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Symptoms and Signs – Differential Diagnosis of Hemoptysis
Frightening to the patient and commonly ominous, hemoptysis is the expectoration of blood or bloody sputum from the lungs or tracheobronchial tree. It’s sometimes confused with bleeding from the mouth, throat, nasopharynx, or GI tract. (See Identifying Hemoptysis.) Expectoration of 200 mL of blood in a single episode suggests severe bleeding, whereas expectoration of 400 mL in 3 hours or more than 600 mL in 16 hours signals a life-threatening crisis.
Hemoptysis usually results from chronic bronchitis, lung cancer, or bronchiectasis. However, it may also result from inflammatory, infectious, cardiovascular, or coagulation disorders and, rarely, from a ruptured aortic aneurysm. In up to 15% of patients, the cause is unknown. The most common causes of massive hemoptysis are lung cancer, bronchiectasis, active tuberculosis (TB), and cavitary pulmonary disease from necrotic infections or TB.
EXAMINATION TIP Identifying Hemoptysis
These guidelines will help you distinguish hemoptysis from epistaxis, hematemesis, and brown, red, or pink sputum.
HEMOPTYSIS
Typically frothy because it's mixed with air, hemoptysis is typically bright red with an alkaline pH (tested with nitrazine paper). It's strongly suggested by the presence of respiratory signs and symptoms, including a cough, a tickling sensation in the throat, and blood produced from repeated coughing episodes. (You can rule out epistaxis because the patient's nasal passages and posterior pharynx are usually clear.)
HEMATEMESIS
The usual site of hematemesis is the GI tract; the patient vomits or regurgitates coffee-ground material that contains food particles, tests positive for occult blood, and has an acid pH. However, he may vomit bright red blood or swallowed blood from the oral cavity and nasopharynx. After an episode of hematemesis, the patient may have stools with traces of blood and may also complain of dyspepsia.
BROWN, RED, OR PINK SPUTUM
Brown, red, or pink sputum can result from oxidation of inhaled bronchodilators. Sputum that looks like old blood may result from rupture of an amebic abscess into the bronchus. Red or brown sputum may occur in a patient with pneumonia caused by the enterobacterium Serratia marcescens.
Several pathophysiologic processes can cause hemoptysis. (See What Happens in Hemoptysis.)
EMERGENCY INTERVENTIONS
If the patient coughs up copious amounts of blood, endotracheal intubation may be required. Suction frequently to remove blood. Lavage may be necessary to loosen tenacious secretions or clots. Massive hemoptysis can
cause airway obstruction and asphyxiation. Insert an I.V. line to allow fluid replacement, drug administration, and blood transfusions, if needed. An emergency bronchoscopy should be performed to identify the bleeding site. Monitor the patient's blood pressure and pulse to detect hypotension and tachycardia, and draw an arterial blood sample for laboratory analysis to monitor respiratory status.
What Happens in Hemoptysis
Hemoptysis results from bleeding into the respiratory tract by bronchial or pulmonary vessels. Bleeding reflects alterations in the vascular walls and in blood-clotting mechanisms. It can result from any of these pathophysiologic processes:
Hemorrhage and diapedesis of red blood cells from the pulmonary microvasculature into the alveoli
Necrosis of lung tissue that causes inflammation and rupture of blood vessels or hemorrhage into the alveolar spaces
Rupture of an aortic aneurysm into the tracheobronchial tree
Rupture of distended endobronchial blood vessels from pulmonary hypertension due to mitral stenosis
Rupture of a pulmonary arteriovenous fistula or of bronchial or pulmonary artery or pulmonary venous collateral channels
Sloughing of a caseous lesion into the tracheobronchial tree
Ulceration and erosion of the bronchial epithelium
History and Physical Examination
If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had a recent infection. Has he been exposed to TB? When was his last tine test and what were the results?
Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal
movement during breathing, the use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.
Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.
Obtain a sputum sample and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.
Medical etiology
Bronchial adenoma. In up to 30% of patients, bronchial adenoma is a nasty condition characterized by recurrent hemoptysis, a persistent cough, and local wheezing.
Bronchiectasis
Hemoptysis, attributed to inflamed bronchial surfaces and corroded bronchial blood vessels, can manifest as blood-tinged sputum or, in around 20% of cases, blood. The patient's sputum may also demonstrate copiousness, malodor, and purulent consistency. Indications of a late stage of the disease include a persistent cough, coarse crackles, clubbing, fever, weight loss, weariness, weakness, malaise, and dyspnea during physical activity.
Bronchitis (chronic).
Primarily, chronic bronchitis manifests as an initial productive cough that persists for a minimum duration of 3 months. In due course, this results in the generation of sputum containing blood; significant bleeding is quite rare. Additional respiratory manifestations include dyspnea, extended expiration, wheezing, dispersed rhonchi, auxiliary muscle activity, barrel chest, tachypnea, and clubbing (a late diagnosis).
Coagulation disorders.
Thrombocytopenia and disseminated intravascular coagulation are conditions that can lead to hemoptysis. In addition to their particular associated symptoms, many diseases may exhibit common general signs such as multisystem hemorrhaging (e.g., gastrointestinal bleeding or epistaxis) and purpuric lesions.
Pulmonary abscess
Approximately half of the patients with lung abscess experience the production of blood-stained sputum due to bronchial ulceration, necrosis, and granulation tissue. Typical presenting symptoms include a cough with copious quantities of purulent, malodorous sputum; a fever accompanied by chills; excessive sweating; lack of appetite; weight loss; a headache; weakness; difficulty breathing; chest discomfort that is either pleuritic or dull; and clubbing. Auscultation indicates both tubular and cavernous respiration. Ambient sounds and sonications. Affected side exhibits dullness upon percussion.
Lung cancer
Recurrent hemoptysis, an early indication, is often caused by bronchial ulceration and can range from blood-streaked sputum to untreated blood. Associated symptoms include a productive cough, difficulty breathing, elevated body temperature, loss of appetite, loss of body weight, wheezing, and chest discomfort (a delayed symptom).
Plague (Yersinia pestis).
This acute bacterial infection can manifest in its pneumonic form as hemoptysis, a productive cough, chest pain, tachypnea, dyspnea, increased respiratory distress, cardiopulmonary insufficiency, as well as the abrupt onset of chills, a fever, a headache, and myalgia.
Pneumonia
In as many as 50% of instances, Klebsiella pneumonia generates a viscous dark brown or crimson (currant jelly) sputum, which is so persistent that the patient experiences difficulties in clearing it from their mouth. The onset of this form of pneumonia is sudden and characterized by chills, a fever, difficulty breathing, a strong cough, and intense chest pain located in the pleura. Possible secondary manifestations may encompass cyanosis, prostration, tachycardia, reduced breath sounds, and crackles.
The mucoid sputum produced by pneumococcal pneumonia is pinkish or reddish in color. The presentation starts with abrupt, trembling shivers; a swiftly increasing body temperature; and, in more than 80% of instances, increased heart rate and fast breathing. Within a few hours, the patient usually develops a productive cough accompanied by intense, stabbing, pleuritic discomfort. With splinting, the excruciating chest pain causes quick, shallow, grunting respirations. An examination shows respiratory distress characterized by dyspnea and the utilization of auxiliary muscles, as well as crackles and dullness when percussion is applied to the afflicted lung. Pallor, debility, muscle soreness, and hunching posture are symptoms that accompany a high temperature.
Pulmonary edema
. The presence of severe dyspnea, orthopnea, gasping, anxiety, cyanosis, diffuse crackles, a ventricular gallop, and cold, clammy skin is often accompanied with the production of frothy, blood-tinged pink sputum in cases of severe cardiogenic or noncardiogenic pulmonary edema. Furthermore, this potentially fatal disorder can result in tachycardia, lethargy, cardiac arrhythmias, tachypnea, hypotension, and a thready pulse.
Pulmonary embolism with infarction.
In pulmonary embolism with infarction, a life-threatening condition, hemoptysis is a frequent observation, although major hemoptysis is rare. Typical early symptoms include shortness of breath and chest pain characterized by angiopathy or pleuritis. Additional typical clinical manifestations include rapid heart rate, rapid breathing, a mild low-grade fever, and excessive sweating. Less frequently, the patient may have chest splinting, leg swelling, and, in cases of a significant embolism, cyanosis, syncope, and distension of the jugular vein. Examination indicates reduced breath sounds, a pleural friction rub, crackles, and widespread wheezing. The patient presents with dullness upon percussion, as well as indications of circulatory collapse (a weak and rapid pulse; hypotension), cerebral ischemia (transient loss of consciousness, convulsions), and hypoxemia (restlessness and, especially in older patients, hemiplegia and other localized neurological weakness).
Pulmonary hypertension (primary)
Features typically manifest rather late. Common symptoms include haemoptysis, exertional dyspnea, and weariness. Exertion often triggers angina-like pain that may radiate to the neck but not to the arms. Additional characteristics observed are arrhythmias, syncope, cough, and hoarseness.
Pulmonary tuberculosis
Pulmonary tuberculosis often presents with blood-streaked or blood-tinged sputum, while advanced cavitary tuberculosis may result in profuse hemoptysis. The respiratory symptoms include a persistent productive cough, presence of fine crackles after coughing, difficulty breathing, dullness when percussioned, heightened tactile sensitivity, and potential amphoric breath noises. In addition, the patient may experience nocturnal perspiration night sweats, malaise, fatigue, a fever, anorexia, weight loss, and pleuritic chest pain.
Systemic lupus erythematosus (SLE). In 50% of patients with SLE, pleuritis and pneumonitis cause hemoptysis, a cough, dyspnea, pleuritic chest pain, and crackles. Related findings are a butterfly rash in the acute phase, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, anorexia with weight loss, and lymphadenopathy.
Tracheal trauma
Torn tracheal mucosa may cause hemoptysis, hoarseness, dysphagia, neck pain, airway occlusion, and respiratory distress.
Quantitative diagnostic testing. Surgical procedures such as bronchoscopy, laryngoscopy, mediastinoscopy, or lung biopsy might result in lung or airway damage, leading to bleeding and hemoptysis.
Key Factors to Consider
Console and comfort the patient, who may respond to this concerning indication with unease and fear. If deemed essential, put him in the lateral decubitus posture, with the suspected bleeding lung pointing downwards, in order to safeguard the nonleaking lung. Execute this procedure with prudence as hypoxemia may exacerbate when the healthy lung is oriented upwards.
Administer diagnostic tests to the patient in order to ascertain the underlying cause of the bleeding. Potential diagnostic tests may include a complete blood count, a sputum culture and smear, and a chest X-ray.
Radiography, coagulation tests, bronchoscopy, pulmonary biopsy, pulmonary arteriography, and a pulmonary computed tomography scan.
Therapeutic Counseling for Patients
Clarify the significance of reporting recurring incidents. Provide the patient with written guidelines for submitting sputum samples.
Guidelines for Pediatric Populations
Pediatric hemoptysis can result from Goodpasture's syndrome, cystic fibrosis, or, in rare cases, idiopathic primary pulmonary hemosiderosis. Sometimes, pulmonary bleeding occurring within the first 2 weeks of life cannot be attributed to any specific cause; in such instances, the prognosis is adverse.
Guidelines for Geriatrics
If the patient is prescribed anticoagulants, ascertain any necessary modifications in his diet or other drugs (including over-the-counter and natural supplements) as these elements can impact the process of clotting.
Frightening to the patient and commonly ominous, hemoptysis is the expectoration of blood or bloody sputum from the lungs or tracheobronchial tree. It’s sometimes confused with bleeding from the mouth, throat, nasopharynx, or GI tract. (See Identifying Hemoptysis.) Expectoration of 200 mL of blood in a single episode suggests severe bleeding, whereas expectoration of 400 mL in 3 hours or more than 600 mL in 16 hours signals a life-threatening crisis.
Hemoptysis usually results from chronic bronchitis, lung cancer, or bronchiectasis. However, it may also result from inflammatory, infectious, cardiovascular, or coagulation disorders and, rarely, from a ruptured aortic aneurysm. In up to 15% of patients, the cause is unknown. The most common causes of massive hemoptysis are lung cancer, bronchiectasis, active tuberculosis (TB), and cavitary pulmonary disease from necrotic infections or TB.
EXAMINATION TIP Identifying Hemoptysis
These guidelines will help you distinguish hemoptysis from epistaxis, hematemesis, and brown, red, or pink sputum.
HEMOPTYSIS
Typically frothy because it's mixed with air, hemoptysis is typically bright red with an alkaline pH (tested with nitrazine paper). It's strongly suggested by the presence of respiratory signs and symptoms, including a cough, a tickling sensation in the throat, and blood produced from repeated coughing episodes. (You can rule out epistaxis because the patient's nasal passages and posterior pharynx are usually clear.)
HEMATEMESIS
The usual site of hematemesis is the GI tract; the patient vomits or regurgitates coffee-ground material that contains food particles, tests positive for occult blood, and has an acid pH. However, he may vomit bright red blood or swallowed blood from the oral cavity and nasopharynx. After an episode of hematemesis, the patient may have stools with traces of blood and may also complain of dyspepsia.
BROWN, RED, OR PINK SPUTUM
Brown, red, or pink sputum can result from oxidation of inhaled bronchodilators. Sputum that looks like old blood may result from rupture of an amebic abscess into the bronchus. Red or brown sputum may occur in a patient with pneumonia caused by the enterobacterium Serratia marcescens.
Several pathophysiologic processes can cause hemoptysis. (See What Happens in Hemoptysis.)
EMERGENCY INTERVENTIONS
If the patient coughs up copious amounts of blood, endotracheal intubation may be required. Suction frequently to remove blood. Lavage may be necessary to loosen tenacious secretions or clots. Massive hemoptysis can
cause airway obstruction and asphyxiation. Insert an I.V. line to allow fluid replacement, drug administration, and blood transfusions, if needed. An emergency bronchoscopy should be performed to identify the bleeding site. Monitor the patient's blood pressure and pulse to detect hypotension and tachycardia, and draw an arterial blood sample for laboratory analysis to monitor respiratory status.
What Happens in Hemoptysis
Hemoptysis results from bleeding into the respiratory tract by bronchial or pulmonary vessels. Bleeding reflects alterations in the vascular walls and in blood-clotting mechanisms. It can result from any of these pathophysiologic processes:
Hemorrhage and diapedesis of red blood cells from the pulmonary microvasculature into the alveoli
Necrosis of lung tissue that causes inflammation and rupture of blood vessels or hemorrhage into the alveolar spaces
Rupture of an aortic aneurysm into the tracheobronchial tree
Rupture of distended endobronchial blood vessels from pulmonary hypertension due to mitral stenosis
Rupture of a pulmonary arteriovenous fistula or of bronchial or pulmonary artery or pulmonary venous collateral channels
Sloughing of a caseous lesion into the tracheobronchial tree
Ulceration and erosion of the bronchial epithelium
History and Physical Examination
If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had a recent infection. Has he been exposed to TB? When was his last tine test and what were the results?
Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal
movement during breathing, the use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.
Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.
Obtain a sputum sample and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.
Medical etiology
Bronchial adenoma. In up to 30% of patients, bronchial adenoma is a nasty condition characterized by recurrent hemoptysis, a persistent cough, and local wheezing.
Bronchiectasis
Hemoptysis, attributed to inflamed bronchial surfaces and corroded bronchial blood vessels, can manifest as blood-tinged sputum or, in around 20% of cases, blood. The patient's sputum may also demonstrate copiousness, malodor, and purulent consistency. Indications of a late stage of the disease include a persistent cough, coarse crackles, clubbing, fever, weight loss, weariness, weakness, malaise, and dyspnea during physical activity.
Bronchitis (chronic).
Primarily, chronic bronchitis manifests as an initial productive cough that persists for a minimum duration of 3 months. In due course, this results in the generation of sputum containing blood; significant bleeding is quite rare. Additional respiratory manifestations include dyspnea, extended expiration, wheezing, dispersed rhonchi, auxiliary muscle activity, barrel chest, tachypnea, and clubbing (a late diagnosis).
Coagulation disorders.
Thrombocytopenia and disseminated intravascular coagulation are conditions that can lead to hemoptysis. In addition to their particular associated symptoms, many diseases may exhibit common general signs such as multisystem hemorrhaging (e.g., gastrointestinal bleeding or epistaxis) and purpuric lesions.
Pulmonary abscess
Approximately half of the patients with lung abscess experience the production of blood-stained sputum due to bronchial ulceration, necrosis, and granulation tissue. Typical presenting symptoms include a cough with copious quantities of purulent, malodorous sputum; a fever accompanied by chills; excessive sweating; lack of appetite; weight loss; a headache; weakness; difficulty breathing; chest discomfort that is either pleuritic or dull; and clubbing. Auscultation indicates both tubular and cavernous respiration. Ambient sounds and sonications. Affected side exhibits dullness upon percussion.
Lung cancer
Recurrent hemoptysis, an early indication, is often caused by bronchial ulceration and can range from blood-streaked sputum to untreated blood. Associated symptoms include a productive cough, difficulty breathing, elevated body temperature, loss of appetite, loss of body weight, wheezing, and chest discomfort (a delayed symptom).
Plague (Yersinia pestis).
This acute bacterial infection can manifest in its pneumonic form as hemoptysis, a productive cough, chest pain, tachypnea, dyspnea, increased respiratory distress, cardiopulmonary insufficiency, as well as the abrupt onset of chills, a fever, a headache, and myalgia.
Pneumonia
In as many as 50% of instances, Klebsiella pneumonia generates a viscous dark brown or crimson (currant jelly) sputum, which is so persistent that the patient experiences difficulties in clearing it from their mouth. The onset of this form of pneumonia is sudden and characterized by chills, a fever, difficulty breathing, a strong cough, and intense chest pain located in the pleura. Possible secondary manifestations may encompass cyanosis, prostration, tachycardia, reduced breath sounds, and crackles.
The mucoid sputum produced by pneumococcal pneumonia is pinkish or reddish in color. The presentation starts with abrupt, trembling shivers; a swiftly increasing body temperature; and, in more than 80% of instances, increased heart rate and fast breathing. Within a few hours, the patient usually develops a productive cough accompanied by intense, stabbing, pleuritic discomfort. With splinting, the excruciating chest pain causes quick, shallow, grunting respirations. An examination shows respiratory distress characterized by dyspnea and the utilization of auxiliary muscles, as well as crackles and dullness when percussion is applied to the afflicted lung. Pallor, debility, muscle soreness, and hunching posture are symptoms that accompany a high temperature.
Pulmonary edema
. The presence of severe dyspnea, orthopnea, gasping, anxiety, cyanosis, diffuse crackles, a ventricular gallop, and cold, clammy skin is often accompanied with the production of frothy, blood-tinged pink sputum in cases of severe cardiogenic or noncardiogenic pulmonary edema. Furthermore, this potentially fatal disorder can result in tachycardia, lethargy, cardiac arrhythmias, tachypnea, hypotension, and a thready pulse.
Pulmonary embolism with infarction.
In pulmonary embolism with infarction, a life-threatening condition, hemoptysis is a frequent observation, although major hemoptysis is rare. Typical early symptoms include shortness of breath and chest pain characterized by angiopathy or pleuritis. Additional typical clinical manifestations include rapid heart rate, rapid breathing, a mild low-grade fever, and excessive sweating. Less frequently, the patient may have chest splinting, leg swelling, and, in cases of a significant embolism, cyanosis, syncope, and distension of the jugular vein. Examination indicates reduced breath sounds, a pleural friction rub, crackles, and widespread wheezing. The patient presents with dullness upon percussion, as well as indications of circulatory collapse (a weak and rapid pulse; hypotension), cerebral ischemia (transient loss of consciousness, convulsions), and hypoxemia (restlessness and, especially in older patients, hemiplegia and other localized neurological weakness).
Pulmonary hypertension (primary)
Features typically manifest rather late. Common symptoms include haemoptysis, exertional dyspnea, and weariness. Exertion often triggers angina-like pain that may radiate to the neck but not to the arms. Additional characteristics observed are arrhythmias, syncope, cough, and hoarseness.
Pulmonary tuberculosis
Pulmonary tuberculosis often presents with blood-streaked or blood-tinged sputum, while advanced cavitary tuberculosis may result in profuse hemoptysis. The respiratory symptoms include a persistent productive cough, presence of fine crackles after coughing, difficulty breathing, dullness when percussioned, heightened tactile sensitivity, and potential amphoric breath noises. In addition, the patient may experience nocturnal perspiration night sweats, malaise, fatigue, a fever, anorexia, weight loss, and pleuritic chest pain.
Systemic lupus erythematosus (SLE). In 50% of patients with SLE, pleuritis and pneumonitis cause hemoptysis, a cough, dyspnea, pleuritic chest pain, and crackles. Related findings are a butterfly rash in the acute phase, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, anorexia with weight loss, and lymphadenopathy.
Tracheal trauma
Torn tracheal mucosa may cause hemoptysis, hoarseness, dysphagia, neck pain, airway occlusion, and respiratory distress.
Quantitative diagnostic testing. Surgical procedures such as bronchoscopy, laryngoscopy, mediastinoscopy, or lung biopsy might result in lung or airway damage, leading to bleeding and hemoptysis.
Key Factors to Consider
Console and comfort the patient, who may respond to this concerning indication with unease and fear. If deemed essential, put him in the lateral decubitus posture, with the suspected bleeding lung pointing downwards, in order to safeguard the nonleaking lung. Execute this procedure with prudence as hypoxemia may exacerbate when the healthy lung is oriented upwards.
Administer diagnostic tests to the patient in order to ascertain the underlying cause of the bleeding. Potential diagnostic tests may include a complete blood count, a sputum culture and smear, and a chest X-ray.
Radiography, coagulation tests, bronchoscopy, pulmonary biopsy, pulmonary arteriography, and a pulmonary computed tomography scan.
Therapeutic Counseling for Patients
Clarify the significance of reporting recurring incidents. Provide the patient with written guidelines for submitting sputum samples.
Guidelines for Pediatric Populations
Pediatric hemoptysis can result from Goodpasture's syndrome, cystic fibrosis, or, in rare cases, idiopathic primary pulmonary hemosiderosis. Sometimes, pulmonary bleeding occurring within the first 2 weeks of life cannot be attributed to any specific cause; in such instances, the prognosis is adverse.
Guidelines for Geriatrics
If the patient is prescribed anticoagulants, ascertain any necessary modifications in his diet or other drugs (including over-the-counter and natural supplements) as these elements can impact the process of clotting.
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