Hemoptysis

Ralph Corey

Definition

Hemoptysis is the expectoration of blood or blood-tinged sputum from the lungs or tracheobronchial tree.

Technique

Hemoptysis is an important symptom that elicits fear in both the patient and physician. Work-up for this symptom should be undertaken immediately unless the problem is both mild and recurrent, in which case a conservative approach may sometimes be preferable.

A thorough history may help define not only the site but also the cause of bleeding. When evaluating hemoptysis, the first step is to convince yourself that the lower respiratory tract is the source of the bleeding. Coughing is important because nonpulmonary sources of bleeding are not usually associated with hemoptysis. Questions regarding epistaxis and spitting blood without coughing help rule out the upper respiratory tract as the source of bleeding, but do not replace a thorough nose and throat examination. Further, the physician must be convinced that the bleeding is not of gastrointestinal origin. A history of nausea, vomiting, heartburn, and abdominal pain may be helpful, but occasionally the differential diagnosis is difficult and requires either direct observation of the patient's hemoptysis or endoscopic evaluation of the upper gastrointestinal tract.

The physician should quantify the amount of bleeding that has taken place, being as specific as possible (e.g., a teaspoon, a cupful). Patients and physicians usually overestimate the amount of bleeding, so nothing can replace direct observation. The approximate rate of bleeding requires careful quantification. Because the rapidity and the extent of the work-up depend to a large degree on the above quantification, the importance of this aspect of the history cannot be overemphasized.

Note if this is the first episode of hemoptysis or whether it is a chronic and/or recurrent problem. The quantity of past bleeding and the extent of previous evaluations are quite helpful. Despite the fact that repeated evaluations for recurrent hemoptysis are often advocated by experts, such evaluations can be both expensive and unrewarding in many patients.

One should next investigate thoroughly the material being produced. Is the patient coughing up bright red blood or blood clots (as in carcinoma of the lung, tuberculosis, pulmonary embolism); blood-streaked, purulent sputum (as in bronchitis, bronchiectasis, or pneumonia); blood-tinged, white, frothy sputum (as in congestive heart failure); or foul-smelling, bloody sputum (as in an anaerobic lung abscess)? Red sputum that contains no blood is seen in a rare case of Serratia marcescens pneumonia with its red pigmentation, in glass sanders with sputum discolored by iron oxide, and in ruptured hepatic amebic liver abscess with its "anchovy paste" sputum. Rarely, a patient will present with pseudo-hemoptysis created artificially by various means.

Associated pulmonary symptoms such as chronic cough with sputum production, change in cough, shortness of breath on exertion, chest pain (especially of a pleuritic nature), and wheezing are also important in the evaluation of hemoptysis. The relation between these symptoms and the onset of hemoptysis can be quite helpful. For example, hemoptysis in lung cancer or tuberculosis usually is a late symptom preceded by weight loss, change in cough, fatigue, and other chronic symptoms.