Hemoptysis

Diagnosis/Definition

Hemoptysis is the coughing of blood from the lower respiratory tract below the vocal cords. Epistaxis, bleeding gums and gastrointestinal bleeding occasionally give the illusion of hemoptysis but should be excluded to the greatest extent possible by history and physical exam.

Initial Diagnosis and Management

Common causes of hemoptysis include lower respiratory tract infections, neoplasm and pulmonary infarction. The many infectious causes of hemoptysis include acute bronchitis, flare-up of chronic bronchitis, pneumonia, anaerobic lung abscess and cavitary lung diseases associated with necrotizing bacteria, fungi or mycobacteria. Management depends on the amount of hemoptysis and the underlying cause.
Patients with hemoptysis should receive a thorough examination of the nasopharynx, neck and chest; a chest x-ray and CBC. Arterial blood gases should be obtained in most patients. Ventilation/perfusion scanning or CT angiography is appropriate in patients with pleuritic chest pain and in selected patients without evidence of infection or neoplasm.

Ongoing Management and Objectives

Management by degree of hemoptysis. The amount of hemoptysis per 24 hours should be determined by history and observation.
Mild hemoptysis. Such patients have less than 50 ml of hemoptysis per 24 hours. In most cases hemoptysis is associated with mucous secretions due to bronchitis (and a negative chest x-ray). These patients should receive antibiotics for bronchitis as outpatients with primary care follow up within 72 hours. Patients with pulmonary infarction should be admitted for anticoagulant therapy.
Moderate hemoptysis. These patients have 50 to 300 ml per 24 hours of hemoptysis. Such patients should receive the evaluation above, be admitted, and receive in-patient consultation by the Pulmonary Service.
Massive hemoptysis. These patients have more than 300 ml per 24 hours of hemoptysis. Such patients should receive the evaluation above and be admitted to intensive care with evaluation by Pulmonary Service.

Indications for Specialty Care Referral

Patients with mild hemoptysis and chest x-ray evidence of neoplasm or cavitary lung disease should receive outpatient Pulmonary consultation within 72 hours.

Patients with mild hemoptysis and negative chest x-ray despite 7 days of antibiotic therapy should receive outpatient Pulmonary consultation within 72 hours.

Patients with smoking history of 15 pack years or more, or age over 40 years should receive a routine Pulmonary consultation to consider bronchoscopy even if hemoptysis resolves.

Criteria for Return to Primary Care