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CHAPTER 59: Massive Hemoptysis

Niral Mukund Patel; Ali Musani; Richard K. Albert

KEY POINTS

KEY POINTS

  • Ensure proper oxygenation and secure the patient’s airway if necessary.

  • Correct coagulation abnormalities.

  • Localize bleeding with bronchoscopy (unstable patient) or CT scan (stable patient) and position the bleeding site in a dependent position.

  • In unstable, hypoxemic patients, consider urgent bronchoscopy for suctioning, endobronchial hemostatic therapy, and balloon tamponade, utilizing local Interventional Pulmonology experts and resources if available.

  • Interventional radiology-guided bronchial artery embolization is effective and should be performed after initial stabilization.

  • Surgery is required in rare circumstances.

INTRODUCTION

Hemoptysis, or the expectoration of blood, can result from a wide variety of illnesses (Table 59-1). The prevalence of these different etiologies depends on the characteristics of the specific patient population studied. For example, tuberculosis is the most common cause of hemoptysis in underdeveloped countries, while bronchiectasis is the most common cause in the industrialized world.1,2

TABLE 59-1Causes of Massive Hemoptysis and Pulmonary Hemorrhage
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TABLE 59-1 Causes of Massive Hemoptysis and Pulmonary Hemorrhage

Localized Bleeding

Infections

Mycobacteria (TB most common)

Necrotizing bacterial pneumonia (particularly Klebsiella and Staphylococcus aureus)

Lung abscess

Mycetoma (Aspergillus most common)

Bronchiectasis (eg, cystic fibrosis or immune deficiencies)

Parasites (hydatid cyst, paragonimiasis)

Leptospirosis

Endocarditis

Tumors

Bronchogenic carcinoma (ie, squamous cell)

Pulmonary metastatic disease

Bronchial adenoma

Sarcoma

Pulmonary vascular problems

Pulmonary arteriovenous malformations (eg, Rendu-Osler-Weber syndrome)

Pulmonary embolus with infarction

Pulmonary aneurysm (eg, Behçet syndrome)

Dieulafoy lesion

Mitral stenosis

Coagulopathy (usually requires coexisting mucosal disruption)

Thrombocytopenia or platelet dysfunction (eg, von Willebrand disease, uremia)

Hemophilia A or B

Prolonged coagulation tests (due to coagulation factor production or consumption defect)

Trauma

Iatrogenic

Biopsies

Lung transplant

Atrial fibrillation ablation (cryotherapy or radiofrequency)

Thoracic surgery

Airway/Vascular stent erosion

Brachytherapy

Pulmonary artery catheterization with pulmonary arterial rupture

Tracheoinominate fistula (rare complication of tracheostomy)

Miscellaneous

Lymphangioleiomyomatosis

Catamenial (endometriosis)

Cryptogenic

Broncholithiasis

Sarcoidosis (usually from cavitary lesions with mycetoma)

Tracheoinominate fistula

Bronchiectasis (anatomic abnormalities)

Chronic obstructive pulmonary disease

Foreign body aspiration

Blast lung injury

Fibrosing mediastinitis

Amyloidosis

Diffuse Bleeding

Capillaritis (seen on biopsy)

Drug- and chemical-induced (propylthiouracil, phenytoin, retinoic acid)

Connective tissue diseases (ie, systemic lupus erythematosus, rheumatoid arthritis, mixed connective tissue disease, systemic sclerosis, antiphospholipid antibody syndrome, polymyositis)

Systemic vasculitides (Behçet, cryoglobulinemia, IgA nephropathy, microscopic polyangiitis, granulomatous vasculitis, pauci-immune, Henoch-Schonlein purpura)

Bland hemorrhage (seen on biopsy)

Connective tissue diseases (ie, systemic lupus erythematosus, Goodpasture syndrome)

Drugs (anticoagulant and antiplatelet therapy-glycoprotein IIa/IIIb inhibitors)

Other (pulmonary veno-occlusive disease, mitral stenosis, idiopathic pulmonary hemosiderosis)

Diffuse alveolar damage with bleeding (seen only on biopsy)

Infection (any infection that can cause ARDS)

Drugs (amiodarone, crack cocaine, nitrofurantoin, penicillamine, sirolimus, most cytotoxic drugs)

Connective tissue diseases (systemic lupus erythematosus, rheumatoid arthritis, polymyositis)

Other (pulmonary capillary hemangiomatosis, pulmonary infarct, ARDS of any cause)

Massive hemoptysis has been variably defined as production of more than 100 to 1000 mL of blood in 24 hours, depending on the study.3,4 However, estimating the amount ...

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