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Am Fam Physician. 2022;105(2):144-151

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Hemoptysis is the expectoration of blood from the lower respiratory tract, usually from bronchial arteries. The most common causes are acute respiratory infections, cancer, bronchiectasis, and chronic obstructive pulmonary disease. No cause is identified in 20% to 50% of cases. Hemoptysis must be differentiated from pseudohemoptysis, which is blood that originates from nasopharyngeal or gastrointestinal sources. The initial evaluation includes determining the severity of bleeding and stability of the patient and may require bronchoscopy for airway protection. Mild hemoptysis comprises more than 90% of cases and has a good prognosis, whereas massive hemoptysis has a high mortality rate. A history and physical examination can assist in identifying an etiology, but diagnostic testing is often required. Chest radiography is a good initial test, but it has limited sensitivity for determining the site and etiology of the bleeding. Computed tomography and computed tomography angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding; however, bronchoscopy may also be needed. In addition to supportive medical treatment, management should include treatment of the underlying etiology because recurrence often takes place in the absence of treatment of the identified cause. Bronchial arterial embolization is used to treat massive hemoptysis, particularly when an involved artery is noted on computed tomography angiography. Surgery is reserved for patients whose medical treatment and embolization are not effective.

Hemoptysis is the expectoration of blood from the lower respiratory tract (airways or lungs).16 The expectoration of blood-tinged sputum and mild to moderate hemoptysis should be distinguished from life-threatening, massive hemoptysis.4 More than 90% of hemoptysis cases are mild, self-limiting, and have a good prognosis with conservative management.5,7 However, massive hemoptysis has a mortality rate of greater than 50%.3,5,6,8

Clinical recommendationEvidence ratingComments
Chest radiography should be performed as part of the initial evaluation of patients with hemoptysis.2,3,5 CExpert opinion
Computed tomography or computed tomography angiography with intravenous contrast should be performed to determine the etiology of hemoptysis when no cause is found on chest radiography.2,17,19 CRetrospective cohort studies showing that computed tomography with intravenous contrast is more effective in determining site and etiology of bleeding compared with bronchoscopy in patients with hemoptysis
Bronchial arterial embolization is the treatment of choice in patients with massive hemoptysis, and in patients with non-massive hemoptysis with a bleeding artery identified on computed tomography angiography.2,7,8 CRetrospective studies showing better outcomes of patients with hemoptysis who undergo bronchial arterial embolization compared with conservative treatment

Causes

The differential diagnosis of hemoptysis is broad, with the incidence of various etiologies depending on geographic location and care setting (Table 11,36,9 and Table 21013). Worldwide, tuberculosis is the most common cause of hemoptysis.2 In ambulatory settings of countries without limited resources, hemoptysis is often caused by acute respiratory infections, chronic obstructive pulmonary disease, cancer, and bronchiectasis.2,10,11 However, 20% to 50% of cases are cryptogenic, with no cause found on computed tomography (CT) or bronchoscopy.35

Pulmonary: airway/tracheobronchialBronchial tumors, carcinomas, metastases
Bronchiectasis (cystic fibrosis)
Bronchitis (viral, bacterial [Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis])
Foreign body
Trauma (hematoma, fistula)
Pulmonary: parenchymalInfectious
Fungal infections (mycetomas [aspergillosis], paragonimiasis)
Leptospirosis
Lung abscess
Parasitic diseases
Pneumonia
Tuberculosis, nontuberculous mycobacteria
Rheumatologic diseases
Anti–glomerular basement membrane disease (Goodpasture syndrome)
Antiphospholipid syndrome
Behçet disease
Granulomatosis with polyangiitis and microscopic polyangiitis (Wegener granulomatosis)
Henoch-Schönlein purpura
Microscopic polyarteritis
Mixed cryoglobulinemia
Sarcoidosis
Systemic lupus erythematosus
Takayasu arteritis
Other
Acute lung allograft rejection
Cocaine inhalation
Diffuse alveolar damage
Idiopathic pulmonary hemosiderosis
Lung contusion
Lymphangiomyomatosis
Pulmonary capillary hemangiomatosis
VascularAneurysms, pseudoaneurysms (thoracic artery, bronchial artery, aorta)
Arteriovenous malformations
Artery rupture (pulmonary artery, thoracic artery)
Bronchial telangiectasia, hemangioma
Bronchovascular fistula
Dieulafoy lesion
Pulmonary embolism/infarction
Pulmonary hypertension
Pulmonary veno-occlusive disease
CardiacPulmonary edema (e.g., heart failure, mitral stenosis, congenital heart disease)
Right-sided endocarditis
LatrogenicMedication: anticoagulation, thrombolytic/fibrinolytic agents, anti-angiogenics (bevacizumab [Avastin])
Postprocedural: lung biopsy, heart catheterization, endoscopic lung volume reduction, pulmonary artery catheterization, bronchoscopy, airway stent, endotracheal tube erosion
MiscellaneousCoagulopathy
Thoracic/pulmonary endometriosis (catamenial hemoptysis)
Thrombocytopenia
Pseudohemoptysis Gastrointestinal source (hematemesis):ulcer, gastritis, variceal bleed
Serratia marcescens (gram-negative bacterium that produces a red pigment)
Upper respiratory airway source
EtiologiesOutpatient (%)Inpatient (%)Limited-resource country, inpatient (%)Pediatric (%)
Aspergillosis0.021.2
Asthma3.2
Bronchiectasis1.06.99.3
Cancer4.017.86.257
Cardiac/pulmonary edema0.24.61.5611
Chronic obstructive pulmonary disease2.5
Coagulopathy/anticoagulation0.0413.5
Cryptogenic/idiopathic48.91.5620
Pulmonary embolism0.82.8
Respiratory infections18.723.110.765
Tuberculosis0.22.565

The etiology of hemoptysis often determines the source of bleeding. In 90% of cases of severe hemoptysis requiring treatment, bleeding is from the bronchial arteries.46 Bleeding from the pulmonary arteries (5%) and nonbronchial systemic arteries (5%) is less common.4,6 Bronchial arteries supply the intrapulmonary airways and are connected to pulmonary arteries by anastomoses.46 When pulmonary arterial perfusion is impaired (e.g., pulmonary embolism, vasculitis, hypoxic pulmonary vasoconstriction), increases in bronchial arterial flow result in greater flow through the anastomoses, which can hypertrophy, become thin-walled, and break into alveoli and bronchi, causing hemoptysis.5,6 Bleeding from pulmonary arteries usually results from pseudoaneurysms that are created by erosion of the artery caused by the destruction of nearby pulmonary parenchyma from chronic inflammation (e.g., cancer, tuberculosis, aspergillosis/mycetoma, lung abscess, trauma [e.g., Swan-Ganz catheter placement]).4,5,8 In inflammatory states, angiogenic growth factors cause neovascularization and recruitment of collateral vessels from nearby nonbronchial systemic arteries, which form anastomoses with the pulmonary arterial circulation that are fragile and can rupture into airways, causing hemoptysis.5,6,8,14

Initial Evaluation

Massive hemoptysis, previously defined as a specific volume of expectorated blood within a particular amount of time, has transitioned to a more functional definition focused on the effects of the bleeding.36 The definition has shifted because of the difficulty in quantifying the volume of hemoptysis.1,4 Clinical factors such as the rate of bleeding, the patient's ability to maintain a patent airway (dependent on the rate of blood clearance, internalized bleeding, airway obstruction, and respiratory status), and the patient's physiologic reserve (a function of hemodynamic stability, cardiopulmonary reserve, and risk of recurrent bleeding) are more important than volume.4,5 The mortality rate from untreated massive hemoptysis is greater than 50%.8 The most immediate life-threatening risk is usually asphyxia due to airway obstruction, rather than exsanguination; therefore, any degree of hemoptysis causing cardiovascular collapse should be considered life-threatening.5,6

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