatory processes causing necrosis of branches of the pulmonary artery.[15]
Neoplastic
In malignancy, there is an increase in the bronchial artery supply to the region of the tumour. Haemoptysis
results from necrosis, mucosal invasion, or direct local invasion of a blood vessel. Massive haemoptysis may
happen when tumour invasion into a blood vessel and its adjacent airway results in vascular airway fistula.
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Assessment of haemoptysis Overview
Iatrogenic
Haemoptysis may occur with traumatic intubation, bronchoscopy, and endobronchial therapeutic
manoeuvres. Massive fatal haemoptysis may rarely happen from erosion of a tracheostomy or laryngectomy
into an innominate (brachiocephalic) artery. Other causes include catheter-induced pulmonary artery rupture
OVERVIEW
or infarct. Drug-induced haemoptysis may occur with exposure to anticoagulants, aspirin, and thrombolytic
agents.
Vasculitic
Haemoptysis may be found in patients with pulmonary haemorrhage from a small-vessel vasculitis (such as
granulomatosis with polyangiitis [formerly Wegener's granulomatosis]), and may be the presenting symptom
in some patients.
The mechanisms responsible for haemoptysis in vasculitis are multiple. However, the most important is
pulmonary haemorrhagic alveolar capillaritis. This involves neutrophilic infiltration of the alveolar septa,
where disruption of the alveolar-capillary basement membranes results in extensive haemorrhage into
the alveolar spaces.[16] [17] Though performing diffusing capacity measurements is often difficult in the
acutely bleeding patient and is only infrequently clinically feasible, an elevated value of diffusing capacity can
indicate alveolar bleeding because intra-alveolar blood adsorbs carbon monoxide avidly.
Cardiac
In left ventricular failure and mitral stenosis, blood-streaked sputum is caused by rupture of pulmonary
veins or capillaries, or by anastomoses between bronchial and pulmonary arteries distended by elevated
intravascular pressure or pulmonary venous hypertension.[12] [18] [19]
Vascular
Vascular anomalies such as Dieulafoy's disease, characterised by the presence of a tortuous dysplastic
artery in the submucosa, can be a cause of haemoptysis. Pulmonary arteriovenous malformation may also
cause haemoptysis. Pulmonary thromboembolic disease that progresses to pulmonary infarct may result in
haemoptysis and bloody pleural effusion.
Haematological
Haemoptysis can be caused by bleeding- and coagulation-related disorders or abnormalities, such as
thrombocytopenia, coagulopathies, or disseminated intravascular coagulation.
Congenital
Congenital lung malformations such as bronchogenic cyst can cause haemoptysis.
Idiopathic
Idiopathic haemoptysis is a diagnosis of exclusion. In approximately one third of patients presenting with
haemoptysis, the underlying cause is not identified even after careful assessment.
Factitious
Factitious haemoptysis is a diagnosis of exclusion with more than 20 reported cases. However, factitious
haemoptysis is likely to be both under-reported and under-diagnosed. Because factitious haemoptysis is
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Assessment of haemoptysis Overview
an exclusionary diagnosis, patients with factitious disorders frequently undergo multiple invasive and non-
invasive studies before the diagnosis is made.[20] [21]
OVERVIEW
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Assessment of haemoptysis Emergencies
Urgent considerations
(See Differential diagnosis for more details)
Massive haemoptysis
A patient with massive haemoptysis, defined as the expectoration of blood from a source below the glottis
exceeding 600 mL of blood over a 24-hour period or 150 mL of blood (which may flood the lung dead space)
over a 1-hour period, is a medical emergency and should be addressed immediately. The rapidity of blood
loss and the identification of poor underlying cardiopulmonary reserve are critical in determining the urgency
and level of intervention.
Awareness of prognosis in haemoptysis may also inform management. An analysis of 1087 patients with
haemoptysis gave rise to a model-based score (using clinical characteristics such as chronic alcoholism,
pulmonary artery involvement, and radiographic patterns) for early prediction of in-hospital mortality with
haemoptysis.[22]
EMERGENCIES
1. Initial stabilisation
Initial priorities are assessment of the need for intubation or mechanical ventilation, and the patient's
haemodynamic stability. Attending to ABC (Airway, Breathing, and Circulation) is paramount. Coagulopathy,
thrombocytopenia, and platelet dysfunction should be identified and reversed immediately, and blood
products should be readily available.
If haemoptysis is active and unilateral, there is risk of blood spillage into the non-bleeding lung, and rapid
action should be taken to protect the non-bleeding lung. The patient may be placed in a lateral decubitus
position with the bleeding lung downward in a dependent position. Alternatively, the non-bleeding lung may
be selectively intubated with the largest endotracheal tube available. A double-lumen endotracheal tube
has a very limited role in managing massive haemoptysis due to the complexity of its proper placement, the
need for significant operator experience, and the small lumen sizes, which do not allow room for therapeutic
bronchoscopy.
Once the patient has been stabilised and the non-bleeding lung has been protected, early bronchoscopy
should be performed. Airway control can be attained by flexible bronchoscopy through a large-bore
endotracheal tube or through the barrel of a rigid bronchoscope. Rigid bronchoscopy is a safe, effective
way of securing the airway with therapeutic control of bleeding.[6] [23] [24] [25] An endobronchial blocker or
Fogarty balloon may be placed into the bleeding bronchus for tamponade of the bleeding site.
Bronchial arteriography with embolisation of the source of bleeding can be used as a diagnostic and
therapeutic intervention when available.[26] In cystic fibrosis, bronchial artery embolisation is effective in
controlling haemoptysis, but the recurrence rate is high.[27] [28]
4. Surgical consideration
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Assessment of haemoptysis Emergencies
For patients who do not respond to embolisation or other minimally invasive techniques, surgery is the
treatment of choice. Some causes of haemoptysis, such as mitral stenosis, leaking aortic aneurysm,
iatrogenic pulmonary artery rupture, traumatic injury to the chest, tracheo-innominate fistula, focal
bronchiectasis, or aspergilloma resistant to other therapies, should be treated surgically. The thoracic
surgeon should be involved early in the care of patients with massive haemoptysis, and a multi-disciplinary
approach is needed to optimise the outcome.[29]
5. Other
Bridging therapies with potential to reduce bleeding time and severity include nebulised or bronchoscopic
tranexamic acid, bronchoscopic fibrinogen-thrombin injection, and tissue glue.[30] [31] [32] [33] [34] [35]
EMERGENCIES
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Assessment of haemoptysis Diagnosis
Characteristically, haemoptysis tends to be indicated by bright red, frothy sputum that is alkaline and with
an oxygen saturation (SaO₂) similar to peripheral arterial saturation. Blood from gastrointestinal sources
tends to be darker, may have admixed food particles, is acidic, and has an SaO₂ similar to that found in
venous blood.[5] [6] The exception is when brisk bleeding in the gastrointestinal tract overcomes the acidic
environment of the stomach.
• A history of untreated tuberculosis, lung cancer, or extrapulmonary metastatic cancer, and significant
weight loss increase the risk for haemoptysis.
• A history of smoking or of exposure to asbestos or silica confers an increased risk of lung cancer.
• A history of chronic mucopurulent sputum production with chronic lung disease is suggestive of
bronchiectasis.
• A history of exertion, orthopnoea, or paroxysmal nocturnal dyspnoea suggests the presence of
congestive heart failure or mitral stenosis.
• Detailed medication history: the use of anticoagulation therapy may indicate coagulopathy. A
history of deep venous thrombosis, pulmonary embolism, or hypercoagulable state with inadequate
anticoagulation suggests the possibility of pulmonary embolism as the source of haemoptysis.
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Assessment of haemoptysis Diagnosis
• Travel history to endemic areas: this may point to potential endemic sources of lung infection, such
as: histoplasmosis in the Midwest river valleys of the US; coccidioidomycosis in the southwestern US;
paragonimiasis in East Asia; or schistosomiasis in the tropics of South America, Africa, and the Far
East.
Physical findings are uncommon but may help to establish the cause of haemoptysis.
Aspiration of blood into the contralateral lung can cause the CXR to be misleading in determining the side of
bleeding.[42] In addition, some causes of haemoptysis may not produce changes on a CXR; these include
bronchitis, mild bronchiectasis, small areas of infection, angioma, infarction, aortopulmonary fistula, or an
endobronchial lesion that is not large enough to cause bronchial occlusion.[6] [43]
If diagnosis remains unclear, further imaging with a chest computed tomography (CT) scan is indicated.[44]
DIAGNOSIS
The American College of Radiology recommends the use of CT chest with contrast for optimal enhancement
of the systemic arterial circulation most commonly implicated in haemoptysis.[44]
If pulmonary embolism is suspected due to acute shortness of breath with or without pleuritic chest pain, a
chest CT angiogram or a ventilation/perfusion (V/Q) scan is indicated.
Bronchoscopy
If the history, exam, and chest imaging do not identify a clear cause for the haemoptysis, bronchoscopy is
indicated. Bronchogenic carcinoma is found in 9.6% of patients with haemoptysis with normal CXR.[45]
The flexible bronchoscope is the instrument of choice for evaluating non-massive haemoptysis, as flexible
bronchoscopy (FB) can be performed in the outpatient setting, or at the bedside under moderate sedation.
FB allows for sub-segmental visualisation of the airways, including the upper lobe orifices.[12] To identify
the bleeding site, FB is the most accurate method during active bleeding, with a success rate of 86%, and
is widely recognised as the study of choice.[46] [47] [48] It can also be used as a therapeutic tool to block
the bleeding site, and to introduce mechanical or thermal tools to treat it.[24] Although identification of the
bleeding bronchopulmonary segment cannot be achieved in every patient, the yield can be increased by
examining and performing diagnostic washing in every bronchial orifice. Sometimes, a bleeding tumour can
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Assessment of haemoptysis Diagnosis
be identified in the sub-segmental bronchus. All abnormalities must be appropriately biopsied, brushed,
or lavaged for adequate specimens when possible. The bronchoscopist should pay special attention and
document vascular capillaries, bronchial inflammation, and subtle mucosal abnormalities.
[Fig-1]
Available studies show a higher success rate when bronchoscopy is carried out early.[46] [49] [50]
Identification of the bleeding site allows the clinician to focus on appropriate treatment. The flexible
bronchoscope can be used to evacuate clots from the airway, obtain diagnostic sampling, and deliver local
heat- or cold-based therapy.
The use of a rigid rather than a flexible bronchoscope in massive haemoptysis is debated. The choice
is mostly driven by the experience of the operator and the clinical scenario. The advantages of the rigid
bronchoscope (airway control, larger lumen, the opportunity to use larger instruments, and suction capability)
may be offset by the disadvantages (need for an available operating theatre, general anaesthesia, and
reduced reach into distal airways).[23]
Flexible bronchoscopy and rigid bronchoscopy are considered to be complementary techniques by many
experts.[12] [24] [51]
Angiography has been compared with flexible bronchoscopy (FB) for the diagnosis of the bleeding
DIAGNOSIS
site in haemoptysis.[50] FB appeared to have a higher diagnostic yield (particularly when performed
early), but angiography was able to identify the bleeding site in 2 out of 8 patients with non-diagnostic
bronchoscopies.[50]
CT angiography is useful for identifying airway and parenchymal disease and vascular anatomy and
anomalies. In patients presenting with haemoptysis, it has been shown to provide new diagnostic information
in 47%, to clarify abnormalities in 15%, and to localise the site of bleeding in 88%.[42] With the use of
iterative model reconstruction and ECG-synchronised prospective-triggered technology in multi-detector-
row CT angiography, the bronchial anatomy can be depicted in patients with haemoptysis.[61] In patients
with haemoptysis of unknown source and a normal CXR, such CT technology may help identify the possible
source of bleeding. The 3-dimensional volume rendering reconstruction allows a virtual trip down the
airways and may facilitate the bronchoscopic procedure.[62] This technology, while interesting, is not
universally available and its role in the work-up of patients with haemoptysis remains unclear. From a
practical standpoint, CT angiography should be the CT of choice in the initial work-up of patients presenting
with haemoptysis, a non-diagnostic CXR, and clinically suspected pulmonary thromboembolic disease. If
pulmonary thromboembolism is ruled out, information gleaned from the CT angiogram is usually adequate
to map the way for bronchoscopy and for subsequent bronchial artery embolisation, should the latter
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Assessment of haemoptysis Diagnosis
become necessary. In most cases, identifying a bronchial artery source of haemoptysis is most useful in
guiding therapy, which usually means embolisation of the vessel. Virtual bronchoscopy and CT angiogram,
despite the high quality of image renderings, still require conventional bronchial angiography for therapeutic
purposes.
Urgent bronchoscopy in an unstable patient facilitates the introduction of a balloon-tip catheter into the
bleeding bronchus to tamponade the haemorrhagic site, thereby protecting the non-bleeding lung from
aspiration.[63]
Laboratory assessment
The laboratory assessment should be focused towards the suspected diagnosis.
• Full blood count may help to identify infection, chronic blood loss, or a haematological disorder (e.g.,
leukaemia).
• Coagulation studies may suggest treatable coagulopathies that facilitate the occurrence of
haemoptysis.
• Arterial blood gases are indicated, particularly when haemoptysis is severe or there is concern about
respiratory failure.
• Uraemia should be considered as a factor contributing to haemoptysis due to the adverse effect of
uraemia on platelet aggregation.
• Urinalysis may help identify a pulmonary-renal syndrome or vasculitis. If there is clinical suspicion for
a pulmonary-renal syndrome, an anti-glomerular basement membrane antibody test, anti-neutrophil
cytoplasmic antibody test, and/or renal biopsy should be considered.
• Sputum and serum studies should be obtained if an infectious cause is suspected. If there is
suspicion for granulomatous or cavitary lung infection, sputum collection for acid-fast bacilli and
fungal cultures should be obtained. If endemic fungal infection (e.g., histoplasmosis, blastomycosis,
coccidioidomycosis) is suspected, fungal serologies should be obtained.
DIAGNOSIS
If a cardiac cause of haemoptysis is suspected, an ECG and echocardiogram can help to identify the
presence of pulmonary hypertension, left ventricular failure, endocarditis, mitral stenosis, or ischaemic heart
disease.
Predictors of mortality
Retrospective data indicate that mechanical ventilation at the time of referral, cancer, aspergillosis, chronic
alcoholism, pulmonary artery involvement, and infiltrates involving two quadrants or more on admission are
independent predictors of increased mortality among in-hospital patients with haemoptysis.[22]
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Assessment of haemoptysis Diagnosis
Common
Acute/chronic bronchitis
Pulmonary tuberculosis
Lung abscess
Pneumonia
Lung metastasis
Toxic inhalation
Bronchiectasis
Pulmonary thromboembolism
Coagulopathy
Thrombocytopenia
Uncommon
Aspergilloma
Endobronchial carcinoid
Broncholithiasis
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Assessment of haemoptysis Diagnosis
Uncommon
Tracheo-oesophageal fistula
Bronchial telangiectasia
Airway trauma
Dieulafoy's disease
Thoracic endometriosis
Fat embolism
Tumour thromboembolism
Arteriovenous malformation
Systemic vasculitis
Tricuspid endocarditis
DIAGNOSIS
Bronchogenic cyst
Factitious haemoptysis
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Assessment of haemoptysis Diagnosis
Differential diagnosis
Common
◊ Acute/chronic bronchitis
frequent cough with may be normal, cough »chest x-ray: normal »bronchoscopy:
excessive mucus with variable degrees or faint diffuse infiltrates non-diagnostic, or
production; chest of haemoptysis, normal small amount of blood
»sputum culture:
pressure or pain; to mildly elevated in airways, signs of
bacteria most
triggers include tobacco temperature, rhonchi, often recovered: chronic inflammation
smoke, cannabis, air expiratory wheezing In minor haemoptysis,
Haemophilus
pollutants, and various bronchoscopy may not
influenzae ,
infectious agents Streptococcus be needed if the chest
pneumoniae ,
x-ray is normal, and
Moraxella catarrhalis
, less commonly a history of acute or
Bordetella pertussis ; chronic bronchitis can
viral agents: respiratory be elicited.
syncytial virus,
rhinovirus, echovirus, Diagnosis of bronchitis
parainfluenza, herpes
is clinical.
virus, Coxsackie virus,
influenza, coronavirus,
adenovirus
Viral agents are
the most common
infectious causes of
acute bronchitis.
DIAGNOSIS
Pulmonary tuberculosis
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Assessment of haemoptysis Diagnosis
Common
Pulmonary tuberculosis
DIAGNOSIS
pulmonary artery antigens. This test
adjacent to a cavity is used increasingly
can be the source of in the US in patients
bleeding. with prior vaccination
with Bacillus Calmette-
Residual bronchiectasis
Guérin (BCG) vaccine
from old TB can cause
or those unlikely to
haemoptysis.
return for purified
»sputum acid-fast protein derivative (PPD)
bacilli stain and interpretation.
cultures: positive for
acid-fast bacilli PPD and IGR assays
are useful for identifying
M tuberculosis
infection but cannot be
used alone to diagnose
active disease.
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Assessment of haemoptysis Diagnosis
Common
Pulmonary tuberculosis
vaccine.
◊ Lung abscess
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Assessment of haemoptysis Diagnosis
Common
◊ Lung abscess
DIAGNOSIS
◊ Pneumonia
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Assessment of haemoptysis Diagnosis
Common
◊ Pneumonia
»sputum Gram
stain: visualisation of
suspected infecting
organisms such as
gram-negative rods,
gram-positive cocci
»sputum culture:
growth of infecting
organism
»blood culture: may
be positive for infecting
organism
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Assessment of haemoptysis Diagnosis
Common
Lung metastasis
DIAGNOSIS
often irregular, often a PET scan aids in
in the periphery of
the lower lung zones, the identification of the
sometimes with primary site, and allows
cavitation; may see for appropriate staging
lymphadenopathy whenever malignancy
A search for the
is confirmed.
primary site should
be performed. It may »bronchoscopy with
include abdominal biopsy: positive for
malignant cells
and pelvic CT scans
The accurate sampling
accompanied by
of a nodule depends
imaging of the brain
on the location and
with CT scanning or
size of the nodule,
MRI. Extrapulmonary
presence of bronchus
cancers that
sign (e.g., a bronchus
metastasise to the lung
leading directly to a
include melanoma,
peripheral pulmonary
sarcomas, and
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Assessment of haemoptysis Diagnosis
Common
Lung metastasis
Endobronchial
lesions may occur
as metastases of
a wide variety of
cancers, including
renal cell carcinoma,
thyroid carcinoma,
oesophageal cancer,
ovarian cancer,
melanoma, breast
cancer, colorectal
cancer, and sarcomas.
Bronchoscopy has
a very high yield for
endobronchial lesions.
[Fig-4]
[Fig-5]
DIAGNOSIS
»sputum cytology:
positive for malignant
cells
Yield is higher in large
endobronchial lesions
or large masses.
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Assessment of haemoptysis Diagnosis
Common
Toxic inhalation
DIAGNOSIS
◊ Bronchiectasis
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Assessment of haemoptysis Diagnosis
Common
◊ Bronchiectasis
»sputum culture:
pathogens most
often recovered:
Pseudomonas
, Haemophilus
influenzae ,
Streptococcus
pneumoniae ,
Moraxella catarrhalis ,
Mycobacterium avium
, Aspergillus , viral
pathogens
Pulmonary thromboembolism
DIAGNOSIS
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Assessment of haemoptysis Diagnosis
Common
Pulmonary thromboembolism
A large central
pulmonary artery
with abrupt tapering
(Fleischner sign) may
also be observed.
»chest CT
angiogram: low-
attenuation filling
defects within a well-
opacified pulmonary
artery, clot, vessel cut-
off, rim sign
Use of intravenous
contrast with a
DIAGNOSIS
pulmonary embolism
protocol is necessary
to reliably identify
pulmonary embolism.
»D-dimer: positive
A negative test in a low-
probability case has
a very high negative
predictive value,
thus ruling out deep
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Assessment of haemoptysis Diagnosis
Common
Pulmonary thromboembolism
A high pre-test
probability or a positive
result requires further
work-up with imaging
techniques.
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Assessment of haemoptysis Diagnosis
Common
DIAGNOSIS
abnormal QRS duration
»chest x-ray:
cardiomegaly,
pulmonary vascular
congestion, Kerley B
lines, pleural effusions
»serum electrolytes
(including calcium
and magnesium):
decreased sodium
(usually <135 mmol/L
[<135 mg/dL]), altered
potassium
»Urea and
creatinine: normal to
elevated
»blood glucose:
elevated in diabetes
»LFTs: normal to
elevated
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Assessment of haemoptysis Diagnosis
Common
Coagulopathy
Thrombocytopenia
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Assessment of haemoptysis Diagnosis
Common
Thrombocytopenia
DIAGNOSIS
fever, cough, dyspnoea, petechiae, »FBC with
confusion, epistaxis, gastrointestinal or differential:
bleeding gums; genitourinary tract pancytopenia
possible history of bleeding, hypotension, »peripheral blood
sepsis, obstetric tachycardia, pleural smear: thrombotic
complications friction rub microangiopathy
such as placental (schistocytes)
abruption, snake bite,
malignancy (e.g., »serum INR and
acute promyelocytic activated PTT:
leukaemia), or tissue elevated
trauma (e.g., surgery) »serum fibrinogen:
low
»D-dimer: elevated
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Assessment of haemoptysis Diagnosis
Uncommon
Aspergilloma
◊ Endobronchial carcinoid
endobronchial nodule,
parenchymal nodule
Approximately 20%
present as solitary
lung nodules. May
cause post-obstructive
pneumonia.
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Endobronchial carcinoid
Despite risk of
bleeding, endobronchial
biopsies are indicated.
DIAGNOSIS
abuse, sedative previously,
use, poor dentition, Aspiration may have bronchial stenosis,
neurological disease, occurred many years bronchiectasis, or an
loss of consciousness, previously. Comparison
seizure in older adults endobronchial mass or
with old films is key. granulation tissue can
Suspect foreign be seen.
body aspiration in
cases of recurrent
focal pneumonias.
Occasionally expiratory
films show air trapping
that can be missed on
inspiratory films.
»bronchoscopy:
chronic foreign body
usually covered with
mucus and granulation
tissue
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Assessment of haemoptysis Diagnosis
Uncommon
history of GORD, age fever, crackles, »chest x-ray: patchy »chest CT scan:
>70 years, male sex, wheezing, dyspnoea airspace consolidations opacities in dependent
general anaesthesia, segments
cerebrovascular Chest CT scan
DIAGNOSIS
Necrosis, cavity
formation, and
empyema are potential
complications of
aspiration that are
visualised better with
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Broncholithiasis
◊ Tracheo-oesophageal fistula
DIAGNOSIS
pneumonia, cough and cyanosis are non- filled gastrointestinal
specific findings tract, dependent
infiltrates; insertion
of a nasogastric tube
may show coiling in the
upper pouch
»upper
gastrointestinal
series: spilling of
contrast into the
trachea
Thickened water-
soluble contrast should
be used.
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Bronchial telangiectasia
◊ Airway trauma
or lobar anatomy
◊ Dieulafoy's disease
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Thoracic endometriosis
catamenial symptoms no physical findings; »no test required: »chest CT scan: may
(within 24-48 pelvic tenderness, cul- diagnosis is clinical be negative; pulmonary
hours of onset of de-sac nodularity may or pleural nodules seen
menstruation); may be present during menses
have dysmenorrhoea,
dyspareunia; chest
pain, shortness of
breath
◊ Fat embolism
DIAGNOSIS
and axillae
◊ Tumour thromboembolism
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Arteriovenous malformation
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Arteriovenous malformation
»ABG analysis:
decreased partial
pressure of oxygen,
decreased oxygen
saturation when
arteriovenous flow is
severe
In cases of severe
systemic arteriovenous
malformation, chronic
hypoxaemia may
cause polycythaemia.
However, more
commonly, epistaxis
may result in anaemia.
DIAGNOSIS
history of bone marrow presence of infiltrates, usually sedimentation rate:
transplant; history leukocytoclastic patchy or diffuse usually elevated
of connective tissue vasculitis, arthritis, or »FBC: decreased »urinary sediment:
disease or vasculitis synovitis, indicative haemoglobin level may be present
of connective tissue
»bronchoscopy with If present may indicate
disease
bronchoalveolar pulmonary-renal
lavage: sequential syndrome.
lavage yields
progressively more »ANA, C-ANCA, anti-
haemorrhagic fluid; GBM, and anti-DNA
cytology shows antibodies: may be
haemosiderin-laden positive
macrophages ANA: antinuclear
antibodies.
C-ANCA: anti-
neutrophil cytoplasmic
antibodies.
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Assessment of haemoptysis Diagnosis
Uncommon
Anti-DNA: antibodies to
double-stranded DNA.
»pulmonary
function test with
diffusing capacity of
the lung for carbon
monoxide: usually
restrictive pattern with
elevated diffusing
capacity of the lung for
carbon monoxide
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Assessment of haemoptysis Diagnosis
Uncommon
»CT-guided
transthoracic
needle aspiration:
presence of necrotising
granulomatous
inflammation
Granulomas on tissue
obtained by CT-guided
transthoracic needle
aspiration should
be identified by a
pathologist and stained
for infectious agents
before a non-infectious
cause is assumed.
◊ Systemic vasculitis
DIAGNOSIS
History Exam 1st Test Other tests
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Systemic vasculitis
◊ Tricuspid endocarditis
history of intravenous fever, Janeway lesions, »FBC: elevated white »urinalysis: red blood
drug use, mitral valve Osler's nodes, splinter blood cells cell casts, white blood
prolapse, or congenital haemorrhages, cardiac cell casts, proteinuria,
»blood cultures:
heart disease; fever, murmur pyuria
bacteraemia,
malaise, fatigue, chest fungaemia
pains, weakness, night
sweats, palpitations »ECG: prolonged
PR interval; non-
specific ST/T wave
abnormalities;
atrioventricular block
»echocardiogram:
mobile valvular
vegetations
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Assessment of haemoptysis Diagnosis
Uncommon
◊ Bronchogenic cyst
»chest CT scan:
non-enhancing
homogeneous
attenuation near water
density; a smooth, thin
wall; typically presents
as a cystic mediastinal
mass
If higher-than-water
density is seen,
this is related to
proteinaceous material
or calcium deposits.
◊ Factitious haemoptysis
DIAGNOSIS
History Exam 1st Test Other tests
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Assessment of haemoptysis Diagnosis
Diagnostic guidelines
Europe
North America
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Assessment of haemoptysis References
Key articles
• Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and
REFERENCES
management. Respiration. 2010 Jan 8;80(1):38-58. Full text Abstract
• Comforti J. Management of massive hemoptysis. In: Simoff MJ, Sterman DH, Ernst A, eds.
Thoracic endoscopy: advances in interventional pulmonology. Malden, MA: Blackwell Publishing;
2006:23:330-43.
• Miller A, Chan M, Wiik A, et al. An approach to the diagnosis and management of systemic vasculitis.
Clin Exp Immunol. 2010 Jan 12;160(2):143-60. Full text Abstract
References
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of the topics can be found on bestpractice.bmj.com . Use of this content is
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Assessment of haemoptysis References
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44 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 24, 2019.
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Assessment of haemoptysis References
26. Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn
Interv Radiol. 2017 Jul-Aug;23(4):307-17. Full text Abstract
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27. Flume PA, Mogayzel Jr PJ, Robinson KA, et al; Clinical Practice Guidelines For Pulmonary Therapies
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28. Flight WG, Barry PJ, Bright-Thomas RJ, et al. Outcomes following bronchial artery embolisation for
haemoptysis in cystic fibrosis. Cardiovasc Intervent Radiol. 2017 Mar 13;40(8):1164-8. Abstract
29. Shigemura N, Wan IY, Yu SC, et al. Multidisciplinary management of life-threatening massive
hemoptysis: a 10-year experience. Ann Thorac Surg. 2009 Mar;87(3):849-53. Abstract
30. Solomonov A, Fruchter O, Zuckerman T, et al. Pulmonary hemorrhage: a novel mode of therapy.
Respir Med. 2009 Feb 28;103(8):1196-200. Full text Abstract
31. Tsukamoto T, Sasaki H, Nakamura H. Treatment of hemoptysis patients by thrombin and fibrinogen-
thrombin infusion therapy using a fiberoptic bronchoscope. Chest. 1989 Sep;96(3):473-6. Abstract
32. Bhattacharyya P, Dutta A, Samanta AN, et al. New procedure: bronchoscopic endobronchial sealing; a
new mode of managing hemoptysis. Chest. 2002 Jun;121(6):2066-9. Abstract
33. Chawla RK, Madan A, Aditya C. Glue in hemoptysis. J Bronchology Interv Pulmonol. 2016
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controlled pilot study. Pulm Pharmacol Ther. 2016 Jul 25;40:80-3. Abstract
35. Prutsky G, Domecq JP, Salazar CA, et al. Antifibrinolytic therapy to reduce haemoptysis from any
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36. Bobrowitz ID, Ramakrishna S, Shim YS. Comparison of medical v surgical treatment of major
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Assessment of haemoptysis References
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53. Barben J, Robertson D, Olinsky A, et al. Bronchial artery embolization for hemoptysis in young
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55. Cohen AM, Doershuk CF, Stern RC. Bronchial artery embolization to control hemoptysis in cystic
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Abstract
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Assessment of haemoptysis References
59. Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery embolization for life-
threatening hemoptysis. Chest. 1999 Apr;115(4):996-1001. Abstract
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60. Park HS, Kim YI, Kim HY, et al. Bronchial artery and systemic artery embolization in the
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62. Chung JH, Kanne JP. Multidetector-row computed tomography of diffuse tracheal disease: pictorial
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63. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000
May;28(5):1642-7. Abstract
64. Kim YH, Kim HT, Lee KS, et al. Serial fiberoptic bronchoscopic observations of endobronchial
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Abstract
65. So SY, Lam WK, Yu DY. Rapid diagnosis of suspected pulmonary tuberculosis by fiberoptic
bronchoscopy. Tubercle. 1982 Sep;63(3):195-200. Abstract
66. McIndoe RB, Steele JD, Samson PC, et al. Routine bronchoscopy in patients with active pulmonary
tuberculosis. Am Rev Tuberc. 1939;39:617-28.
67. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and
management of acute pulmonary embolism. Eur Heart J. 2014 Aug 29;35(43):3033-69, 3069a-k. Full
text Abstract
68. Yates M, Watts RA, Bajema IM, et al. EULAR/ERA-EDTA recommendations for the management of
ANCA-associated vasculitis. Ann Rheum Dis. 2016 Jun 23;75(9):1583-94. Full text Abstract
69. Miller A, Chan M, Wiik A, et al. An approach to the diagnosis and management of systemic vasculitis.
Clin Exp Immunol. 2010 Jan 12;160(2):143-60. Full text Abstract
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Assessment of haemoptysis Images
Images
IMAGES
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Assessment of haemoptysis Images
IMAGES
Figure 2: Aspergillus infection
From the personal collection of Dr Jeffrey Kanne, with permission
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IMAGES Assessment of haemoptysis Images
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Assessment of haemoptysis Images
IMAGES
Figure 5: Endobronchial metastatic melanoma
From the personal collection of Dr Erik Folch
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 24, 2019.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
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IMAGES Assessment of haemoptysis Images
52 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 24, 2019.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2019. All rights reserved.
Assessment of haemoptysis Images
IMAGES
Figure 7: Loquat seed completely occluding the bronchus intermedius
From the collection of Dr Septimiu Murgu and Dr Henri Colt; used with permission
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 24, 2019.
BMJ Best Practice topics are regularly updated and the most recent version
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of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2019. All rights reserved.
Assessment of haemoptysis Disclaimer
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54 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Jan 24, 2019.
BMJ Best Practice topics are regularly updated and the most recent version
of the topics can be found on bestpractice.bmj.com . Use of this content is
subject to our disclaimer. © BMJ Publishing Group Ltd 2019. All rights reserved.
Contributors:
// Authors:
Joanne M. Bando, MD
Associate Professor of Medicine
David Geffen School of Medicine, University of California, Los Angeles, CA
DISCLOSURES: JMB declares that she has no competing interests.
// Acknowledgements:
Dr Irawan Susanto and Dr Joanne Bando would like to gratefully acknowledge Dr Erik Folch and Professor
James K. Stoller, previous contributors to this topic.
DISCLOSURES: EF and JKS are authors of references cited in this topic.
// Peer Reviewers: