Why does hemoptysis occur

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Sign in with your library card Please enter your library card number. Disclaimer Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Top Next Introduction Haemoptysis is defined as the expectoration of blood or blood-streaked sputum from the lower respiratory tract. Top Previous Next Causes Haemoptysis may derive from a variety of very different conditions, such as infections, pulmonary diseases, neoplastic conditions, cardiovascular alterations, vasculitis, traumatic events, haematological derangements, and iatrogenic or drug-induced events see Box In the primary care setting, the most common causes of hemoptysis are acute and chronic bronchitis, pneumonia, tuberculosis, and lung cancer.

The differential diagnosis and underlying etiologies are listed in Table 1. Pulmonary artery rupture secondary to balloon-tip pulmonary artery catheter manipulation. Adapted with permission from Weinberger SE. Principles of pulmonary medicine. Philadelphia: Saunders, Infection is the most common cause of hemoptysis, accounting for 60 to 70 percent of cases.

In a retrospective study 6 of inpatient and outpatient hemoptysis in the United States, bronchitis caused 26 percent of cases, pneumonia caused 10 percent, and tuberculosis accounted for 8 percent. Invasive bacteria e. Viruses such as influenza also may cause severe hemoptysis. Primary lung cancers account for 23 percent of cases of hemoptysis in the United States. Breast, renal, and colon cancers have a predilection for lung metastasis; however, metastatic lung carcinoma rarely results in bleeding.

Cardiovascular conditions that result in pulmonary venous hypertension can cause cardiac hemoptysis. The most common of these is left ventricular systolic heart failure. Other cardiovascular causes include severe mitral stenosis and pulmonary embolism. Although hemoptysis is a recognized pulmonary embolism symptom, pulmonary embolism is an uncommon cause of hemoptysis.

For example, in a patient without underlying cardiopulmonary disease, the positive and negative likelihood ratios for hemoptysis in pulmonary embolism are 1. Therefore, the presence or absence of hemoptysis alone has no significant effect on the likelihood of pulmonary embolism.

Idiopathic hemoptysis is a diagnosis of exclusion. In 7 to 34 percent of patients with hemoptysis, no identifiable cause can be found after careful evaluation. The major cause of hemoptysis in children is lower respiratory tract infection. The second most common cause is foreign body aspiration, with most cases occurring in children younger than four years.

Another important cause is bronchiectasis, which often is secondary to cystic fibrosis. Primary pulmonary tuberculosis is a rare cause estimated to occur in less than 1 percent of cases. Blunt-force trauma may result in hemoptysis secondary to pulmonary contusion and hemorrhage.

Bleeding caused by suffocation, deliberate or accidental, also should be considered. Historic clues are useful for differentiating hemoptysis from hematemesis Table 2 4 , 17 , Patient history also can help identify the anatomic site of bleeding, differentiate between hemoptysis and pseudohemoptysis, and narrow the differential diagnosis Table 3 4 , 5 , 17 , Factors such as age, nutrition status, and comorbid conditions can assist in the diagnosis and management of hemoptysis.

Information from references 4 , 17 , and Dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, frothy pink sputum.

Upper respiratory infection, acute sinusitis, acute bronchitis, pneumonia, lung abscess. History of chronic lung disease, recurrent lower respiratory track infection, cough with copious purulent sputum. Nausea, vomiting, melena, alcoholism, chronic use of nonsteroidal anti-inflammatory drugs. Tuberculosis, parasites e. Information from references 4 , 5 , 17 , and Once true hemoptysis is suspected, the investigation should focus on the respiratory system.

Blood from the lower bronchial tree typically induces cough, whereas a history of epistaxis or expectorating without cough would be consistent with an upper respiratory source but does not exclude a lower tract site.

Bleeding is difficult to quantify clinically. Patients may find it difficult to discern whether they are throwing up, coughing, or spitting out bloody material. The amount of blood loss usually is overestimated by patients and physicians, but an attempt to determine the volume and rate of blood loss should be made. Methods of determination include observing as the patient coughs and the use of a graduated container. Blood-streaked sputum deserves the same diagnostic consideration as blood alone.

The amount or frequency of bleeding does not correlate with the diagnosis or incidence of cancer. It is helpful to determine whether there have been previous episodes of hemoptysis and what diagnostic assessments have been done. Mild hemoptysis recurring sporadically over a few years is common in smokers who have chronic bronchitis punctuated with superimposed acute bronchitis.

Because smoking is an important risk factor, these patients are at higher risk for lung cancer. Environmental exposure to asbestos, arsenic, chromium, nickel, and certain ethers increases risk for hemoptysis. Bronchial adenomas, although malignant, are slow growing and may present with occasional bleeding over many years. Malignancy in general, especially adenocarcinomas, can induce a hypercoagulable state, thereby increasing the risk for a pulmonary embolism.

A history of chronic, purulent sputum production and frequent pneumonias, including tuberculosis, may represent bronchiectasis. Association of hemoptysis with menses i. A travel history may be helpful.

Tuberculosis is endemic in many parts of the world, and parasitic etiologies should be considered. Historic clues often will narrow the differential diagnosis and help focus the physical examination Table 4 4 , 5 , Examining the expectoration may help localize the source of bleeding. Constitutional signs such as cachexia and level of patient distress also should be noted. The skin and mucous membranes should be inspected for cyanosis, pallor, ecchymoses, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa.

Primary lung cancer, bronchiectasis, lung abscess, severe chronic lung disease, secondary lung metastases. Fever, tachypnea, hypoxia, hypertrophied accessory respiratory muscles, barrel chest, intercostal retractions, pursed lip breathing, rhonchi, wheezing, tympani to percussion, distant heart sounds.

Gingival thickening, mulberry gingivitis, saddle nose, nasal septum perforation. Tachycardia, tachypnea, hypoxia, jugulovenous distention, S3 gallop, decreased lung sounds, bilateral rales, dullness to percussion in lower lung fields. Congestive heart failure caused by left ventricular dysfunction or severe mitral valve stenosis. Tachypnea, tachycardia, dyspnea, fixed split S2, pleural friction rub, unilateral leg pain and edema.

Information from 4 , 5 , and The examination for lymph node enlargement should include the neck, supraclavicular region, and axillae. The cardiovascular examination includes an evaluation for jugular venous distention, abnormal heart sounds, and edema.

The physician should check the chest and lungs for signs of consolidation, wheezing, rales, and trauma. The abdominal examination should focus on signs of hepatic congestion or masses, with an inspection of the extremities for signs of edema, cyanosis, or clubbing. Figure 1 5 presents an algorithm for the evaluation of nonmassive hemoptysis. After a careful history and examination, a chest radiograph should be obtained Table 5 4 , The amount of blood produced can vary from a few streaks of blood mixed with normal sputum to large amounts of pure blood.

Other symptoms, such as fever and difficulty breathing, may be present, depending on the cause of hemoptysis. Although hemoptysis can be frightening, most causes turn out not to be serious. Blood-streaked sputum is common in many minor respiratory illnesses, such as upper respiratory infections URIs and viral bronchitis. Sometimes the cause is blood from the nose that has traveled down the throat and then is coughed up.

Such blood is not considered hemoptysis. Infection is the most common cause see table Some Causes and Features of Hemoptysis Some Causes and Features of Hemoptysis Coughing up blood from the respiratory tract is called hemoptysis. The amount of blood produced can vary from a few streaks of blood mixed with normal sputum to large amounts of pure blood Bronchitis Acute Bronchitis Acute bronchitis is inflammation of the windpipe trachea and the airways that branch off the trachea bronchi caused by infection.

Acute bronchitis is usually caused by a viral upper respiratory Bronchiectasis Bronchiectasis Bronchiectasis is an irreversible widening dilation of portions of the breathing tubes or airways bronchi resulting from damage to the airway wall. The most common cause is severe or repeated Pneumonia Overview of Pneumonia Pneumonia is an infection of the small air sacs of the lungs alveoli and the tissues around them.

Pneumonia is one of the most common causes of death worldwide. Often, pneumonia is the final Lung cancer Lung Cancer Lung cancer is the leading cause of cancer death in both men and women. One common symptom is a persistent cough or a change in the character However, cancer that has spread to the lungs from elsewhere in the body rarely causes hemoptysis. Fungal infection with Aspergillus called aspergillosis Aspergillosis Aspergillosis is an infection, usually of the lungs, caused by the fungus Aspergillus.

A ball of fungus fibers, blood clots, and white blood cells may form in the lungs or sinuses. People may Tuberculosis Tuberculosis TB Tuberculosis is a chronic contagious infection caused by the airborne bacteria Mycobacterium tuberculosis.

It usually affects the lungs. Tuberculosis is spread mainly when people breathe air Other causes include a blood clot in an artery in a lung pulmonary embolism Pulmonary Embolism PE Pulmonary embolism is the blocking of an artery of the lung pulmonary artery by a collection of solid material brought through the bloodstream embolus —usually a blood clot thrombus or People usually have difficulty breathing and may cough up blood The cause is unknown.

Heart failure and heart valve disorders can rarely cause mild hemoptysis. Massive hemoptysis is the production of more than about a pint about milliliters of blood within 24 hours.

Left ventricular failure causes shortness of breath and fatigue, and right ventricular failure causes peripheral and abdominal fluid Most thoracic aortic aneurysms do not cause symptoms, although some patients Exposure to TB is important, particularly in patients with HIV infection or another immunocompromised state. A history of frequent nosebleeds, easy bruising, or liver disease suggests possible coagulopathy.

The drug profile should be reviewed for use of anticoagulants and antiplatelet drugs. Vital signs are reviewed for fever, tachycardia, tachypnea, and low oxygen saturation.

Constitutional signs eg, cachexia and level of patient distress eg, accessory muscle use, pursed lip breathing, agitation, decreased level of consciousness should also be noted. A full lung examination is done, particularly including adequacy of air entry and exit, symmetry of breath sounds, and presence of crackles, rhonchi, stridor Stridor Stridor is a high-pitched, predominantly inspiratory sound. It is most commonly associated with acute disorders, such as foreign body aspiration, but can be due to more chronic disorders, such It is a symptom as well as a physical finding.

Prolonged expiratory Signs of consolidation eg, egophony, dullness to percussion should be sought. The cervical and supraclavicular areas should be inspected and palpated for lymphadenopathy suggesting cancer or TB. Neck veins should be inspected for distention, and the legs and presacral area should be palpated for pitting edema suggesting heart failure. Heart sounds should be auscultated with notation of any extra heart sounds or murmur that might support a diagnosis of heart failure and elevated pulmonary pressure.

The abdominal examination should focus on signs of hepatic congestion or masses, which could suggest either cancer or hematemesis from potential esophageal varices. The skin and mucous membranes should be examined for ecchymoses, petechiae, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa.

If the patient can reproduce hemoptysis during examination, the color and amount of blood should be noted. The history and physical examination often suggest a diagnosis and guide further testing see table Some Causes of Hemoptysis Some Causes of Hemoptysis Hemoptysis is coughing up of blood from the respiratory tract. Despite the many possibilities, some generalities can be made. A previously healthy person with a normal examination and no risk factors eg, for TB, pulmonary embolism who presents with acute-onset cough and fever most likely has hemoptysis due to an acute respiratory illness; chronic disorders are much lower on the list of possibilities.

However, if risk factors are present, those specific disorders must be strongly suspected. Clinical prediction can help estimate the risk of pulmonary embolism Pulmonary Embolism PE Pulmonary embolism PE is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. A normal oxygen saturation does not exclude pulmonary embolism.

Patients whose hemoptysis is due to a lung disorder eg, COPD, cystic fibrosis, bronchiectasis or heart disease eg, heart failure typically have a clear history of those disorders. Hemoptysis is not an initial manifestation.

Patients with symptoms or signs of chronic illness but no known disorders should be suspected of having cancer or TB, although hemoptysis can be the initial manifestation of lung cancer in a patient who is otherwise asymptomatic. Known renal failure or hematuria suggests a pulmonary-renal syndrome eg, Goodpasture syndrome, granulomatosis with polyangiitis.

Patients with hemoptysis due to a bleeding disorder usually have cutaneous findings petechiae, purpura, or both or a history of anticoagulant or antiplatelet drug use. Patients with massive hemoptysis require treatment and stabilization, usually in an intensive care unit, before testing. Patients with minor hemoptysis can undergo outpatient testing. Imaging is always done, typically chest x-ray, although sometimes eg, with known bronchiectasis CT is the initial test.