Neeraj Jain, Vibha Mangal, Vibhu Kabatra.
Department of Pediatrics, HIMS Jolly Grant, Rishikesh, India.
ADDRESS FOR CORRESPONDENCE
Neeraj Jain , 77 SBM Complex, Rishikesh- 249201 India.
Email: neerajjain@vsnl.net | Definition:
Hemoptysis is defined as the spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage. (1) The lungs receive blood from the pulmonary and bronchial arterial systems. (2) The low-pressure pulmonary system tends to produce small-volume hemoptysis whereas bleeding from the bronchial system which is at systemic pressure tends to be profuse. (2)
Types of hemoptysis:
- Frank hemoptysis: it is expectoration of blood only.
- Spurious hemoptysis: hemoptysis is present secondary to upper respiratory tract infection above level of larynx.
- Pseudo-hemoptysis: It is due to pigment prodigiosin produced by gram negative organism such as serratia marcescens.
- Endemic hemoptysis: present in infection with paragonimus westermani.
After confirming the presence of blood, an initial task is differentiating between hemoptysis, pseudohemoptysis (i.e. the spitting of blood that does not come from the lungs or bronchial tubes) and hematemesis (i.e. the vomiting of blood).
Table 1: Differentiating Features of Hemoptysis and Hematemesis (2-4):
| | Hemoptysis | Hematemesis | History | Absence of nausea and vomiting | Presence of nausea and vomiting | Lung disease | Gastric or hepatic disease | Asphyxia possible | Asphyxia unusual | Sputum examination | Frothy | Rarely frothy | Liquid or clotted appearance | Coffee ground appearance | Bright red or pink | Brown to black | Laboratory | Alkaline pH | Acidic pH | Mixed with macrophages and neutrophils | Mixed with food particles |
Causes of hemoptysis (5):
- Infection
- Tracheobronchitis
- Pneumonia
- Bacterial (Staphylococcus aureus, Pseudomonas aeruginosa)
- Tuberculosis
- Fungal organisms (e.g. Aspergillosis)
- Influenza
- Parasitic (e.g. echinococcosis)
- Tracheostomy related
- Bronchiectasis
- Cystic fibrosis
- Ciliary dyskinesia
- Immunodeficiency
- Foreign body
- Congenital heart disease (mainly with pulmonary vascular obstructive diseases)
- Pulmonary AV malformations
- Trauma
- Alveolar hemorrhage syndromes
- Connective tissue disease/vasculitis (e.g. Goodpasture syndrome, Wegener's granuloma)
- Primary pulmonary hemosiderosis (e.g. Idiopathic Heiner syndrome)
- Pulmonary thromboembolism
- Tumour
- Bronchial adenoma
- Metastatic
Diagnosis:
Patient History
Historic clues are useful for differentiating hemoptysis from hematemesis. Patient history also can help identify the anatomic site of bleeding, differentiate between hemoptysis and pseudohemoptysis and narrow the differential diagnosis. Factors such as age, nutrition status, and comorbid conditions can assist in the diagnosis and management of hemoptysis.
Table 2: Diagnostic Clues in Hemoptysis:
Physical History | Suggested diagnosis | Anticoagulant use | Medication effect, coagulation disorder | Association with menses | Catamenial hemoptysis | Dyspnea on exertion, fatigue, nocturnal dyspnea, frothy pink sputum | Congestive heart failure, left ventricular orthopnea, paroxysmal dysfunction, mitral valve stenosis | Fever, productive cough | Upper respiratory infection, acute sinusitis, acute bronchitis, pneumonia, lung abscess | History of chronic lung disease | Bronchiectasis, lung abscess | Recurrent lower respiratory track infection, cough with copious purulent sputum | HIV, immunosuppression, Neoplasia, tuberculosis, Kaposi's sarcoma | Nausea, vomiting, malena | Gastritis, gastric or peptic ulcer, chronic use of nonsteroidal anti-inflammatory drugs, esophageal varices | Pleuritic chest pain, calf tenderness | Pulmonary embolism or infarction | Travel history | Tuberculosis, parasites (eg., paragonimiasis, schistosomiasis, amebiasis, leptospirosis), biologic agents (eg. plague, tularemia, T2 mycotoxin) |
Once true hemoptysis is suspected, the investigation should focus on the respiratory system. Blood from the lower bronchial tree typically induces cough, whereas a history of epistaxis or expectorating without cough would be consistent with an upper respiratory source but does not exclude a lower tract site.
Bleeding is difficult to quantify clinically. Patients may find it difficult to discern whether they are throwing up, coughing or spitting out bloody material. The amount of blood loss usually is overestimated by patients and physicians but an attempt to determine the volume and rate of blood loss should be made. Methods of determination include observing as the patient coughs and the use of a graduated container. Blood-streaked sputum deserves the same diagnostic consideration as blood alone. It is helpful to determine whether there have been previous episodes of hemoptysis and what diagnostic assessments have been done. Low-risk patients with normal chest radiographs can be treated on an outpatient basis with close monitoring and appropriate oral antibiotics, if medication is clinically indicated. Bronchial adenomas, although malignant, are slow growing and may present with occasional bleeding over many years. A history of chronic, purulent sputum production and frequent pneumonias, including tuberculosis may represent bronchiectasis. Association of hemoptysis with menses (i.e., catamenial hemoptysis) may represent intrathoracic endometriosis. (6) A travel history may be helpful. Tuberculosis is endemic in many parts of the world, and parasitic etiologies should be considered. (7,8). In regions where drinking from springs is common, there are case reports of hemoptysis caused by leeches attaching to the upper respiratory tract mucosa. (9) Also, biologic weapons such as plague may cause hemoptysis. (3,10).
Physical Examination
Historic clues often will narrow the differential diagnosis and help focus the physical examination (2,3,5). Examining the expectoration may help localize the source of bleeding.(2,3,4) The physician should record vital signs including pulse oximetry levels to document fever, tachycardia, tachypnea, weight changes, and hypoxia. Constitutional signs such as cachexia and level of patient distress also should be noted. The skin and mucous membranes should be inspected for CYANOSIS, pallor, ecchymoses, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa. The examination for lymph node enlargement should include the neck, supraclavicular region, and axillae. The cardiovascular examination includes an evaluation for jugular venous distention, abnormal heart sounds, and edema. The physician should check the chest and lungs for signs of consolidation, wheezing, rales, and trauma. The abdominal examination should focus on signs of hepatic congestion or masses, with an inspection of the extremities for signs of edema, cyanosis, or clubbing. (2, 11).
Table 3: Clinical Clues to Diagnosis:
Clinical clues | Suggested diagnosis | Cachexia, clubbing, voice hoarseness | primary lung cancers | hyperpigmentation | Cushing's syndrome, Horner's syndrome | Clubbing | bronchiectasis, lung abscess, severe chronic lung disease | Dullness to percussion, fever, unilateral rales | Pneumonia | Facial tenderness, fever | Acute upper respiratory infection | Acute mucopurulent nasal discharge, postnasal drainage | Sinusitis | Gingival thickening | Wegener's granulomatosis | Gingivitis, saddle nose | Nasal septum perforation | Heart murmur, pectus excavatum | Mitral valve stenosis | Lymph node enlargement, cachexia, violaceous tumors on skin | Kaposi's sarcoma | Orofacial and mucous membrane, telangiectasia, epistaxis | Osler-Weber-Rendu disease | Tachycardia, tachypnea, hypoxia, jugulovenous distention, S3 gallop, decreased lung sounds, bilateral rales, dullness to percussion in lower lung fields | Congestive heart failure caused by left ventricular dysfunction or severe mitral valve stenosis | Tachypnea, tachycardia, dyspnea, fixed split S2, pleural friction rub, unilateral leg pain and edema | Pulmonary thromboembolic disease | Tympani to percussion over lung apices, cachexia | Tuberculosis |
Diagnostic Evaluation: After a careful history and examination, a chest radiograph should be obtained. If a diagnosis remains unclear, further imaging with chest Computed tomography (CT) or direct visualization with bronchoscopy often is indicated.
Table 4: Diagnostic Clues in Hemoptysis by Chest Radiograph (2,3):
Chest radiograph finding | Diagnosis | Cardiomegaly, increased pulmonary vascular distribution | Chronic heart failure, mitral valve stenosis | Cavitary lesions | Lung abscess, tuberculosis | Diffuse alveolar infiltrates | Chronic heart failure, pulmonary edema, aspiration, toxic injury | Hilar adenopathy or mass | infectious process, sarcoid | Lobar or segmental infiltrates | Pneumonia, thromboembolism, obstructing carcinoma | Mass lesion, nodules, granulomas | Wegener's granulomatosis, septic embolism, vasculitides | Normal or no change from baseline | upper respiratory infection, sinusitis, pulmonary embolism | Patchy alveolar infiltrates (multiple bleeding sites) | Bleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture's syndrome |
Diagnosing Non-massive Hemoptysis: Fiber-optic bronchoscopy is mainly for diagnostic purpose as it permits tissue biopsy, bronchial lavage, or brushings for pathologic diagnosis. Fiber-optic bronchoscopy also can provide direct therapy in cases of continued bleeding. Rigid bronchoscopy is the preferred tool for cases of massive bleeding because of its greater suctioning and airway maintenance capabilities. High-resolution CT has become increasingly useful in the initial evaluation of hemoptysis and is preferred if parenchymal disease is suspected. Its complementary use with bronchoscopy gives a greater positive yield of pathology. (12-14) Its role in hemoptysis continues to evolve, and further studies are needed to evaluate its effect on patient management and outcome. Patients with recurrent or unexplained hemoptysis may need additional laboratory evaluation to establish a diagnosis (3,5).
Table 5: Diagnostic Clues in Hemoptysis: Laboratory Tests:
Test | Diagnostic findings | White blood cell count and differential | Elevated cell count and differential shifts may be present in upper and lower respiratory tract infections | Hemoglobin, hematocrit | Decreased in anemia | Platelet count | Decreased in Thrombocytopenia | Prothrombin time, International Normalized Ratio, partial thromboplastin time | Increased in anticoagulant use, disorders of coagulation | Arterial blood gases | Hypoxia, hypercarbia | d-dimer | Elevated in pulmonary embolism | Sputum Gram stain, culture | Pneumonia, lung abscess | Acid-fast bacillus smear and culture | Tuberculosis, mycobacterial infections | Purified protein derivative skin test | Positive increases risk for tuberculosis | Human immunodeficiency virus test | Positive increases risk for tuberculosis, Kaposi's sarcoma | Erythrocyte sedimentation rate | Elevated in infection, Autoimmune Disorders(e.g., Wegener's syndrome, systemic lupus erythematosus, sarcoid, Goodpasture's syndrome) |
| | | | Compliance with Ethical Standards | | Funding None | | | | Conflict of Interest None | | |
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| Cite this article as: | | Jain N, Mangal V, Kabatra V. Approach in case of Hemoptysis. Pediatr Oncall J. 2009;6: 38-40. |
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