Synonym: Haemoptysis
Definition of Hemoptysis
Simple definition: Expectoration of blood or bloody sputum
Hemoptysis is defined as the expectoration of blood from the respiratory tract, a spectrum that varies from blood-streaking of sputum to coughing up large amounts of pure blood. 1
True hemoptysis is expectoration of blood from the lower respiratory tree, below the glottis. 2
Classification of Hemoptysis
Hemoptysis has been quantified with different numerical values by different studies and researches.
Massive hemoptysis has been quantified by various studies from as less as 100 ml/day to more than 1000 ml/day. Since, the consensus definition for massive hemoptysis is lacking – let us first define massive hemoptysis:.
a. Expectoration of 100 to 600 ml of blood over 24 hours. 3
b. Volumetric: expectoration of 600 ml of blood within 24 to 48 hours; and Magnitude of effect: clinical (hemodynamic and respiratory compromise) 4
c. Expectoration of 600 ml/day or 25 ml/h of blood 5
d. >8 mL/kg/day in children (this reference is widely accepted in pediatrics)
The reason for such a wide variable for quantification may be in part due to the difference in the anatomical deadspace among people. Normally, anatomical deadspace is 100-200 ml and hence, many prefer to use “massive hemoptysis” for expectoration of blood more than 100 or 150 ml/day.
Another, term that has been introduced is the – Exsanguinating hemorrhage which is considered as hemoptysis of:
- >300 ml (in single expectoration)
- >150 ml/hour
- >1000 ml/day
Now, let’s define other spectrum of severity of hemoptysis using a single reference to avoid confusion:
- Mild: <20 ml/day
- Moderate or submassive: 20-600 ml/day 6
How to Quantify Hemorrhage when Asking the Patient ?
1 tea spoon full (tspf) = 5 ml
1 table spoon full (tbspf) = 15 ml
1 cup ~ 250 ml
Hence, hemoptysis quantified as 1-2 tbspf is generally mild hemoptysis and that >1 cup is usually massive hemoptysis.
Causes of Hemoptysis
Mnemonic: CAVITATES (remember pulmonary cavitation causes massive hemoptysis)
C – CHF
A – Airway disease, bronchiectasis
V – Vasculitis/ Vascular malformations
I – Infection (eg TB)
T – Trauma
A – Anticoagulation
T – Tumour
E – Embolism
S – Stomach 7
- Infection: TB, Lung abscess, Bronchiectasis, Pneumonia, Fungal
- Neoplasm: Carcinoma, adenoma, Metastatic
- Congenital: Bronchial cyst, Sequestration of lung
- Traumatic, Iatrogenic, Bleeding disorder
- Cardiovascular: Mitral stenosis, Pulmonary HTN, Aortic aneurysm, AV malformation, PE
- Collagen Vascular Disease: Vasculitis, Wegner’s granulomatosis, Good pasture’s syndrome
Common causes of sub-massive and massive hemoptysis – “3 B”:
- Bronchitis
- Bronchiectasis
- Bronchogenic carcinoma
- Along with Tuberculosis
Hematemesis vs Hemoptysis
| HEMOPTYSIS | HEMATEMESIS |
|---|---|
|
History |
|
|
Absence of nausea and vomiting |
Presence of nausea and vomiting |
|
Lung disease |
Gastric or hepatic disease |
|
Asphyxia possible |
Asphyxia unusual |
|
Sputum examination |
|
|
Frothy |
Rarely frothy |
|
Liquid or clotted appearance |
Coffee ground appearance |
|
Bright red or pink |
Brown to black (acid hematin) |
|
Laboratory |
|
|
Alkaline pH |
Acidic pH |
|
Mixed with alveolar macrophages and neutrophils |
Mixed with food particles |
Pseudo-hemoptysis vs Hemoptysis
Pseudohemoptysis refers to the coughing of blood from a source other than the lower respiratory tract.
Sources of pseudohemoptysis:
- Nasopharynx
- Oral cavity
- Hematemsis aspirated into the lungs
Mechanism or Pathogenesis of Hemoptysis
Understand the vascular anatomy:
Lung has a dual blood supply:
- Low pressure supply (15-20/5-10 mmHg): Pulmonary circulation carries deoxygenated blood from the right ventricle across the pulmonary capillary bed and returns oxygenated blood via the pulmonary veins.
- Supplies pulmonary parenchyma including respiratory bronchioles
- Systemic pressure supply: Bronchial arteries branch from the aorta and are at systemic pressure. They can bleed profusely when airways are diseased.
- Supplies airways (main stem bronchi to terminal bronchioles), pleura, intrapulmonary lymphoid tissue.
- Non-bronchial systemic arteries can also be involved when collateral circulation develops in the regions of chronic inflammation.
Bronchial circulation is responsible bleeding in 90% cases.
Mechanisms involved in various etiologies:
- Neoplasms: Invasion of superficial mucosa and erosion of blood vessels; High vascular tumor with fragile walls
- Pulmonary venous hypertension: High pressure damage venous walls
- Infection: Inflammation and repeated cough disrupts pulmonary vasculature
History taking for Hemoptysis
| Symptoms of upper respiratory or gastrointestinal disease |
| Quantity and rate of bleeding |
| Previous hemoptysis, including extent of previous evaluations Previous history of TB, lung cancer, etc. |
| Appearance of sputum |
| Other pulmonary symptoms (e.g., chronic cough, chest pain) |
| Other systemic symptoms suggesting TB or malignancy (e.g., fever, weight loss) |
| Other bleeding problems and use of drugs (anti-platelet, anti-coagulant) |
| Toxic exposures – cigarette smoke, asbestos, silica |
Aids to Diagnosis Possible Cause of Hemoptysis
Streaky hemoptysis in a tobacco smoker or former smoker over 40 years of age – think chronic bronchitis and possibility of bronchogenic carcinoma.
Remember the most common causes of hemoptysis and massive hemoptysis when evaluating.
Uncommonly think of,
- Monthly hemoptysis – Pulmonary endometriosis
- Cryptogenic hemoptysis (Even after extensive evaluation, a sizable proportion of patients have no identifiable etiology for their hemoptysis) – Dieulafoy disease
Management of Massive Hemoptysis
