Hemoptysis – A Clinical Lecture Note
Definition
Hemoptysis refers to the expectoration of blood originating from the lower respiratory tract below the vocal cords. It may vary from blood-streaked sputum to massive bleeding that can be life-threatening.
Classification of Hemoptysis
- Mild: <20 mL per 24 hours
- Moderate: 20–200 mL per 24 hours
- Massive: >200–600 mL per 24 hours (can cause airway obstruction and asphyxiation)
Differential Diagnosis
Always differentiate hemoptysis from:
- Epistaxis: Blood from the nose entering the oropharynx
- Hematemesis: Vomiting blood from GI tract (often with nausea, abdominal pain, and dark coffee-ground blood)
Common Causes of Hemoptysis
Infectious Causes:
- Tuberculosis
- Bronchiectasis
- Pneumonia (especially necrotizing)
- Lung abscess
- Fungal infections (e.g., Aspergilloma)
Neoplastic Causes:
- Bronchogenic carcinoma
- Metastatic lung tumors
Cardiovascular Causes:
- Mitral stenosis (pulmonary hypertension)
- Pulmonary embolism with infarction
- Arteriovenous malformations
Other Causes:
- Trauma (chest injury or iatrogenic)
- Coagulopathies
- Autoimmune disorders (e.g., Goodpasture’s syndrome, Wegener's granulomatosis)
- Idiopathic pulmonary hemosiderosis
Approach to History and Examination
Key points in history:
- Onset and frequency of bleeding
- Associated symptoms: cough, fever, weight loss, chest pain
- Past history: TB, smoking, lung diseases
- Drug use: anticoagulants, NSAIDs
Physical examination should include:
- Vital signs – shock, fever, tachypnea
- Chest auscultation – crepitations, bronchial breathing
- Signs of anemia or cyanosis
- Examine for clubbing, lymphadenopathy, or signs of systemic disease
Investigations
- CBC: Check anemia, leukocytosis
- Coagulation profile: PT/INR, aPTT
- Chest X-ray: First-line imaging
- HRCT Chest: For detecting bronchiectasis, masses, or cavitations
- Sputum AFB / Culture: For TB, infections
- Bronchoscopy: Especially useful in localized or unexplained bleeding
- CT Pulmonary Angiography: Suspected PE or AV malformations
Management
General Supportive Measures:
- Ensure airway protection – patient in lateral decubitus (bleeding side down)
- Oxygen supplementation
- IV fluids or blood transfusion if needed
- Correction of coagulopathy
Specific Treatment:
- Antibiotics: If infection suspected (e.g., TB or pneumonia)
- Antitubercular therapy: In diagnosed TB cases
- Bronchial artery embolization (BAE): For massive or recurrent bleeding
- Surgery: Reserved for cases like aspergilloma, cancer, or when BAE fails
Prognosis
Depends on the underlying cause. Recurrent or massive hemoptysis requires aggressive diagnostic and therapeutic intervention. Tuberculosis remains a leading cause of hemoptysis in many countries.
Clinical Pearls
- In elderly patients, always rule out malignancy.
- Never ignore small or intermittent hemoptysis — early investigation can be life-saving.
- Massive hemoptysis is a medical emergency requiring multidisciplinary intervention.
Lecture prepared by: MediTalk | For appointments and guidance: 01644254845
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