Problems in Family Practice

Hemoptysis

Gibbe H. Parsons, MD and Glen A. Lillington, MD Davis, California

Hemoptysis is an alarming symptom that should not be dis­ missed lightly. A thorough evaluation will lead to the correct diagnosis in 80 to 90 percent of cases. Surgery is occasionally necessary where life-threatening hemorrhage is present but, more commonly, appropriate therapy can only be determined when the etiology is discovered, thus mandating a careful, thorough diagnostic search.

Hemoptysis, the coughing up of blood, is a In contrast to hematemesis, the blood is startling symptom which usually brings the patient coughed up and not vomited, is often frothy as it is promptly to the physician and results in well- mixed with air and sputum, and is usually (but not deserved apprehension on the part of both.1 always) bright red. In hematemesis the blood may The first task of the physician is to determine be dark red or brownish in color, due to hemoglo­ that, in fact, the blood has originated from the bin conversion to hematin by gastric acid. Hemop­ airway (larynx, trachea, bronchi) or lungs, and tysis may be preceded by a gurgling noise as the does not represent bleeding from the mouth, blood is moved by air flow in large bronchi or the nasopharynx, or gastrointestinal tract. In the trachea. The pH of the blood in hemoptysis is pediatric age group the vast majority of children usually alkaline, whereas the pH of vomited blood brought to the physician by the parent for spitting is more likely acidic. Following an episode of up blood have a source of bleeding outside the hemoptysis, the sputum may be blood-tinged for lower respiratory tract, for example epistaxis. several days, whereas vomited blood, unless it is Sometimes the patient with true hemoptysis can aspirated, is not associated with blood-tinged describe a sensation of fluid in an area of the chest sputum. Actual observation by the physician of immediately prior to hemoptysis. When this oc­ the sputum is often helpful because occasionally curs, it helps to localize the point of origin to a oxidation of inhaled bronchodilators will result in specific side and region in the tracheobronchial a brownish-red color which can impart a tree, but this is not invariably reliable. homogeneous pink color to the expectorated material. The majority of diseases that affect the pulmo­ nary system can result in hemoptysis, thus the list of possible etiologies is lengthy and will not be From the Department of Internal Medicine, Section of Pul­ reviewed in its entirety here. Nevertheless, a di­ monary Medicine, University of California, Davis, School of Medicine, Davis, California. Requests for reprints should be vision of the more common causes of hemoptysis addressed to Dr. Gibbe H. Parsons, Section of Pulmonary by age, ie, children vs adults, may be of use (Ta­ Medicine, UCD Professional Building, 4301 X Street, Sac­ ramento, CA 95817. bles 1 and 2). 0094-3509/78 !01 -0353$01.75 ® 1978 Appleton -Century-Crofts

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Table 1. Some Causes of Hemoptysis in Chil­ dren

Aspirated foreign body Bronchiectasis with Agammaglobulinemia Cystic fibrosis Necrotizing pneumonia Pulmonary hemosiderosis Congenital heart disease

Hemoptysis in Children Idiopathic pulmonary hemosiderosis, which is As children under the age of six years rarely an uncommon disease, occurs predominantly in expectorate sputum even with extensive coaching, children and young adults, is associated with dif­ the presence of hemoptysis may not be apparent fuse recurrent alveolar hemorrhage, and char­ unless the amount of hemorrhage is large. When a acteristically presents with expectoration of pink child does present with hemoptysis, a common frothy sputum, diffuse parenchymal infiltrates on etiology is an aspirated foreign body. This diag­ chest roentgenogram, and iron deficiency anemia. nosis is especially likely if coughing is pronounced Congenital heart disease of various types as and if unilateral wheezing is present. Nonopaque well as other congenital pulmonary vascular ab­ foreign bodies resulting in “ asthma” and recurrent normalities may cause hemoptysis in children. hemoptysis have been reported in children refrac­ tory to the usual pharmacologic management of Hemoptysis in Adults asthma. Therefore, persistent wheezing that may Hemoptysis is a more frequent complaint in be generalized in association with hemoptysis adults than in children, and the list of possible should suggest the diagnosis of an aspirated etiologies is considerably longer. These etiologies foreign body. can be grouped into five categories: infections, Bronchiectasis, an abnormal dilatation of neoplastic diseases, cardiovascular diseases, im­ bronchi usually related to chronic or recurrent in­ munologic diseases, and miscellaneous (Table 2). fection and bronchial obstruction, is seen in chil­ dren with agammaglobulinemia or related im­ munologic deficiency states, with cystic fibrosis, Infections or following infections such as pertussis. Bron­ Chronic bronchitis is one of the most frequent chiectasis is associated with proliferation of bron­ causes of mild hemoptysis. A history of chronic chial blood vessels that commonly rupture, result­ productive cough, usually with a history of ciga­ ing in hemoptysis. rette smoking, is present. Caution is advised in Cystic fibrosis does not commonly give rise to attributing hemoptysis to chronic bronchitis as hemoptysis until the obstructive pulmonary dis­ more serious diseases, such as lung cancer, also ease and bronchiectasis associated with it is pro­ occur predominantly in cigarette smokers. nounced. In such cases, hemoptysis may first ap­ Bronchiectasis, if it is symptomatic, is accom­ pear in adolescence after many years of recurrent panied by hemoptysis in about 50 percent of cases. or chronic pulmonary infections. Chronic bronchitis and bronchiectasis were the Lower respiratory tract infections, especially major causes of hemoptysis in adults in one recent necrotizing pneumonias, may result in hemop­ study.2 Bronchography establishes a diagnosis of tysis. Thus, Klebsiella, staphylococcal, and bronchiectasis in most cases. Unlike bronchiec­ Pseudomonas pneumonias, when they occur in tasis of the lower lobes that usually is symptomatic children, may cause hemoptysis. with chronic production of copious amounts of

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purulent sputum, the upper lobe bronchiectasis Table 2. Some Causes of Hemoptysis in Adults that is a common consequence of healed apical tuberculosis is often “dry,” without sputum pro­ Infections duction. Both varieties may cause hemoptysis, Chronic bronchitis and in “dry” bronchiectasis it may be the only Bronchiectasis symptom. Lung abscess Lung abscess, frequently due to an indolent Pulmonary tuberculosis anaerobic infection especially in patients who Bacterial pneumonias have had seizures or unconsciousness with aspi­ Parasitic and fungal pneumonias Neoplastic Diseases ration, has become a major cause of hemoptysis in Bronchogenic carcinoma adults. It should be noted that lung abscess is Bronchial adenoma usually a roentgenographic diagnosis and does not Metastatic carcinoma in lung define the etiology. Not uncommonly, the bleed­ Cardiovascular Diseases ing actually originates from a tumor or foreign Pulmonary infarction body beyond which the abscess develops. Bron­ Mitral stenosis choscopy is always indicated in cases of lung Pulmonary Arteriovenous Fistula abscess to exclude these two possibilities and es­ Telangiectatic bronchial wall vessels tablish the etiology. Major hemoptysis occurs in Immunologic Diseases about five percent of cases of lung abscess and is Collagen vascular disease one clear indication for surgical resection. Systemic lupus erythematosus Wegener granulomatosis Pulmonary tuberculosis was, in the past, a very Periarteritis nodosa common cause of hemoptysis in adults, being the Goodpasture syndrome leading etiologic factor in several reported stud­ Miscellaneous ies.3 Aneurysms of bronchial vessels within tuber­ Thoracic trauma culosis cavities, named after Rasmussen who orig­ Broncholith inally described them in 1868, are a cause of mas­ Bullae and cysts sive hemoptysis. Bronchiectasis resulting from the Iatrogenic causes healing of tuberculosis contributes to the fre­ Excessive anticoagulation quency of bleeding. Although the incidence of Idiopathic causes tuberculosis is declining, hemoptysis is still the presenting symptom in this disease in some cases. This accentuates the need for adequate sputum examination for the tubercle bacillus in all cases of Neoplastic Diseases hemoptysis. Hemoptysis occurs in over 50 percent of cases Bacterial pneumonias are occasionally as­ of bronchogenic carcinoma at some time in the sociated with mild hemoptysis, particularly in nec­ course of the disease. The bleeding is usually not rotizing pneumonias. A slowly clearing pneumonia profuse, but the seriousness of this disease de­ or recurrent pneumonia in one segment or lobe mands a thorough diagnostic evaluation. A normal suggests an obstructing lesion and is an indication chest roentgenogram does not exclude this diag­ for further diagnostic work-up. nosis even though hemoptysis is usually a late Hemoptysis is an occasional manifestation in a symptom of lung cancer rather than an early one. number of parasitic and fungal pneumonias. In With fiberoptic bronchoscopy and adequate current practice, the presence of a mycetoma sputum cytologic examination a diagnosis can (fungus ball) has become an increasingly important usually be readily established. cause of hemoptysis. A mycetoma is a saprophytic Bronchial adenoma, a vascular tumor found growth of fungus within a preexisting cavity or usually in large airways, is accompanied by bulla. It has a characteristic radiologic appearance hemoptysis in about 50 percent of cases. Surgical of a mass, often mobile, within the cavity with a resection is curative. “meniscus” of air at the top. In most instances, Metastatic tumors in the lung are often the fungus involved is Aspergillus, but cases due asymptomatic but may grow into the bronchial to Candida have been described. tree, causing hemoptysis.

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Cardiovascular Diseases patient does not first succumb from pulmonary in­ Hemoptysis is a symptom in 25 percent of cases sufficiency. of pulmonary infarction. The bleeding is rarely Miscellaneous massive and is typically associated with shortness of breath and pleuritic chest pain. A friction rub is Thoracic trauma due to a puncture wound, rib sometimes noted and, rarely, frank pleural effu­ fracture, or blunt contusion may result in expecto­ sion may be present. Occasionally, an infarct may ration of blood. Rarely, a blunt rapid deceleration cavitate, simulating a bacterial lung abscess. The chest injury such as a steering wheel injury will serious prognostic implications pf pulmonary em­ fracture a bronchus. This syndrome should be bolic disease emphasize the necessity to consider suspected in the presence of pneumomediastinum, the possible presence of this condition in all pneumothorax, subcutaneous emphysema, and patients with hemoptysis. hemoptysis. Mitral stenosis (or any other cause of pulmo­ A broncholith results from a calcified lymph nary venous hypertension) can result in hemop­ node eroding into the airway. Hemoptysis may be tysis, probably due to rupture of distended pulmo­ the only symptom, but a history of coughing up nary capillaries or bronchial veins. Expectoration “ stones” is present in 50 percent of cases. Bron­ of blood is seen in 10 to 20 percent of cases of choscopy usually allows visualization of the erod­ mitral stenosis, may occur in mild as well as se­ ing, calcified particle with its associated hemor­ vere stenosis, and frequently follows exercise. rhage. Rarely, massive hemoptysis occurs resulting in An uncommon cause of massive hemoptysis is death. Valvular surgery, by reducing the pulmo­ rupture of a blood vessel in the wall of an em­ nary vascular pressures, has led to cessation of the physematous bullae or cyst. Considering the fre­ hemoptysis. quency of bullae in patients with pulmonary em­ Pulmonary arteriovenous fistula, usually pre­ physema, it is surprising that this is not more senting radiologically as a solitary mass or nodule, commonly seen. may resul) in expectoration of blood. Cutaneous Iatrogenic causes of hemoptysis usually pre­ changes qf hereditary hemorrhagic telangiectasia sent no diagnostic problem. Bronchoscopic bron­ are usually present. chial or transbronchial biopsy, percutaneous nee­ Several recent reports have indicated that care­ dle aspiration of lung, and transtracheal needle ful fiberoptic bronchoscopic examination of seg­ aspiration often cause minimal, and occasionally mental apd subsegmental bronchi may reveal mul­ massive, hemoptysis. Hemoptysis may accom­ tiple telangiectatic bronchial wall vessels in some pany the use of the Swan-Ganz catheter. Erosion patients in whom no other cause for hemoptysis into the innominate artery with massive bleeding is can be found.4 The etiology of these bronchial occasionally seen with chronic endotracheal tube telangiectases is not understood. Some of the or tracheostomy tube placement where the trachea cases diagnosed in the past as “idiopathic hemop­ is eroded anteriorly. Excessive anticoagulation tysis” probably fall into this category. may result in alveolar hemorrhage with an alveolar filling pattern on chest roentgenogram that is often diffuse in extent. An underlying bronchial lesion Immunologic Diseases must be suspected in these cases, particularly if A number of immunologic diseases, including the radiologic involvement is localized rather than systemic lupus erythematosus, periarteritis diffuse. nodosa, and Wegener granulomatosis occasionally Even after careful evaluation, 10 to 20 percent result in hemoptysis, probably related to the as­ of cases of hemoptysis have no identifiable cause, sociated necrotizing pulmonary vasculitis. Good- ie, are idiopathic. The diagnosis of idiopathic (es­ pasture syndrome, which occurs primarily in sential) hemoptysis should not be made unless all young adults, with antibodies formed against both the following criteria are satisfied: (1) a normal glomerular and alveolar basement membranes, re­ chest x-ray, (2) a normal fiberoptic bronchoscopic sults in recurrent diffuse alveolar hemorrhage that examination, (3) a normal bronchographic exam­ usually, but not always, results in hemoptysis. ination, and (4) sputum examinations negative for Progressive renal failure always occurs if the tubercle bacilli and malignant cells.

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Table 3. Diagnostic Evaluation in Hemoptysis

Procedure Comment

1. History 2 . Physical examination the minimum 3. Chest film posterior-anterior and lateral 4. Sputum examination culture including diagnosis made in mycobacterium tuberculosis majority of cases cytology 5. Fiberoptic bronchoscopy 6. Special roentgenograms apical lordotic views for apical disease lateral decubitus views for effusion tom ogram s masses, hilar lesions bronchograms diagnostic in bronchiectasis 7. Ventilation-perfusion lung scans pulmonary infarction and emboli 8 . Pulmonary angiogram pulmonary infarction or arteriovenous fistula 9. Thoracentesis 10. Biopsy scalene node, mediastinal node bronchoscopic biopsy percutaneous needle aspiration open lung biopsy

11. Blood studies complete blood count, fungal serologies, bleeding studies 12. Transtracheal aspiration

Diagnostic Studies in Hemoptysis shortness of breath in situations conducive to the development of thrombophlebitis suggests pulmo­ Every patient who experiences hemoptysis nary embolism. The coughing up of “ stones” is should have a careful history, physical examina­ indicative of broncholithiasis, whereas a clear his­ tion, and chest roentgenogram as the minimal tory of “choking” when eating peanuts or other evaluation (Table 3). solids followed by intractable coughing is good evidence for foreign body aspiration. A history of History anticoagulant drug use is obviously important. The history will often help pinpoint the etiology of the symptom. A chronic productive cough Physical Examination suggests chronic bronchitis or bronchiectasis, The physical examination, done with the care whereas a subacute illness with fever, cough, and time it deserves, may demonstrate that the weight loss, and night sweats suggests tuber­ bleeding is not from the airway or lungs or may culosis or lung abscess. Recurrent pneumonias help to define the cause of hemoptysis. Inspection suggest an immune deficiency state, cystic fib­ of the thorax may reveal a lag on inspiration of one rosis, or a partial airway obstruction. Age over 40 hemithorax suggesting the presence of an effusion, and a smoking history increase the likelihood of pneumonia, or lung abscess on that side. Digital lung cancer. Dyspnea on exertion is a common clubbing is often seen in bronchiectasis, lung complaint when mitral stenosis is present. Sudden abscess, bronchogenic carcinoma, and cystic fi-

THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 2, 1978 357 HEMOPTYSIS brosis, but rarely in chronic bronchitis or em­ red cells makes finding the tumor cells more dif­ physema alone. Palpation may reveal tracheal ficult, as the red cell may overlay the cells of major shift toward the side of a contracted apex of healed interest. tuberculosis or an atelectatic lobe due to a foreign Bronchoscopy provides a powerful tool in the body. Firm cervical and supraclavicular nodes diagnostic work-up of hemoptysis and, with rare indicate metastatic disease, whereas increased exception, is the next test performed following vocal fremitus suggests consolidation. Dullness to chest films and sputum examination. The fiberop­ percussion is seen over consolidation, or pleural tic bronchoscope is capable of making directly vis­ effusion. Auscultation may reveal only a tracheal ible the subsegmental airways beyond the reach of “rattle” from the presence of unexpectorated the standard rigid bronchoscope. If less than mas­ blood, but localized wheezing should suggest sive bleeding is occurring at the time of fiberoptic airflow obstruction perhaps due to an endobron­ bronchoscopy, segmental lavaging with careful chial mass or foreign body. A pleural rub may search has revealed the site of bleeding in 66 of 71 occur with pneumonia or pulmonary infarction. cases in a recent study.2 Localization of the bleed­ ing site is important for future surgical resection. Roentgenographic and Laboratory Studies Also, brushings or biopsy of an observed lesion Although the etiology of the majority of cases of frequently permits a precise diagnosis. hemoptysis can be diagnosed with chest Additional diagostic tests are often of value de­ roentgenograms, sputum examination, and bron­ pending on the clinical setting. If pleural effusion choscopy, several other tests or procedures are is present, a thoracentesis should always be per­ sometimes required. formed unless congestive heart failure or volume The standard posterior-anterior (PA) and lateral overload is clearly causing the effusion. If a lung chest films should be obtained in all cases. Surpris­ or mediastinal mass is present, scalene or medias­ ingly, these studies will be entirely negative in tinal node biopsy may yield a diagnosis. Per­ about half of all patients with hemoptysis. A nor­ cutaneous needle aspiration biopsy of a peripheral mal chest film, however, does not exclude serious lung mass may be helpful when less invasive pro­ disease and should rarely be the final test per­ cedures have failed to establish a diagnosis. If lung formed. When a lesion is present, comparison with tissue cannot be obtained by percutaneous needle previous films is of paramount importance. Other aspiration, either a transbronchial lung biopsy occasionally useful roentgenographic tests include through the bronchoscope or an open lung biopsy apical lordotic views, tomography of masses or through a limited thoracotomy may be necessary. hilar lesions, and pulmonary angiograms to iden­ Certain blood studies are sometimes indicated, tify pulmonary arteriovenous fistula or emboli. such as a complete blood count, serologic titers for One crucial radiologic study in many cases of coccidioidomycosis when appropriate, and a hemoptysis is the bronchogram, as this technique screening test, such as the partial thromboplastin delineates bronchiectasis in regions beyond the time, when a bleeding diathesis is suspected. range of the fiberoptic bronchoscope. Bronchiec­ When the history and chest roentgenogram are tasis is frequently undetectable on the standard PA suggestive of cystic fibrosis, a sweat chloride test film but is still a common cause for hemoptysis. may be diagostic. Transtracheal aspiration as a Endobronchial tumors can also be detected with diagnostic test is most helpful in lung abscess or bronchography, but care must be taken to wait indolent pneumonia where an anaerobic organism until hemoptysis clears, as retained blood clots is a possible etiologic agent. Sputum and even will make definitive interpretation difficult. bronchial washings from fiberoptic bronchoscopy Sputum collection for cultures (bacteria, fungi, are usually contaminated with oropharyngeal tubercle bacilli) and for cytologic examination flora. should be a standard part of the evaluation of hemoptysis. The presence of blood in the sputum Diagnostic Management and Therapy of makes cytologic evaluation more difficult but not Hemoptysis impossible. If the blood clots, the tumor cells fre­ The treatment of hemoptysis is the treatment of quently adhere to the surface of the clot. If the the underlying disease, making the etiologic diag­ blood does not clot, the routine slide with many nosis mandatory for proper management. The ex-

358 THE JOURNAL OF FAMILY PRACTICE, VOL. 7, NO. 2, 1978 HEMOPTYSIS ception is in the case in which massive hemoptysis The Family Physician and Hemoptysis may be lethal, more commonly due to asphyxia­ In most instances, the patient with hemoptysis tion than to exsanguination. The major diagnostic is first seen by his/her primary care physician, who problem here is to determine the anatomic location thus assumes an onerous responsibility. As many of hemorrhage to guide the surgeon to segmental, of the diagnostic techniques employed (such as lobar, or lung resection. Where mitral stenosis is bronchoscopy) are not ordinarily within the pur­ the cause, valvular surgery has been curative. view of the family physician, referral to a specialty During acute massive hemoptysis, where the site diagnostician is indicated in most cases. The obli­ of bleeding has been identified as coming from a gations of the family physician in such cases can single lobe or segment, varioils tamponade proce­ be outlined as follows: dures have been used to temporarily control bleed­ 1. He/she should seek early consultation if the ing and prevent asphyxiation. These include surgi­ hemorrhage is massive or potentially so. For cal packing through a rigid bronchoscope, Fogarty example, the presence of a lung abscess with a catheter inflation in the appropriate airway, or use “fluid level” in a patient with only mild expecto­ of a double lumen Carlens catheter to keep one ration of blood may represent a potentially mas­ lung free of blood and well oxygenated. sive hemoptysis.5 In cases of less than massive hemoptysis, a 2. He/she should convince the patient of the more orderly approach to diagnosis can be carried necessity for full diagnostic studies even if the out. Following chest films and sputum examina­ hemoptysis was minor and transitory initially. tion, a fiberoptic bronchoscopy is usually indi­ 3. He/she should recognize at an early stage the cated and is often more helpful in localizing the possibility of pulmonary infarction as a cause of source of bleeding if performed while hemoptysis the hemorrhage and should initiate the necessary is present. Bronchoscopy is probably unnecessary diagnostic studies. in a young person with a clearcut, acute bron­ 4. In many cases, he/she can carry out or chitis, severe cough, and a single episode of mild supervise the entire diagnostic and treatment pro­ hemoptysis. Typical lobar pneumonia, diagnosed gram. Conditions which are often suitable for this pulmonary infarction, and known mitral stenosis approach include hemoptysis in acute bronchitis are other conditions where bronchoscopy is usu­ or pneumonia, proven tuberculosis, mitral ally not needed. Bronchoscopy, especially with stenosis, anticoagulant overdosage, uncompli­ biopsy, is relatively contraindicated with a severe cated chest trauma, and cystic fibrosis. In all bleeding diathesis. The rigid bronchoscope is the cases, the possible presence of neoplasms, tuber­ instrument of choice when large volumes of blood culosis, or pulmonary infarction must be con­ are present that cannot be effectively suctioned stantly reconsidered. through the small diameter channel of the fiberop­ tic bronchoscope. In most other cases fiberoptic bronchoscopy is indicated and is very useful. The early recognition of cases of hemoptysis due to pulmonary infarction is of critical impor­ tance. Suspicion should be aroused if predisposing factors to thrombophlebitis are present (prolonged recumbency, obesity, recent surgery, congestive failure, birth control pills), if dyspnea and pleuritic References pain are present, and if radiological findings 1. Liilington GA, Jamplis RW: A Diagnostic Approach to Chest Diseases, ed 2. Baltimore, Williams and Wilkins, suggestive of infarction (pleural effusion, basilar 1977, pp 493-507 opacities, hemidiaphragmatic elevation) are noted. 2. Smiddy JF, Elliott RC: The evaluation of hemoptysis with fiberoptic bronchoscopy. Chest 64:158, 1973 Lung scans are often helpful, and angiography is 3. Lyons HA: Differential diagnosis of hemoptysis and usually diagnostic. its treatment. In Pierce AK (ed): Basics of RD, vol 5, no. 2. New York, American Lung Association, 1976, pp 1-5 Treatment during expectoration of blood in­ 4. Masson RG, Altose MD, Mayock RL: Isolated bron­ cludes rest, codeine for minimal cough suppres­ chial telangiectasia. Chest 65:450, 1974 5. Thoms NW, Wilson RF, Puro HE, et al: Life threaten­ sion unless bleeding is massive, and an aggressive ing hemoptysis in primary lung abscess. Ann Thorac Surg diagnostic investigation. 14:347, 1972

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