Patients may present with:
- Chronic haemoptysis preceeding cancer diagnosis
- Acute onset of haemoptysis during or after therapy
- Massive haemoptysis (greater than 200-1000 mL, no universal definition), usually due to involvement of the bronchial arteries
Patients are commonly distressed by any degree of haemoptysis, and it may require urgent investigation or intervention if severe.
Emergency Management
Massive haemoptysis is an uncommon mode of death, but is incredibly traumatic for the patient, relatives and medical staff. The patient usually presents with a large volume of blood from the mouth. Management should be instigated urgently, after a brief and focussed history - see the Management topic.
History
Presenting Complaint
The goal of this portion of the history is:
- To determine the site of bleeding (bronchial vs pharyngeal vs gastrointestinal)
- To determine the volume of bleeding, which in turn determines the urgency of treatment
- To determine the cause of bleeding (malignancy, either primary or secondary, or other differential diagnoses such as pulmonary embolism, pneumonia, iatrogenic trauma, coagulpathy)
Identifying duration of symptoms is also important as it may provide some reassurance if bleeding has been present over months.
Past History
The underlying malignant condition should be evaluated, as should the overall prognosis for the patient. A patient who is terminally ill from their malignancy may not benefit from some of the management options. Malignant involvement of the liver or bone marrow may lead to coagulopathy.
Other medical problems which may contribute to the haemoptysis should be evaluated (eg. liver disease, thrombocytopenia).
Past history of radiotherapy to the spine or mediastinum may limit the safe dose deliverable, and may lead to the choice of other therapies (eg. bronchial artery embolism).
Medications
Special attention should be paid to anticoagulants such as NSAIDs (aspirin, ibuprofen), steroids, clopidogrel, warfarin or enoxaparin. If possible, these medications should be stopped and alternatives considered (eg. IVC filter).
Allergies
No specific questions
Family History
No specific questions
Social History
No specific questions
Examination
A focussed examination should be performed. Signs of cardiovascular compromise (elevated pulse, lowered blood pressure) suggest massive haemoptysis requiring urgent intervention. Massive haemoptysis may also lead to aspiration of blood into the alveoli and respiratory distress. Bleeding from the oral cavity should be excluded.
Imaging
Imaging is vital to diagnose the site of bleeding, and is important for direction of therapy (for example, a mid tracheal lesion may not be amenable to bronchial artery embolism).
The best method of locating the lesion remains chest CT with contrast, performed in the arterial phase. This should identify the site of bleeding accurately. In patients with massive haemoptysis, progression immediately to the angiography suite might be indicated if there are signs of acute cardiovascular compromise.
