Haemoptysis

Related Subjects: | Lung Cancer

🫁 Introduction

Haemoptysis = coughing up blood originating from the lower respiratory tract. ⚠️ Massive haemoptysis is a medical emergency → mortality is usually due to asphyxiation rather than blood loss. 💡 As little as 250 mL can fill the bronchial tree and obstruct the airway. 🎯 Always confirm the source (lung vs nasopharynx vs GI tract).

📊 About

• Common causes: TB, bronchiectasis, aspergilloma, lung cancer.
• Lungs have dual blood supply: pulmonary + bronchial arteries.
• 👉 Most haemoptysis originates from the bronchial arterial system (systemic pressure → brisk bleeding).
• Pulmonary circulation can shunt blood away from hypoxic zones.

🦠 Causes

• 🎗️ Malignancy: Bronchogenic carcinoma, metastases (esp. in smokers >40).
• 🦠 Infective: Pneumonia, lung abscess, TB (upper lobe lesions in young).
• 🍄 Aspergilloma: Cavitary disease → classically recurrent haemoptysis.
• 🌪️ Bronchiectasis: Purulent sputum, recurrent infection, CF common.
• 🚨 Trauma: Biopsy, bronchoscopy, penetrating injury.
• 🧬 Vasculitis: GPA (c-ANCA), Goodpasture’s (anti-GBM).
• 🫀 Vascular: PE with infarction, AVMs.
• 💉 Bleeding disorders: Thrombocytopenia, anticoagulation (warfarin, DOACs).
• ❤️ Cardiac: Mitral stenosis → pulmonary venous hypertension.
• 🌀 Other: Autoimmune disease, factitious haemoptysis.

🧑‍⚕️ Clinical Features

• History: smoking 🚬, TB exposure, weight loss ⚖️, bleeding disorders.
• Massive haemoptysis = >600 mL/24h or rapid bleeding with airway threat.
• Exam: clubbing, cachexia, chest crepitations, signs of chronic lung disease.
• Always distinguish from: – Epistaxis (nasopharyngeal blood trickling) 👃 – Haematemesis (vomiting blood from GI tract) 🍷

🧪 Investigations

• 🩸 Bloods: FBC, U&E, clotting, ABG.
• 🩻 CXR: May show cavitation, mass, consolidation, bronchiectasis.
• 🖥️ CT Angiography: Gold standard for source localisation if stable.
• 👁️ Bronchoscopy: Rigid/flexible to visualise + tamponade bleeding site.
• 🧬 Autoimmune tests: c-ANCA, anti-GBM.

🚨 Management of Massive Haemoptysis

• ABC first! Senior help immediately (respiratory, IR, cardiothoracics).
• 🫁 Position: Lie on side of bleeding lung → protect good lung.
• 💨 Oxygen: High-flow. Intubation if decompensating (selective main bronchus intubation or double-lumen tube).
• 💉 IV Access: Wide-bore cannulae; crossmatch.
• 💊 Drugs: – Nebulised adrenaline (epinephrine) 5–10 mL of 1:10,000. – Nebulised tranexamic acid (e.g. 500 mg in 5 mL). – IV tranexamic acid (1 g IV over 10 min, then infusion if needed).
• 🖥️ Imaging: Urgent portable CXR; CT angiography if stable.
• 🔧 Bronchoscopy: Endobronchial blocker, suction, topical haemostatics.
• 🩻 Interventional Radiology: Bronchial artery embolisation (BAE) = first-line definitive therapy.
• 🔪 Surgery: Lobectomy/pneumonectomy if localised + fit for surgery.
• 🤲 Palliation: In terminal cancer → symptom control (morphine, midazolam, palliative sedation).

📌 Clinical Pearls

• Death in massive haemoptysis = airway obstruction, not blood loss.
• First priority = protect unaffected lung and maintain oxygenation.
• Tranexamic acid is increasingly used (nebulised or IV).
• BAE is highly effective but recurrence is common → monitor long term.
• Always rule out lung cancer in smokers >40 with unexplained haemoptysis.

📚 References

• British Thoracic Society (BTS) Guidelines – Management of Haemoptysis
• BMJ Best Practice: Haemoptysis
• Oxford Handbook of Clinical Medicine