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Original Article

Etiology and Outcome of Moderate‑to‑massive Hemoptysis:

Experience from a Tertiary Care Center of North India
Ashish Bhalla, Ashok Kumar Pannu, Vikas Suri
Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Abstract
Background: The aim of this study was to evaluate the etiology of hemoptysis in patients presenting to emergency department of Post Graduate
Institute of Medical Education and Research (PGIMER), Chandigarh, India. Method: Prospectively 110 patients presenting to the emergency
department with history of hemoptysis were screened for a period of one and half years. Out of these, 64 patients having true hemoptysis were
enrolled in the study. The patients were clinically evaluated with detailed history. Radiological evaluation included chest x rays and computerized
tomogram. Sputum examination and bronchoscopy was done to establish the etiology. All the patients were conservatively managed using
intravenous fluids, antibiotics, anti-tussive and anti-fibrinolytic drugs. Bronchial/pulmonary artery embolization was performed for controlling
ongoing bleeding/re-bleeding. All the patients were followed up till discharge or death. Results: The mean age was 41.8 ± 15.16 years with male
preponderance. Pulmonary tuberculosis (active/ sequel) was the most common etiology (65%), followed by community acquired pneumonia
(10.93%), bronchiectasis (9.3%), carcinoma lung (7.18%) and miscellaneous causes (8.6%). Almost all patients (98%) had severe hemoptysis
(>100 ml in 24 hours). Abnormalities in bronchial circulation were present in 59.4% and 14% of patients had pulmonary circulation abnormalities.
65% patients responded to conservative treatment. 23.4% patients under went intervention out of which 73.3% underwent bronchial artery
embolization (BAE) and remaining 26.6% underwent pulmonary artery embolization (PAE). One patient died during hospital stay due to
necrotizing pneumonia and another left hospital against medical advice (outcome unknown). Conclusions: TB (active/sequel) remains the most
common cause of hemoptysis in patients admitted in emergency department. Non-TB causes like primary bronchiectasis, carcinoma lung and
pneumonia are other important causes. Conservative management suffices in majority patients for controlling active bleed.

Keywords: Emergency, hemoptysis, tuberculosis

Introduction hemoptysis is based on the site of origin within the lungs.

Hemoptysis is defined as expectoration of blood from respiratory
tract. It can arise in the airways from glottis to alveoli. Often
it ranges from streaking of sputum with blood to frank blood
without accompanying sputum. Hemoptysis usually results due
to bleeding from pulmonary arteries and/or bronchial arteries.
Involvement of bronchial vessels is responsible for majority of
cases with pulmonary artery being the culprit in <10% of the
cases.[1] Severity of hemoptysis is usually classified based on the
amount of blood expectorated in 24 h. Hemoptysis is classified
as mild (<30 ml), moderate (31–100 ml), severe (100–600 ml),
and massive.[2] Massive hemoptysis defined by a number of
criteria, often ranging from 100 ml to more than 600 ml over 24 h
with respiratory or hemodynamic compromise.[3] The reported
mortality ranges from 7% to 30% for nonmassive hemoptysis,
to up to 80% for massive hemoptysis.[4,5] The mortality generally
depends on the rate of bleeding. Etiologic classification of
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Common causes of hemoptysis include tracheobronchial source,
pulmonary parenchymal source, and primary vascular source. In
developing countries like India, pulmonary tuberculosis accounts
for the majority of cases of severe and nonsevere hemoptysis,
whereas in developed countries where the prevalence of
tuberculosis has been significantly decreased, bronchiectasis,
bronchitis, and lung cancer are common etiologies.
Our aim of the study was to study the etiology and outcome
of patients with hemoptysis presenting to the Emergency
Department of Postgraduate Institute of Medical Education
Address for correspondence: Dr. Ashish Bhalla,
Department of Internal Medicine, 4th Floor, F Block, Postgraduate Institute
of Medical Education and Research, Chandigarh ‑ 160 012, India.
E‑mail: bhalla.chd@gmail.com
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and build upon the work non‑commercially, as long as the author is credited and the
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DOI: How to cite this article: Bhalla A, Pannu AK, Suri V. Etiology and outcome
10.4103/ijmy.ijmy_54_17 of moderate‑to‑massive hemoptysis: Experience from a tertiary care center
of North India. Int J Mycobacteriol 2017;6:307-10.

© 2017 The International Journal of Mycobacteriology | Published by Wolters Kluwer ‑ Medknow 307

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Bhalla, et al.: Etiology and outcome of significant hemoptysis
and Research, Chandigarh, India, and to compare the results
with findings reported in literature.
Methods
All prospective patients with a history of active hemoptysis,
presenting to the emergency department at our institute were
screened, and only patients with true hemoptysis were included
in the study. Institute Ethics Committee approval was obtained
before the recruitment was started.
Patients were enrolled in the study with their knowledge, and
a written informed consent was obtained after informing them
about the aims and method of the study and the institutional
affiliation of the researcher. The study was done by utilizing
known investigation modalities, and all the possible treatment
options will be given and none was withheld. Confidentiality
of data collected from contribution source or individual was
maintained.
A total of 110  patients were screened for a study period of
18 months. Patients having hematemesis, oral bleed, epistaxis,
and upper respiratory tract bleeding were excluded from the
study. Sixty‑four patients with “true hemoptysis” were finally
included in the study. After obtaining informed consent from the
patients, baseline demographic data such as age, sex, address,
and amount of hemoptysis were noted. Severity of hemoptysis
is classified as mild  (<30  ml), moderate  (31–100  ml),
severe  (101–600  ml), and massive hemoptysis  (>600  ml or
any amount of bleeding with hemodynamic and respiratory
compromise) over 24 h. Duration of hospital stay, interventions
done, complications encountered, and final outcome were noted.
Etiological diagnosis was based on clinical history and
examination supported by appropriate investigation.
Radiography of chest, computed tomography  (CT), and
digital subtraction angiography were carried out in all to
evaluate structural changes in the lung. Sputum examination
was carried out for etiological diagnosis including Gram
stain and cultures. Sputum was also examined for acid‑fast
bacilli and fungi. Bronchoscopy and histopathological
examination  (fine‑needle aspiration/biopsy) was carried out
wherever indicated. Active tuberculosis was diagnosed on the
basis of sputum positivity and radiological features (nodules,
alveolar, or interstitial infiltrates) predominantly in upper
lobe of the lung (s) along with constitutional symptoms such
as weight loss, loss of appetite, and low‑grade fever/night
sweats. Inactive tuberculosis/sequelae was diagnosed on the
basis of the previous history of tuberculosis and radiological
features such as fibrocavitary disease predominantly affecting
upper lobes, in patients without having systemic symptoms.
Bronchiectasis was diagnosed on the basis of clinical history
and radiological findings. Lung cancers were diagnosed
on the basis of clinical, radiological, bronchoscopic, and
histopathological examination.
All patients received conservative management which
consisted of maintaining a patent airway, breathing, and
circulation. Cough suppressants, bed rest, and antibiotics/
308 The International Journal of Mycobacteriology  ¦  Volume 6  ¦  Issue 3  ¦  July‑September 2017
antitubercular drugs were initiated wherever indicated.
Bronchial/pulmonary artery embolization  (BAE/PAE) was
considered if hemoptysis was not controlled with conservative
management. Descriptive statistics were applied, and results
presented as mean with standard deviation and percentage.
Results
During the study period, a total of 110 patients were screened
and 64 patients who had true hemoptysis were included in the
study. The study population included 50 males and 14 females.
Mean age of patients was 41.7 years. Mean duration of ongoing
hemoptysis was 2.1 ± 1.22 days. Majority of patients had severe
hemoptysis (98%) and rest had moderate hemoptysis. Baseline
laboratory parameters of these patients are provided in Table 1.
Out of fifty males, thirty were active smoker and ten had quit
smoking in the past 6 months. The mean smoking index of
the patients was 120.1 ± 44.2 out of forty female patients only
two were smokers but had quit in the past 6 months. All the
five patients with a diagnosis of bronchogenic carcinoma had
quit smoking in the past 1 month. None of the patients was on
antiplatelets and anticoagulants at presentation. History and
clinical features suggestive of chronic obstructive pulmonary
disease (COPD) were found in 33 males and 5 female patients.
None of them at presentation had an acute exacerbation of
COPD. Two patients had chronic kidney disease and were on
conservative management. Mean duration of hospital stay of
the patients was 4.81 (±3.22) days.
Majority of the patients had tuberculosis (65%) as the etiology.
Active tuberculosis (sputum positivity for acid‑fast bacillus)
was noted in 40% of patients and sequel of pulmonary
parenchymal tuberculosis was present in 60% of patients.
Pneumonia  (community acquired) was the etiological
diagnosis in 10.75% cases. The other important etiologies
were bronchogenic carcinoma, vasculitis, and congenital heart
disease [Table 2]. Secondary bacterial infections as a cause
of active hemoptysis could be diagnosed in 25 patients with
inactive tuberculosis  (20) and bronchiectasis  (5). The most
common organism causing infection was Pseudomonas (16)
and Klebsiella spp. (9) isolated from sputum. Only one patient
had a fungal ball in the preexisting tubercular cavity (inactive
tuberculosis) causing active hemoptysis.
Nearly 76.6% patients responded to conservative management
and the hemoptysis was controlled. Fifteen  (23.4%) patients
Table 1: Baseline parameters (n=64)
Parameter Mean±SD
Hemoglobin (g/dl) 10.55±2.14
Pulse rate (/min) 94.68±19.3
Systolic BP (mm Hg) 125±15
Platelets (lacks) 2.08±0.96
Serum creatinine (mg/dl) 0.588±0.27
Prothrombin index (%) 90.94±10
PaO2 75.17±18
PaO2: Partial pressure of oxygen on arterial blood gas analysis, BP: Blood
pressure, SD: Standard deviation
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Bhalla, et al.: Etiology and outcome of significant hemoptysis

underwent intervention for controlling ongoing bleeding.
Majority, i.e., 46.7% (7/15) of patients underwent intervention
for controlling ongoing hemoptysis, whereas 26.7%  (4/15)
underwent prophylactic embolization due to hypertrophic
bronchial arteries with increased risk of re‑bleeding. About
26.7% of the patients, who had responded initially to conservative
management, had re‑bleed within first 48 h. They underwent
interventions for recurrence of hemoptysis. Bronchial artery
embolization was done in 11 (73.3%) patients, whereas PAE was
done in 4 (26.7%) patients. Out of 15 patients who underwent
intervention, majority  (60%) of the patients had pulmonary
parenchymal abnormalities secondary to tuberculosis, and
hemoptysis was attributed to increased vascularity in the
cavity wall or pseudoaneurysms. One patient died due to
basic disease (septic shock with necrotizing pneumonia) and
one patient left the hospital against medical advice after the
hemoptysis was not controlled with conventional treatment.
Discussion
Etiology of hemoptysis can vary from infections to malignancy,
and it may differ in developed countries when compared
to developing countries, where infections still are a major
etiological factor. Within a geographic region, the etiology may
change over a period of time due to changing epidemiology
of diseases. In developed countries, studies done during the
1940s and 1950s noted tuberculosis to be an important cause of
hemoptysis.[6] A study by Abbott in 1940 in the USA (Atlanta)
Table 2: Final diagnosis (etiology of hemoptysis) (n=64)
Basic diagnosis
Tuberculosis
Active
inactive
Pneumonia
Bronchogenic carcinoma
Bronchiectasis
Mediastinal mass
ANCA‑associated vasculitis
Cavitary lesion with fungal ball
Congenital heart disease
ANCA: Anti-neutrophil cytoplasmic antibody
reported tuberculosis to be responsible for hemoptysis in
22% patients, with bronchiectasis and malignancy being
other important etiologies.[6] Subsequent studies done during
1977–1985, 1974–1981, and 1980–1995 in developed
countries demonstrated a decreasing trend of tuberculosis from
22% to 1% with proportional rise in the other etiologies.[7‑9]
Earliest study from India in 1960 by Rao reported tuberculosis
to be the most common cause of hemoptysis.[10] The scenario
has remained unchanged in our country. Tuberculosis still
remains the most common cause of hemoptysis as evident
from our study (65%) and other recently reported studies from
India.[11‑14] As evident from our study, both active and inactive
tuberculosis are an important cause of hemoptysis. Structural
damage caused by tubercular bacillus can subsequently result
in pooling of secretions and infections, resulting in hemoptysis
in patients with inactive tuberculosis.[11] Secondary bacterial
infections are common.[13] Secondary fungal infections can
also occur and often difficult to diagnose in resource‑constraint
countries because of similar presentation to tuberculosis
and may require CT thorax, serum precipitating antibodies
to Aspergillus species, respiratory cultures, and even lung
biopsy or videothoracoscopy in some cases.[15] In our study,
secondary bacterial infections were present in patients with
inactive tuberculosis and bronchiectasis, but fungal ball was
demonstrable in only one patient with inactive tubercular cavity.
In developed countries, nontubercular causes such as
malignancy, bronchiectasis, and pneumonia have evolved
as important causes of hemoptysis in posttuberculosis era.
Incidence of malignancy, in various reported studies looking at
n (%) epidemiology of hemoptysis from developed countries, ranges
42 (65) from 5% to 44%.[8,16‑19] Indian studies have not reported very
17 (40) high incidence of lung malignancy as etiology of hemoptysis.
25 (60) In the present study too, malignancy was responsible for active
7 (10.7) hemoptysis in 6.25% patients only. Other Indian studies too have
5 (6.25) also reported similar findings (0%–6.6%).[11‑13,20‑22] It implies that
6 (9.3) in India, malignancy is an important cause but is not as common
1 (1.56) as it is in developed countries, where it has taken over infections
1 (1.56)
to emerge as a major cause of hemoptysis [Table 3].
1 (1.56)
1 (1.56) In our study, community‑acquired pneumonia  (bacterial)
was present in 10.72% whereas other studies from India

Table 3: Comparing etiology of hemoptysis India and developed world

Location Number of cases Bronchiectasis (%) Carcinoma (%) Pneumonia (%) Tuberculosis (%) Bronchitis (%)
Abbott[6] Atlanta 497 21 21 2 22 2
Johnston and Reisz[7] Kansas City 148 1 19 8 7 37
Santiago et al.[8] Los Angeles 264 0.5 29 11 6 23
Hirshberg et al.[9] Israel 208 20 19 16 1 18
McGuiness et al.[23] New York 57 25 12 12 16 5
Rao[10] India, Lucknow 476 3.8 5.7 1.7 79.2 19
Talwar et al.[12] India, Noida 376 21 6.6 25.5 61 ‑
Nawal and Heda[13] India, Mangalore 110 34.55 2.73 ‑ 34.55 14.55
Singh and Tiwari[14] India, Gwalior 346 3.5 7.2 2.6 79.2 4.6
Index study India, Chandigarh 64 9.3 7.18 10.72 65 ‑

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Bhalla, et al.: Etiology and outcome of significant hemoptysis
have reported it to be ranging from 1.7% to 25.5%.[11‑13]
Bronchiectasis was present in 9.3% in our study which is
slightly lower than 13.6% reported by Rao in 1960.[10] More
recent studies from India have reported the incidence of
bronchiectasis to range between 3.8% and 21% whereas studies
from developed world have reported bronchiectasis to range
from 21% (1940–1947) to 19% (1980–1995).[6,9‑13,23]
This highlights the fact that structural lung damage is an important
etiological factor responsible for hemoptysis, which could result
from tuberculosis in developing countries and bronchiectasis due
to various etiologies in developed countries. Secondary bacterial
and fungal infection in bronchiectasis and inactive pulmonary
tubercular lesions was responsible for causing hemoptysis in our
patients, as has been the experience from developed countries,
justifying the use of antibiotics in management.[23,24]
Most of the patients respond to management with conservative
treatment and BAE/PAE for controlling hemoptysis is required
only in few patients. In our study, <25% patients required
intervention for controlling bleeding/preventing re‑bleed.
Since bronchial artery is the most common source of bleeding,
bronchial artery embolization can save many lives by controlling
ongoing bleed. In our study, only one patient died and the death
was not directly related to hemoptysis. One patient left against
medical advice when hemoptysis was not controlled (outcome
not known). Observed mortality was low compared other
studies reported from India which ranges from 8.2% to 18.8%
in various studies.[10,11] Studies from Thailand and Singapore
have reported similar mortality ranging from 17.8% to 13%,
respectively.[25] Other studies have documented mortality ranging
from 9% to 10%.[24,26,27] The reason for low mortality in our study
could be the proactive embolization undertaken by us. This
further strengthens our belief that aggressive management of
moderate‑to‑severe hemoptysis can help in saving many lives.
Conclusion
Tuberculosis still remains an important cause of hemoptysis
in India. Both active tuberculosis and posttubercular sequelae
can result in hemoptysis, whereas in the Western world,
nontubercular causes such as malignancy, bronchiectasis, and
bronchitis are leading causes of hemoptysis. Posttuberculosis
sequelae constituted a most common cause of hemoptysis in
our study, thus emphasizing the importance of controlling
tuberculosis. Early and aggressive intervention with the use
of vessel embolization can reduce mortality.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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