Definition

1. General: coughing of blood from pulmonary parenchyma or tracheobronchial tree
2. Massive: arbitrary quantity: 100-600ml/24hr <5% patients have massive bleeding

Etiology

1. Ascertain source is pulmonary
2. Common causes: (differ in regular vs. massive)
   • chronic bronchitis
   • bronchiectasis
   • bronchogenic carcinoma (50% present with minor hemoptysis)
   • TB (historically #1)
   • fungal disease
   • bacterial pneumonia
   • lung abscess (15% cases hemoptysis)
   • pulmonary infarct
   • cryptogenic (0.8-15%)
   • less common: mitral stenosis, Goodpasture's, endobronchial foreign body, bronchial adenoma, pulmonary AV fistula, coagulopathy
3. Must suspect bronchogenic carcinoma in >40 yo smoker
4. May result from metastatic carcinoma, typically breast, colon, or malignant melanoma

Pathophysiology

1. dual circulation
   • usually from bronchial arteries and collaterals from axillary, intercostal, diaphragmatic and systemic arteries of thorax
   • 10% cases bleed from pulmonary arteries, capillaries or veins
2. vascular mechanisms
   • aneurysm formation
   • vasculitis
   • pulmonary embolism
   • inflammation
   • broncholithiasis
   • direct invasion central pulmonary artery trauma

    

   Diagnosis

   1. Physical examination
      • confirm source
      • which hemithorax
      • localized rales, rhonchi, or wheezing
   2. Chest Radiography
      • confluent or patchy alveolar filling pattern
      • becomes reticular over days
      • clears in 3-10 days
   3. Bronchoscopy
      • visualize potential causes/location
      • rigid vs fiberoptic
        • FOB identifies carcinoma in 2-13% pts with normal CXR
        • timing
   4. Arteriography
      • identify site
      • therapeutic with embolization
        • 80-90% initial control
        • long term recurrence in 10-15%
   5. Radionuclide Scanning
   6. Chest Computed Tomography

Management

1. Three Goals of Therapy
   • prevent asphyxiation
   • stop bleeding
   • treat primary disease
2. Airway Control
   • supplemental oxygen
   • positioning
   • cough control
   • endotracheal intubation a. selective intubation
3. Volume Resuscitation
4. Laboratory Evaluation
   • hematocrit
   • platelet count
   • coagulation profile
   • arterial blood gas, if appropriate
   • renal function testing
   • type and crossmatch blood
   • smear, culture and cytology of sputum
   • DLCO for pulmonary hemorrhage

Consultations

1. Surgical
   • Definitive: resection
2. Medical
   • antibiotics if indicated
   • medical management if nonlocalized bleeding, severely impaired pulmonary function, disseminated terminal carcinoma, advanced bilateral pulmonary disease, vasculitis
   • Modalities
     • bronchial artery embolization
     • balloon tamponade
     • intracavitary antifungal therapy
3. Mortality
   • medically managed patients with massive hemoptysis: 75%
   • surgically managed patients with massive hemoptysis: 23%