Haemoptysis

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Haemoptysis is the coughing of blood originating from the respiratory tract below the level of the larynx. Haemoptysis should be differentiated from:

  • Haematemesis - vomiting of blood from the gastrointestinal (GI) tract.
  • Pseudohaemoptysis - where a cough reflex is stimulated by blood not derived from the lungs or bronchial tubes. This may be from the oral cavity or nasopharynx (eg following an epistaxis) or following aspiration of haematemesis into the lungs.

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 that 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 that from the bronchial system, which is at systemic pressure, tends to be more profuse.

According to source of bleeding:[1][2] *If multiple cases of haemoptysis present concurrently, consider the use of biological weapons such as plague.[3]

Despite haemoptysis being regarded as an 'alarm' symptom, no identifiable cause is found in a significant number of patients and these are termed idiopathic haemoptysis. In a British study, only approximately a quarter had received a diagnosis (malignant or benign) at 3 months following presentation in primary care and, after 3 years' follow-up, just under a half remained without a diagnosis for their haemoptysis.[4]

Haemoptysis is rare in children and often only presents where bleeding is substantial, as children tend to swallow rather than expectorate their sputum. Respiratory tract infection is the most common cause. Foreign body inhalation ranks second (particularly with younger children) and congenital heart disease and bronchiectasis secondary to cystic fibrosis are other important causes.[5]

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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 the past, tuberculosis (TB) was a major cause but in the UK today, the majority of cases of haemoptysis presenting to primary care are due to acute upper and lower respiratory tract infections, with lung cancer a much smaller but significant cause.[4] In another 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 pulmonary embolism (PE). However, research suggests 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.

Haemoptysis or haematemesis?
Haemoptysis Haematemesis
No nausea or vomiting Nausea and vomiting
Concurrent lung disease Concurrent gastric or hepatic disease
Sputum is frothy Vomitus is rarely frothy
Sputum has a liquid or clotted appearance Typical coffee ground appearance
Haemoptysis is bright red or pink Haematemesis is brown to black
Alkaline pH Acidic pH
Mixed with macrophages and neutrophils Mixed with food particles

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:

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.

  • Inspect the nasal cavity and oropharynx for:
    • Extrapulmonary causes (pseudohaemoptysis)
    • Signs of vasculitis
    Gingival thickening, mulberry gingivitis, saddle nose, and nasal perforation suggest Wegener's granulomatosis. Orofacial and mucous membrane telangiectasia are associated with Osler-Weber-Rendu syndrome.
  • Perform a cardiovascular examination. Significant signs may include:
  • Lung signs that may be found with haemoptysis include:
    • Fine inspiratory rales (associated with alveolar blood).
    • Inspiratory and expiratory rhonchi (associated with airway secretions and blood).
    Look for evidence of an exacerbations of chronic obstructive pulmonary disease or lower respiratory tract infection. Unilateral wheeze and distal consolidation raise the suspicion of endobronchial tumour. Unilateral wheeze or stridor may also indicate the presence of a foreign body. With apical dullness and cachexia, TB should be considered.
  • Digital clubbing can reflect chronic lung disease (lung cancer, bronchiectasis, lung abscess).
  • Supraclavicular lymphadenopathy, cachexia, hoarse voice, Cushing's syndrome, hyperpigmentation, and Horner's syndrome are all associated with malignancy.
  • Dependent on the clinical setting but these may include: FBC, ESR, U&Es, coagulation studies, urinalysis, arterial blood gases, sputum cytology and culture, acid-fast bacillus (AFB) smear and culture, D-dimer testing, and HIV test.
  • Imaging - CXR +/- CT scan. About 30% of patients with haemoptysis have normal CXRs. Look for:[1]
    • Cavitations (eg TB, necrotising pneumonia).
    • Segmental or lobar atelectasis (obstructions due to lung cancer, bronchial adenoma, foreign body).
    • Left atrial enlargement, Kerley 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.
  • Electrocardiogram (ECG) +/-echocardiogram (ECHO) - if a cardiac cause or PE is suspected.

Treatment is according to the underlying cause. For management of a PE, see separate article Pulmonary Embolism.

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.
    • There are recurrent episodes of haemoptysis.
    • The volume of haemoptysis is >30 ml per day.
    • The patient is a smoker and >40 years old.
    • There is suspected bronchiectasis.
All smokers or ex-smokers aged >40 years with persistent haemoptysis should urgently be referred to a chest physician under the two-week wait rules.[8]

Moderate haemoptysis

Moderate haemoptysis (30-50 ml in the previous 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 is 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 or, alternatively, the use of a double lumen tube should be considered. 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.[9] Correct any clotting abnormalities. The patient will require admission to intensive care.
  • Localisation of the bleeding site via radiology and early bronchoscopy. 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.
  • Specific therapies to control bleeding:
    • Bronchoscopic therapy:
      • Iced saline lavage.
      • Topical agents, eg use of thrombin or fibrinogen-thrombin glue.
      • Endobronchial balloon catheter tamponade.
      • Laser photocoagulation.
    • Angiography and embolisation - bronchial artery embolisation is an important technique, developed from the care of patients with cystic fibrosis (CF), who were not candidates for surgery. It may be used as definitive treatment or a bridge to surgery. Major complications are now rare, the most feared being spinal cord infarction. Initial control of bleeding is achieved in over 90% of CF patients, although recurrent bleeding occurs in 22-46%.[9]
    • Surgical resection:
      • Segmentectomy
      • Lobectomy
      • Pneumonectomy
      Under emergency conditions, surgery is difficult, has a high risk of septic complications and a significant mortality rate.
    • Radiotherapy - may be used to treat aspergillomas and vascular tumours.
    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[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.[11] 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 of fear in the patient and supporting witnesses and family:

  • Nurse lying on the side of the tumour.
  • Administer parenteral opioid and fast-acting benzodiazepine.
  • Mask blood with red or green towels.

In some, the likelihood of such a bleed can be predicted (based on the 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, eg tranexamic acid.
  • Cough suppression.
  • Anticoagulation (where PE).
  • Antibiotics (where infection).
  • Radiotherapy or laser treatment of the tumour site.

Approximately three-quarters of lung cancer patients with haemoptysis reported an improvement following palliative radiotherapy.[12]

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.[13]

Further reading & references

  1. Johnson JL; Manifestations of hemoptysis. How to manage minor, moderate, and massive bleeding. Postgrad Med. 2002 Oct;112(4):101-6, 108-9, 113.
  2. Bidwell JL, Pachner RW; Hemoptysis: diagnosis and management. Am Fam Physician. 2005 Oct 1;72(7):1253-60.
  3. Inglesby TV, Dennis DT, Henderson DA, et al; Plague as a biological weapon: medical and public health management. Working Group on Civilian Biodefense. JAMA. 2000 May 3;283(17):2281-90.
  4. Jones R, Charlton J, Latinovic R, et al; Alarm symptoms and identification of non-cancer diagnoses in primary care: cohort BMJ. 2009 Aug 13;339:b3094. doi: 10.1136/bmj.b3094.
  5. Batra PS, Holinger LD; Etiology and management of pediatric hemoptysis. Arch Otolaryngol Head Neck Surg. 2001 Apr;127(4):377-82.
  6. Jones R, Latinovic R, Charlton J, et al; Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ. 2007 May 19;334(7602):1040. Epub 2007 May 10.
  7. West J, Goodacre S, Sampson F; The value of clinical features in the diagnosis of acute pulmonary embolism: systematic review and meta-analysis. QJM. 2007 Dec;100(12):763-9.
  8. Referral for suspected cancer; NICE Clinical Guideline (2005)
  9. Ashleigh RJ, Webb AK; Radiological intervention for haemoptysis in cystic fibrosis. J R Soc Med. 2007;100 Suppl 47:38-45.
  10. Davis CL; ABC of palliative care. Breathlessness, cough, and other respiratory problems. BMJ. 1997 Oct 11;315(7113):931-4.
  11. Kvale PA, Selecky PA, Prakash UB; Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007 Sep;132(3 Suppl):368S-403S.
  12. Samant R, Gooi AC; Radiotherapy basics for family physicians. Potent tool for symptom relief. Can Fam Physician. 2005 Nov;51:1496-501.
  13. Ozgul MA, Turna A, Yildiz P, et al; Risk factors and recurrence patterns in 203 patients with hemoptysis. Tuberk Toraks. 2006;54(3):243-8.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Chloe Borton
Current Version:
Last Checked:
26/10/2010
Document ID:
2223 (v22)
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