Haemoptysis

Haemoptysis is the spitting of blood originating from the respiratory tract below the level of the larynx. Haemoptysis should be differentiated from pseudohaemoptysis (spitting of blood not derived from the lungs or bronchial tubes, usually from the nasopharynx) or haematemesis.
Classifications of severity vary: massive haemoptysis has been arbitrarily defined as a loss of between 100-600 ml blood over 24 hours.¹ Massive haemoptysis is a life-threatening medical emergency. The risk of asphyxiation is greater than of exsanguination. Blood loss volume is more useful in guiding management than determining diagnosis although bleeding from the low pressure, pulmonary system tends to be small volume whilst those from the bronchial system, which is at systemic pressure, tends to be more profuse.

Incidence

Haemoptysis is common. In most cases, it is mild, self-limiting and related to transitory infection but it should be considered a serious sign due to the risk of underlying pathology. The relative contribution of different causes depends on the local population. In a Turkish study, bronchiectasis accounted for 22% adult cases, lung cancer for 19% and TB for 22%.⁵ In a UK primary care study, haemoptysis had a 7.5% positive predictive value for lung cancer in men and 4.3% in women, rising to 17.1% in men aged between 75-84 years.⁶ Haemoptysis has been considered a useful clinical sign of PE. However, research suggest that it has limited diagnostic value alone (likelihood ratio 1.62) and, in isolation, only slightly raises the probability of a PE.⁷

Risk factors

• Male>female
• Middle to older age (>40 years increases the risk of a malignant cause)

Patients may find it hard to identify the origin of their bleeding.

Symptoms

• Abrupt onset cough, fever with bloody and purulent sputum - suggestive of acute pneumonia or bronchitis
• Chronic productive cough - suggestive of chronic bronchitis or bronchiectasis.
• Fevers, night sweats and weight loss - consider TB and other infections or malignancy.
• Anorexia, weight loss and changing cough - think of possible bronchogenic carcinoma.
• Dyspnoea, fatigue, orthopnea, paroxysmal nocturnal dyspnoea, frothy pink sputum - suggestive of congestive heart failure.
• Anxiety, dyspnoea and pleuritic chest pain - consider a PE.

Always enquire about:

• Tobacco use
• Travel history
• Weight loss
• Occupational history - particularly exposure to asbestos, arsenic, chromium, nickel and ethers

Signs

Record vital signs, including oxygen saturation levels. Fever, tachycardia, tachypnoea, weight loss and hypoxia are all relevant. Check for cachexia, cyanosis, pallor, ecchymoses, telangiectasia and lymphadenopathy.
In particular:

• Nasal cavity and oropharynx for extrapulmonary causes (pseudo-haemoptysis) and signs of vasculitis. Gingival thickening, mulberry gingivitis, saddle nose, nasal perforation suggest Wegener's granulomatosis. Orofacial and mucous membrane telangiectasia are associated with Osler-Weber-Rendu disease.
• Perform a cardiovascular examination looking for the diastolic murmur of mitral stenosis or signs of left ventricular failure.
• Tachypnoea, tachycardia, fixed split S2, pleural rub, and unilateral leg pain or swelling may indicate thromboembolic disease.
• Lungs – fine inspiratory rales (associated with alveolar blood) or inspiratory and expiratory rhonchi (associated with airway secretions and blood) and wheezing from bronchial narrowing can be found with haemoptysis. Apical dullness and cachexia can indicate TB. Look for exacerbations of COPD or evidence of a lower respiratory tract infection.
• Digital clubbing can reflect chronic lung disease (lung cancer, bronchiectasis, lung abscess)
• Supraclavicular lymphadenopathy, cachexia, hoarse voice, Cushing's syndrome, hyperpigmentation, Horner's syndrome are all associated with malignancy.

• Dependant on clinical setting but may include: FBC, ESR, U&E's, coagulation studies, urinalysis, arterial blood gases, sputum cytology and culture, AFB smear and culture, D-dimers, HIV test. Those with massive haemoptysis or at significant risk (due to TB, mycetoma or bronchiectasis) require IV access, oxygen, typing and cross matching blood.
• Imaging - CXR +/- CT. About 30% of patients with haemoptysis have normal CXRs. Look for:¹
  • Cavitations (e.g. TB, necrotising pneumonia)
  • Segmental or lobar atelectasis (obstructions due to lung cancer, bronchial adenoma, foreign body)
  • Left atrial enlargement, Kerley's B lines (mitral stenosis)
  • Thickened bronchial walls (bronchiectasis)
  • Lymphadenopathy
  • Infiltrates
• Fibreoptic bronchoscopy enables direct visualisation and is required where there is a mass on CXR, there are risk factors for cancer despite normal CXR, or where diagnosis remains open, particularly in instances of recurrent haemoptysis.

Treatment is according to underlying cause.

Minor haemoptysis

Effort should be concentrated on determining the origin of the haemoptysis, providing specific treatment where available and excluding serious underlying pathology.

• Normal CXR, history consistent with bronchitis - oral antibiotic, advise smoking cessation and follow-up in a few weeks.
• Consider Chest CT scan and bronchoscopy where:
  • Haemoptysis lasts longer than 2 weeks
  • Recurrent episodes of haemoptysis
  • Volume of haemoptysis is >30 ml per day
  • Patient is a smoker and >40 years old
  • Suspected bronchiectasis

Moderate haemoptysis

Moderate haemoptysis (30-50 ml in last 24 hours) requires hospitalisation for observation, due to increased risk of further heavy bleeding.

• Nurse in the semi-sitting position when awake and with abnormal lung down when lying in bed.
• Consider cough suppression with codeine but avoid oversedation.
• Await bronchoscopy - diagnostic yield often highest when performed a few days after bleeding has stopped.

Major haemoptysis

This is a medical emergency. However, there are few large, good quality, controlled trials looking at best management to guide practice - particularly in the medical versus surgical dilemma.

• Resuscitate according to 'ABC' principles. Intubate where there are signs of acute respiratory failure. Selective intubation of the right or left main bronchus with a large single-lumen endotracheal tube is usually preferred. Maintain oxygenation saturations with high flow oxygen and suction. Obtain IV access and give fluids/blood transfusion as appropriate. Octreotide and other vasopressor drugs are sometimes used to control acute life-threatening bleeding.⁸ Correct any clotting abnormalities.
• The patient will require admission to intensive care and team care (e.g. respiratory physician, anaesthetist, cardiothoracic surgeon, interventional radiologist).
• Where bleeding continues unabated, bronchoscopy should be undertaken without delay since localisation of the bleeding site is necessary to further management and CXR and even CT scanning may not be helpful (due to the presence of aspirated blood). The use of rigid or flexible fibreoptic bronchoscopy remains controversial and tends to depend on local preference and expertise. Endobronchial control of bleeding can be attempted using techniques such as balloon catheter tamponade, use of thrombin or fibrinogen-thrombin glue and iced saline lavage.
• Bronchial artery embolisation is an important technique, developed from the care of patients with cystic fibrosis (CF), who were not candidates for surgery. Major complications are now rare, the most feared of which is spinal cord infarction. Initial control of bleeding is achieved in over 90% of CF patients, although recurrent bleeding occurs in 22-46%.⁸
• Surgery - segmentectomy, lobectomy or pneumonectomy may be resorted to inorder to control massive haemoptysis. Under emergency conditions, surgery is difficult, has a high risk of septic complications and a significant mortality rate.
• Individualise decisions based on the rate of haemoptysis, the suspected source of bleeding and whether or not the patient is a good candidate for surgery (localised bleeding source, adequate lung function, reasonable prognoses for other underlying medical conditions)

Palliative care^9,10

Haemoptysis is the presenting complaint in 7-10% of lung cancers and about 20-30% patients with lung cancer will experience it over the course of their illness. In 3%, massive haemoptysis is the terminal event. Management of haemoptysis in the context of a malignant disease depends on the volume of blood loss, its cause (bleeding may not be related to tumour progression, thromboembolic disease or infection may also cause it) and prognosis. Given the bleak prognosis of a massive haemoptysis, active resuscitation may not be desired or appropriate. Under these circumstances, the emphasis should be on the relief of pain and fear in the patient and supporting witnesses and family:

• Nurse lying on the side of the tumour.
• Administer parenteral opioid and fast-acting benzodiazepine (intravenously where there is peripheral shutdown).
• Mask blood with red or green towels.

In some, the likelihood of such a bleed can be predicted (based on tumour site, earlier bleeds etc.) and it may be appropriate to discuss and plan for such an eventuality with the patient and their family. Where active treatment is desired, management of a major bleed is as above.
With more minor haemoptysis, additional palliative care measures may include:

• Oral haemostatics e.g. tranexamic acid
• Cough suppression
• Anticoagulation (where PE)
• Antibiotics (where infection)
• Radiotherapy or laser treatment of tumour site

Haemoptysis may be a mild, self-limiting symptom or may herald serious underlying disease. Massive haemoptysis can directly cause death and has a bad prognosis, worse in some groups such as those with an underlying cancer.
Risk of recurrence is associated with haemoptysis lasting more than five days and with a concurrent lung cancer diagnosis.¹¹