Haemoptysis 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. References Aetiology According to source of bleeding: Trachea or bronchus: o Malignancy o Bronchogenic carcinoma o Endobronchial metastatic tumour o Kaposi's sarcoma o Carcinoid tumour o Bronchitis o Bronchiectasis o Broncholithiasis o Airway trauma o Foreign body o o o o o o o o o o o o o o o o Lung parenchyma: Lung abscess Pneumonia - bacterial (egStaphylococcus aureus, Pseudomonas aeruginosa) or viral (eg influenza)* Tuberculosis (TB) Fungal infection and mycetoma Hydatid cysts Goodpasture's syndrome Pulmonary haemosiderosis Wegener's granulomatosis Lupus pneumonitis Lung contusion "Crack" lung Vascular: Arteriovenous malformation Aortic aneurysm Pulmonary embolism (PE) Mitral stenosis Other cause of pulmonary venous hypertension, eg left ventricular failure (LVF)
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Trauma Iatrogenic (eg chest drain malposition, secondary to pulmonary artery catheter manipulation) Other: Pulmonary endometriosis Congenital or acquired systemic coagulopathy, eg leukaemia Anticoagulant or thrombolytic agents Factitious haemoptysis

*If multiple cases of haemoptysis present concurrently, consider the use of biological weapons such as plague. 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
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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.

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

Investigations 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. o Imaging - CXR +/- CT scan. About 30% of patients with haemoptysis have normal CXRs. Look for: 1 Cavitations (eg TB, necrotising pneumonia).
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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.