Haemoptysis

Essentials

• Haemoptysis means coughing up blood that originates at a bleeding site somewhere along the respiratory tract.
• The amount of haemoptysis may vary from scant bloody streaks up to life-threatening massive bleeding.
• There are plenty of reasons for haemoptysis and the reason should always be unravelled.
• A young non-smoking patient with haemoptysis that is clearly associated with pneumonia and with a normalized follow-up chest x-ray does usually not require referral for further investigations.

Aetiology

Investigations and diagnosis

• Patient history, clinical examination and chest x-ray are essential.
• Find out whether the haemoptysis originates from the lungs or possibly from the oral, pharyngeal or nasal regions. Exclude bleeding coming from the gastrointestinal tract (history is usually sufficient for this).
• Other investigations
  • Basic blood count with platelets, CRP
  • INR when the patient is on warfarin
    • Investigations of bleeding tendency by other laboratory tests if indicated
  • Blood pressure, pulse oximetry
  • ECG
• If the chest x-ray reveals e.g. pneumonia or heart failure, treatment is directed at the primary cause and the resolving of the condition is assessed by chest x-rays and other clinical findings.
• If the chest x-ray suggests e.g. a tumour,further investigations are arranged accordingly (see Lung Cancer).
• If the chest x-ray is normal, CT scan and, as necessary, bronchoscopy are often performed to exclude significant underlying causes.
• It is often best to refer the patient to a hospital pulmonary unit for the further investigations.
  • Normal findings on chest x-ray do not exclude all causes of haemoptysis. The image does not reveal acute or chronic bronchitis, small intrabronchial neoplasms or foreign bodies, pulmonary embolism, pulmonary infarction, bronchiectasis nor all causes of cardiac origin.
  • A young non-smoking patient with haemoptysis that is clearly associated with pneumonia and with a normalized follow-up chest x-ray and general condition does usually not require referral for further investigations.

Treatment

• Directed at the primary cause
• Haemoptysis quite rarely is dangerously profuse and requiring immediate treatment. Scant haemoptysis usually resolves spontaneously.
• Discontinuation of medication that may provoke bleeding (ASA, anticoagulants etc.)
• Tranexamic acid is beneficial only if there is increased fibrinolysis in the background (malignancies, liver diseases).
• Angioradiological bronchial artery embolization procedures are indicated when there is significant haemoptysis and the bleeding point can be localized.
• Massive haemoptysis (more than 200 ml) may be life-threatening.
  • Securing the airway
  • Efforts should be made to locate the bleeding point (or at least the bleeding side).
  • There is danger of suffocation by the blood in the bronchial tree: place the patient in lateral recumbent position with the lung that is most probably bleeding directing downwards. Trendelenburg's position may reduce bleeding.
  • Supplemental oxygen
  • Blood must be suctioned from the airways. Suppression of intensive cough reflex can be attempted by administration of tranquillising antitussive drugs (codeine, morphine).
  • Correction of hypovolaemia, red blood cell transfusions if necessary
  • Refer the patient to the nearest hospital with readiness to angioradiological and thoracic surgical procedures.