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AAFP Approach To Hemoptysis PDF
AAFP Approach To Hemoptysis PDF
JOHN SCOTT EARWOOD, MD, Dwight D. Eisenhower Army Medical Center, Fort Gordon, Georgia
TIMOTHY DANIEL THOMPSON, MD, Mendoza Clinic, Fort Bliss, Texas
Hemoptysis is the expectoration of blood from the lung parenchyma or airways. The initial step in the evaluation is
determining the origin of bleeding. Pseudohemoptysis is identified through the history and physical examination. In
adults, acute respiratory tract infections (e.g., bronchitis, pneumonia), bronchiectasis, asthma, chronic obstructive
pulmonary disease, and malignancy are the most common causes. Tuberculosis is a major cause of hemoptysis in
endemic regions of the world. Although tuberculosis rates are low in the United States, they are increased in persons
who are homeless or who were born in other countries; consideration for testing should be made on an individual
basis. Hemodynamic instability, abnormal gas exchange, cardiopulmonary comorbidities, and lesions at high risk of
massive bleeding warrant inpatient evaluation. Chest radiography is recommended as the initial diagnostic test for
hemodynamically stable patients with hemoptysis. Further evaluation with computed tomography with or without
bronchoscopy is recommended in patients with massive hemoptysis, those with abnormal radiographic findings, and
those with risk factors for malignancy despite normal radiographic findings. (Am Fam Physician. 2015;91(4):243-249.
Copyright © 2015 American Academy of Family Physicians.)
H
CME This clinical content
emoptysis is defined as the Illustrative Cases
conforms to AAFP criteria CASE 1
for continuing medical
expectoration of blood from the
education (CME). See lung parenchyma or airways. A 46-year-old man presents with a cough
CME Quiz Questions on The volume of blood produced that has produced blood-streaked sputum
page 230. has traditionally been used to differentiate for the past two days. Associated symptoms
Author disclosure: No rel- between nonmassive and massive hemopty- include rhinorrhea, congestion, and subjec-
evant financial affiliations. sis; the cutoff value ranges from 100 to 600 mL tive fever. He estimates the total amount of
of blood produced in a 24-hour period.1,2 For blood loss to be less than 1 tablespoon. The
the purposes of this article, expectoration of medical history is unremarkable. He has
more than 200 mL of blood per 24 hours is never used tobacco and has not recently trav-
considered massive hemoptysis.3 Because of eled, lost weight, or had night sweats.
the practical difficulties of quantifying the Vital signs are within normal limits, and
volume of expectorated blood, others have the patient appears to breathe comfortably,
proposed the term life-threatening hemop- other than intermittent cough. No blood is
tysis to indicate hemoptysis accompanied by produced in the clinic. Pulmonary exami-
measurable parameters, such as abnormal nation demonstrates normal breath sounds.
gas exchange and hemodynamic instability, Nasal, oropharyngeal, cardiovascular, and
for patients in need of urgent resuscitation abdominal examinations are unremarkable.
and treatment.4,5
CASE 2
A study of 762,325 patients in a primary
care database evaluated the incidence of A 74-year-old woman presents to the emer-
hemoptysis as a presenting symptom in the gency department after coughing up blood.
outpatient setting.6 Hemoptysis occurred She brings a container with approximately
in 4,812 patients in a six-year period, for 100 mL of blood-tinged sputum produced
an incidence of approximately one case over the past 24 hours. She reports that she
per 1,000 patients per year. Thus, a typi- has had similar episodes in the past, which
cal primary care physician could expect to were diagnosed as bronchitis, and that the
encounter patients with the chief presenting symptoms resolved within a few days of ini-
symptom of hemoptysis four or five times tiating oral antibiotic therapy. Her medical
per year. Massive hemoptysis accounts for a history is significant for Sjögren syndrome,
minority of cases (5% to 15%).5 bronchiectasis, and microcytic anemia. She
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Hemoptysis
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating Reference Comments
Chest radiography should be performed as part of the initial evaluation C 15 Recommendation from
of patients with hemoptysis. American College of Radiology
consensus guidelines based on
observational studies
CT is suggested for initial evaluation of patients at high risk of C 15 Recommendation from
malignancy who have suspicious findings on chest radiography. CT American College of Radiology
should be considered in patients with risk factors (e.g., 40 years or consensus guidelines based on
older, smoking history of at least 30 pack-years) who have negative or observational studies
nonlocalizing findings.
Patients with negative findings on chest radiography, CT, and C 15 Recommendation from
bronchoscopy (cryptogenic hemoptysis) have a low risk of malignancy American College of Radiology
and can be observed for three years. No specific recommendations consensus guidelines based on
can be made regarding chest CT or radiography during that interval, observational studies
but imaging should be based on risk factors. If hemoptysis recurs,
multidimensional CT angiography should be considered. Bronchoscopy
may also complement imaging during the observation period.
CT = computed tomography.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.
has a 50 pack-year smoking history and quit smoking examination reveals diffuse inspiratory rales. Cardio-
five years ago. She does not drink alcohol. She has lost vascular examination is normal except for tachycardia.
40 lb (18 kg) over the past 12 months. Abdominal examination is unremarkable.
Vital signs at the time of presentation include a tem-
perature of 99°F (37.2°C), blood pressure of 146/73 mm Differential Diagnosis
Hg, heart rate of 127 beats per minute, respiratory rate of The differential diagnosis of hemoptysis is broad
36 breaths per minute, and oxygen saturation of 83% in (Table 11), and the relative frequency of possible etiolo-
room air. Although the respiratory rate is increased, the gies varies significantly depending on the clinical set-
patient does not appear to be in distress. Nasal exami- ting. In outpatient primary care, acute respiratory tract
nation demonstrates normal mucosa without epistaxis. infections, asthma, chronic obstructive pulmonary
Oropharyngeal examination reveals normal dentition disease, malignancy, and bronchiectasis are the most
and mucosa without signs of bleeding or ulceration. The common diagnoses in patients with hemoptysis.6 In
neck is supple and without lymphadenopathy. Pulmonary comparison, a study of patients with hemoptysis in a
244 American Family Physician www.aafp.org/afp Volume 91, Number 4 ◆ February 15, 2015
Hemoptysis
Table 2. Etiologies of Hemoptysis
in Outpatient and Inpatient Settings
February 15, 2015 ◆ Volume 91, Number 4 www.aafp.org/afp American Family Physician 245
Hemoptysis
Table 4. Historical Findings That Suggest Table 5. Indications for Admission to the
Etiology of Hemoptysis Intensive Care Unit or Referral to Specialty
Center in Patients with Hemoptysis
Finding Suggested etiology
Etiology with high risk of bleeding (e.g., aspergillosis, lesions
Anticoagulant use Coagulopathy with pulmonary artery involvement)
Cough Bronchiectasis, COPD, foreign Gas-exchange abnormalities (respiratory rate > 30 breaths per
body, pneumonia, tuberculosis minute, oxygen saturation < 88% in room air, or need for
Fever Bronchitis, lung abscess, neoplasm, high-flow oxygen [> 8 L per minute] or mechanical ventilation)
pneumonia, pulmonary Hemodynamic instability (hemoglobin < 8 g per dL [80 g per L]
embolism, tuberculosis or a decrease of more than 2 g per dL [20 g per L] from
Heart disease (valvular or Congestive heart failure baseline, consumptive coagulopathy, or hypotension requiring
congestive heart failure) fluid bolus or vasopressors)
Immunosuppression Bronchitis, lung abscess, Massive hemoptysis (> 200 mL per 48 hours or > 50 mL per
pneumonia, tuberculosis episode in patients with chronic pulmonary disease)
Recent surgery or Pulmonary embolism Respiratory comorbidities (e.g., previous pneumonectomy,
immobilization chronic obstructive pulmonary disease, cystic fibrosis)
Smoking Bronchitis, COPD, neoplasia Other comorbidities (e.g., ischemic heart disease, need for
Sputum production Bronchiectasis, COPD, pneumonia, anticoagulation)
tuberculosis
Trauma Airway trauma, pulmonary embolism Information from reference 13.
Weight loss COPD, neoplasia, tuberculosis
Score 0 1 2 3 4 5 6 7
Resolution of Cases
CASE 1: NONMASSIVE HEMOPTYSIS Mortality 1% 2% 6% 16% 34% 58% 79% 91%
This patient has a history of minimal blood
NOTE: Patients with a score greater than 2 should be admitted to the intensive care unit,
production, normal vital signs, and no and those with a score greater than 5 may require urgent interventional radiology.
hemodynamic instability or abnormal gas
Adapted with permission from Fartoukh M, Khoshnood B, Parrot A, et al. Early pre-
exchange. A focused history and physical diction of in-hospital mortality of patients with hemoptysis: an approach to defining
examination should help identify etiologic severe hemoptysis. Respiration. 2012;83(2):111.
clues. Chest radiography should be performed
246 American Family Physician www.aafp.org/afp Volume 91, Number 4 ◆ February 15, 2015
Hemoptysis
Evaluation of Nonmassive Hemoptysis
History and physical examination
Normal Abnormal
(Figure 2)
Chest CT
Figure 1. Algorithm for the evaluation of nonmassive hemoptysis. (CT = computed tomography.)
Information from references 3 and 15.
No risk of cancer; history No risk of cancer; history Risk factors for cancer
not suggestive of lower suggestive of lower
respiratory tract infection respiratory tract infection
No further evaluation
Figure 2. Algorithm for the management of nonmassive hemoptysis in patients with normal findings on chest
radiography.
Information from references 3 and 15.
February 15, 2015 ◆ Volume 91, Number 4 www.aafp.org/afp American Family Physician 247
Hemoptysis
248 American Family Physician www.aafp.org/afp Volume 91, Number 4 ◆ February 15, 2015
Hemoptysis
Sensitivity
REFERENCES
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The authors thank Jordan Mastrodonato, MS, certified medical illustrator, mortality of patients with hemoptysis: an approach to defining severe
for assistance with the preparation of the manuscript. hemoptysis. Respiration. 2012;83(2):106-114.
The views expressed in this abstract/manuscript are those of the authors 15. Ketai LH, Mohammed TL, Kirsch J, et al.; Expert Panel on Thoracic
and do not reflect the official policy or position of the Department of the Imaging. ACR appropriateness criteria hemoptysis. J Thorac Imaging.
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JOHN SCOTT EARWOOD, MD, is a faculty physician and assistant professor
dence in patients with hemoptysis of unknown origin. Chest. 2001;
in the Department of Family Medicine at the Dwight D. Eisenhower Army
120(5):1592-1594.
Medical Center Family Medicine Residency Program, Fort Gordon, Ga.
18. Sirajuddin A, Mohammed TL. A 44-year-old man with hemoptysis:
TIMOTHY DANIEL THOMPSON, MD, is the officer in charge of soldier care a review of pertinent imaging studies and radiographic interventions.
at Mendoza Clinic, Fort Bliss, Tex. Cleve Clin J Med. 2008;75(8):601-607.
February 15, 2015 ◆ Volume 91, Number 4 www.aafp.org/afp American Family Physician 249