Hemoptysis

Etiology (from 1997 tertiary hospital series [MEDLINE])


Etiology

Airway Disorders

  • Acute Bronchitis (see Acute Bronchitis)
    • Epidemiology
      • It is Controversial as to Whether Acute Bronchitis is Associated with Life-Threatening Hemoptysis (with Older Case Series Reporting an Incidence of 5-37%) (Chest, 1994) [MEDLINE], Although it is Generally Believed to Be Rare in Patients Who Have Structurally Normal Lungs by Chest CT Scan
    • Clinical
      • Hemoptysis May Be Massive in Some Cases
  • Airway Foreign Body (see Airway Foreign Body)
    • Epidemiology
      • XXXXX
  • Airway Stent (see Airway Stent)
    • Epidemiology
      • XXX
  • Aspergilloma (see Aspergilloma)
    • Epidemiology
      • Common Etiology of Life-Threatening Hemoptysis
      • Case Series of Endobronchial Aspergilloma Have Been Reported (Exp Ther Med, 2017) [MEDLINE]
  • Bronchial Adenoma (see Bronchial Adenoma)
    • Epidemiology
      • XXXXX
  • Bronchial Carcinoid (see Bronchial Carcinoid)
    • Epidemiology
      • Unrelated to Tobacco Use
      • More Common in Young to Middle-Aged Patients
    • Diagnosis
      • Due to Vascular Nature of Bronchial Carcinoid and Risk of Bleeding, Many Providers Avoid Bronchoscopic Biopsy (Although the Risk of Bleeding is Considered Low) (Lung, 2016) [MEDLINE]
  • Bronchiectasis (see Bronchiectasis)
  • Broncholithiasis (see Broncholithiasis)
    • Epidemiology
    • Physiology
      • Erosion of a Calcified Lymph Node into the Airway Can Result in Hemoptysis (Chest, 2019) [MEDLINE]
  • Chronic Bronchitis (see Chronic Obstructive Pulmonary Disease)
    • Epidemiology
      • XXXXX
  • Cryptococcosis (see Cryptococcosis)
    • Epidemiology
      • Cases of Endobronchial Cryptococcosis Associated with Hemoptysis Have Been Reported (Respir Med Case Rep, 2018) [MEDLINE]
  • Cytomegalovirus (CMV) (see Cytomegalovirus)
    • Epidemiology
      • Cases of Airway Involvement with Associated Hemoptysis Have Been Reported (BMC Nephrol, 2019) [MEDLINE]
  • Bronchial Dieulafoy Lesion (see Bronchial Dieulafoy Lesion)
    • Epidemiology
      • Large Case Series of Bronchial Dieulafoy Lesions Associated with Hemoptysis Has Been Published (BMC Pulm Med, 2019) [MEDLINE]
    • Diagnosis
      • Bronchoscopically Appear Nodular and Red in Color
      • However, Some are Subtle, Being Detected on Endobronchial Ultrasound or Bronchial Angiogram
      • Avoid Bronchoscopic Endobronchial Biopsy (Due to Risk of Hemorrhage)
    • Physiology
      • Dilated Aberrant Submucosal Vessel (Superficial, Subepithelial Bronchial Artery Lesion Contiguous with the Bronchial Mucosa)
  • Endotracheal/Endobronchial Metastases (see Endobronchial Metastases)
  • Hamartoma (see Hamartoma)
    • Clinical
      • Massive Hemoptysis Has Been Reported (Rare Tumors, 2019) [MEDLINE]
  • Herpes Simplex Virus (HSV) (see Herpes Simplex Virus)
    • Epidemiology
      • Cases of Airway Involvement with Associated Hemoptysis Have Been Reported (J Med Case Rep, 2007) [MEDLINE] (Respirol Case Rep, 2016) [MEDLINE]
  • Lung Cancer (see Lung Cancer)
    • Epidemiology
      • Non-Life-Threatening Hemoptysis Occurs in 7-10% of Lung Cancer Patients at the Time of Presentation and in 20% of Lung Cancer Patients at Some Time During Their Course of Illness (Clin Chest Med, 1994) [MEDLINE]
      • Lung Cancer Accounts for Between 5-30% of Massive Hemoptysis Cases (Ann Thorac Surg, 2009) (J Vasc Interv Radiol, 2015) [MEDLINE] [MEDLINE] (Cardiovasc Intervent Radiol, 2018) [MEDLINE]
    • Clinical
      • Hemoptysis May Be Massive
  • Malignant Triton Tumor (see xxxx)
    • Clinical
      • Massive Hemoptysis Has Been Reported (Ann Thorac Surg, 2020) [MEDLINE]
  • Papillary Thyroid Cancer (see Thyroid Cancer)
    • Physiology
      • Tracheal Invasion
    • Clinical
      • Massive Hemoptysis Has Been Reported (BMJ Case Rep, 2019) [MEDLINE]
  • Pulmonary Hemangioma (see Pulmonary Hemangioma)
    • Diagnosis
      • Avoid Bronchoscopic Biopsy (Due to Risk of Bleeding)
  • Tracheovascular/Bronchovascular Fistula
    • Physiology
      • Airway Stent (see Airway Stent)
        • Broncho-Vascular Fistula Cases Have Been Reported with the Use of Self-Expanding Metallic Airway Stents (Ann Thorac Med, 2013) [MEDLINE]
      • Aortic Aneurysm with Erosion into Airway (Tex Heart Inst J, 2009) [MEDLINE]
      • Aortic Infection with Erosion into Airway
      • Aortic Surgery with Stent with Erosion into Airway
      • Indwelling Vascular Device with Erosion into Airway
      • Tracheoinnominate Artery Fistula (see Tracheal-Innominate Artery Fistula): typically associated with low tracheostomy placement (tracheostomy tube can eroide through the tracheal wall into the innominate artery, since the innominate artery crosses the anterolateral surface of the trachea at the level of the upper sternum)
        • Cases Have Been Reported in Association with Tracheostomy Placement (Ann Thorac Cardiovasc Surg, 2013) [MEDLINE]
      • Tracheo-Subclavian Artery Fistula: typically associated with low tracheostomy placement
        • Cases Have Been Reported in Association with Tracheostomy Placement (Eur J Cardiothorac Surg, 2007), [MEDLINE]
    • Clinical
      • Hemoptysis May Be Heralded by Small Episodes of Hemoptysis and May Be Massive

Pulmonary Parenchymal Disorders

Infection

  • Anthrax (see Anthrax)
  • Aspergilloma (see Aspergilloma)
    • Epidemiology
      • Common Etiology of Life-Threatening Hemoptysis
      • Case Series of Endobronchial Aspergilloma Have Been Reported (Exp Ther Med, 2017) [MEDLINE]
    • Physiology
      • Erosion into Blood Vessels
    • Clinical
      • Hemoptysis is Common (Occurs in Approximately 40% of Cases)
      • Hemoptysis May Be Massive (J Cardiothorac Surg, 2013) [MEDLINE] (Ann Thorac Surg, 2014) [MEDLINE]
  • Acute Invasive Pulmonary Aspergillosis (see Acute Invasive Pulmonary Aspergillosis)
    • Epidemiology
      • XXXX
    • Physiology
      • Erosion into Blood Vessels
    • Clinical
      • Hemoptysis May Be Massive
  • Blastomycosis (see Blastomycosis)
    • Epidemiology
      • Cases of Blastomycosis Associated with Hemoptysis Have Been Reported (Mil Med, 2018) [MEDLINE]
    • Physiology
      • Usually Associated with Mucosal Erosion
  • Community-Acquired Pneumonia (CAP) (see Community-Acquired Pneumonia)
    • Epidemiology
      • May Occasionally Cause Life-Threatening Hemoptysis in the Setting of Coagulopathy
  • Crimean-Congo Hemorrhagic Fever (see Crimean-Congo Hemorrhagic Fever)
    • Epidemiology
      • XXXX
  • Cryptococcosis (see Cryptococcosis)
    • Epidemiology
      • Cases of Endobronchial Cryptococcosis Associated with Hemoptysis Have Been Reported (Respir Med Case Rep, 2018) [MEDLINE]
  • Cytomegalovirus (CMV) (see Cytomegalovirus)
    • Epidemiology
      • Cases of Airway Involvement with Associated Hemoptysis Have Been Reported (BMC Nephrol, 2019) [MEDLINE]
  • Dengue Virus (see Dengue Virus)
    • Clinical
      • Hemoptysis May Occur (J Coll Physicians Surg Pak, 2013) [MEDLINE]
  • Herpes Simplex Virus (HSV) (see Herpes Simplex Virus)
    • Epidemiology
      • Cases of Airway Involvement with Associated Hemoptysis Have Been Reported (J Med Case Rep, 2007) [MEDLINE] (Respirol Case Rep, 2016) [MEDLINE]
  • Histoplasmosis (see xxxx)
    • Epidemiology
      • Rare Etiology of Hemoptysis
    • Physiology
      • Usually Associated with Mucosal Erosion
  • Lung Abscess (see Lung Abscess)
    • Epidemiology
      • XXXX
    • Physiology
      • Erosion into Blood Vessels
    • Clinical
      • Hemoptysis May Be Massive
  • Mucormycosis (see Mucormycosis)
    • Epidemiology
      • XXXX
    • Clinical
      • Hemoptysis May Be Massive
  • Necrotizing Pneumonia (see xxxx)
    • Epidemiology
      • XXXX
    • Physiology
      • Erosion into Blood Vessels
  • Non-Tuberculous Mycobacterial Disease
  • Paragonimiasis (see Paragonimiasis)
  • Plague (Yersinia Pestis) (see Plague)
  • Strongyloidiasis (see xxxx)
  • Tuberculosis (see Tuberculosis)
    • Epidemiology
      • Hemoptysis is Common
    • Clinical
      • Hemoptysis May Be Massive
  • Tularemia (see Tularemia)

Diffuse Alveolar Hemorrhage (DAH) (see Diffuse Alveolar Hemorrhage)

Other

  • Ehlers-Danlos Syndrome (Vascular Type) (see Ehlers-Danlos Syndrome)
    • Physiology
      • Due to Genetic Variants of Collagen Type III Gene (OMIM 25940258) (NEJM, 2008) [MEDLINE] (Chest, 2015) [MEDLINE]
  • Endometriosis (Catamenial Hemoptysis (see Endometriosis)
    • Physiology
      • Parenchymal or Endobronchial Endometriosis (Respiration, 2008) [MEDLINE]
    • Clinical
      • Hemoptysis Concomitant with Menses

Pulmonary Vascular Disorders

  • Acute Pulmonary Embolism (PE) (see Acute Pulmonary Embolism)
    • Physiology
      • Presumed Pulmonary Infarction
    • Clinical
      • Hemoptysis is Usually Not Life-Threatening, Unless the Patient is Anticoagulated
  • Congestive Heart Failure (CHF) (see Congestive Heart Failure)
    • Epidemiology
      • XXXX
    • Physiology
      • Pulmonary Venous Hypertension
  • Fat Embolism (see Fat Embolism)
    • Epidemiology
      • XXXX
  • Hughes-Stovin Syndrome (see Hughes-Stovin Syndrome)
    • Epidemiology
    • Physiology
      • Pulmonary and Bronchial Artery Aneurysms
  • Mitral Stenosis (see Mitral Stenosis)
    • Epidemiology
      • XXXX
    • Physiology
      • Pulmonary Venous Hypertension with Reversal of Blood Flow from the Pulmonary Capillaries into the Bronchial Veins
    • Clinical
      • Hemoptysis is Often Minor, But Sudden, Life-Threatening Hemoptysis Can Occur with Rupture of a Bronchial Varix (“Pulmonary Apoplexy”): this may occur during a period of increased pulmonary blood flow and/or increased blood volume (during pregnancy, exercise, hypervolemia, etc)
  • Pulmonary Arteriovenous Malformation (AVM) (see Pulmonary Arteriovenous Malformation)
    • Etiology
      • Idiopathic Pulmonary Arteriovenous Malformation(s)
      • Pulmonary Arteriovenous Malformation(s) Associated with Hereditary Hemorrhagic Telangiectasia (HHT) (Osler-Weber-Rendu Syndrome) (see XXXX)
    • Clinical
      • Hemoptysis May Be Massive (Especially During Pregnancy)
      • More Than 8% of Patients with Pulmonary AVM’s Associated with HHT Had a Episode of Life-Threatening Hemoptysis (Chest, 1994) [MEDLINE]
  • Pulmonary Artery Pseudoaneurysm (Rasmussen Aneurysm) (see Pulmonary Artery Pseudoaneurysm)
    • Etiology
    • Diagnosis
      • Predilection for Peripheral Pulmonary Arteries (AJR Am J Roentgenol, 2017) [MEDLINE]
      • May Be Single or Multiple (AJR Am J Roentgenol, 2017) [MEDLINE]
    • Clinical
      • Active Infection May Result in Sudden Rupture with Massive Hemoptysis (Edinb Med J, 1868) [MEDLINE]
  • Pulmonary Capillary Hemangiomatosis (PCH) (see Pulmonary Capillary Hemangiomatosis)
    • Epidemiology
      • XXXX
    • Physiology
      • Pulmonary Venous Hypertension
    • Clinical
      • XXXXX
  • Pulmonary Veno-Occlusive Disease (VOD) (see xxxx)
    • Epidemiology
      • XXXX
    • Physiology
      • Pulmonary Venous Hypertension
    • Clinical
      • XXXXX
  • Septic Embolism (see Septic Embolism)
    • Epidemiology
      • XXXX
    • Clinical
      • XXXXX
  • Severe Pulmonary Arterial Hypertension/Congenital Heart Disease (see Pulmonary Hypertension)
    • Epidemiology
      • Rare Etiology of Hemoptysis
    • Physiology
      • Pulmonary Arterial Hypertension
    • Clinical
      • Hemoptysis May Be Precipitated by Lung Biopsy

Pulmonary Trauma

  • Airway Stent: see above
  • Atrial Fibrillation Ablation (see Atrial Fibrillation)
    • Epidemiology
      • Pulmonary Vein Isolation During Atrial Cryoballoon Ablation for Atrial Fibrillation Has Been Associated with Hemoptysis (Heart Rhythm, 2011) [MEDLINE] (Chest, 2014) [MEDLINE] (J Cardiovasc Electrophysiol, 2013) [MEDLINE]
  • Balloon Dilation of Airway Lesion
    • Epidemiology
      • XXX
  • Blunt Pulmonary Trauma (Pulmonary Contusion) (see xxxx)
  • Bronchoscopic Ablative Procedure (Brachytherapy, Cryotherapy)
    • Epidemiology
      • XXX
  • Cryobiopsy
    • Epidemiology
      • Life-Threatening Hemoptysis Occurs in <20% of Cases
  • Endobronchial/Transtracheal/Transbronchial/Transthoracic Needle Aspiration or Biopsy
    • Epidemiology
      • Life-Threatening Hemoptysis Occurs in <2% of Transbronchial Biopsies
  • Pacemaker Placement (Via Central Venous Site)
    • Epidemiology
      • Cases of Hemoptysis Have Been Reported (North Clin Istanb, 2018) [MEDLINE]
  • Penetrating Pulmonary Trauma
    • Etiology
      • Knife Wound
      • Gun Shot Wound
  • Swan-Ganz Catheter-Associated Pulmonary Artery (see Swan-Ganz Catheter)
    • Epidemiology
      • XXXX
  • Tracheovascular/Bronchovascular Fistula: see above

Drug/Toxin

  • Argemone Alkaloid-Contaminated Cooking Oil (Epidemic Dropsy) (see xxxx) (Ethiop Med J, 2013) [MEDLINE]
    • Epidemiology
      • XXXXX
  • Bevacizumab (Avastin) (see Bevacizumab) (NEJM, 2006) [MEDLINE] (Lung Cancer, 2007) [MEDLINE]
    • Clinical
      • Hemoptysis Ranges from Minor to Life-Threatening
    • Pharmacology
      • Vascular Endothelial Growth Factor (VEGF) Inhibitor
    • Physiology
      • Mechanism is Unclear, May Be Related to Tissue Destruction from the VEGF Inhibition (Especially in the Setting of a Cavitating Lung Cancer)
  • Riociguat (Adempas) (see Riociguat) (NEJM, 2013) [MEDLINE]
    • Epidemiology
      • XXXXX

Other

  • Fibrosing Mediastinitis (see xxxx)
  • Pulmonary Amyloidosis (see xxxx)
  • Cryptogenic (Idiopathic) Hemoptysis
    • Epidemiology
      • Approximately 30% of Patients with Hemoptysis Have No Identifiable Etiology After Careful Evaluation (Chest, 2001) [MEDLINE] (Am J Respir Crit Care Med, 2007) [MEDLINE] (Respiration, 2010) [MEDLINE]
      • In Long-Term Follow-Up (5 Years) of Patients with Cryptogenic Hemoptysis, <2% of Patients Developed Lung Cancer (Eur Clin Respir J, 2019) [MEDLINE]
    • Diagnosis
      • Bronchial Arteriogram Studies Identify Areas of Hypervascularity or Aneurysm (Suggestive of Bronchial Dieulafoy Lesion) in >80% of Cryptogenic Hemoptysis Cases (Chest, 2017) [MEDLINE] (J Vasc Interv Radiol, 2017) [MEDLINE]

Pseudohemoptysis

  • Aspirated Blood from Upper Airway or Gastrointestinal Source

Anatomy and Physiology (see also Pulmonary Anatomy)

Lungs Have a Dual Arterial Blood Supply (Insights Imaging, 2020) [MEDLINE]

Pulmonary Arteries

  • Function
    • Pulmonary Arteries Predominantly Supply the Lung ParenchymaSize/Pressure
    • Pulmonary Arteries Have a Larger Caliber than the Bronchial Arteries
    • Pulmonary Arteries are a Low-Pressure System
      • Consequently, Most Episodes of Hemoptysis Originate from the Pulmonary Arterial Circulation and are Not Life-Threatening
  • Anatomy
    • Pulmonary Arteries Originate from the Right Ventricle
  • Source of Hemoptysis
    • The Bronchial Arterial System is the Predominant Source of Hemoptysis in 90% of Cases of Massive Hemoptysis (Crit Care Med, 2000) [MEDLINE]
      • Other Sources Include
        • Pulmonary Arteries (5% of Cases)
        • Non-Bronchial Systemic Arteries (5% of Cases)

Bronchial Arteries

  • Function
    • Bronchial Arteries Predominantly Supply the Tracheobronchial Tree, Large Blood Vessels, Lymph Nodes, Esophagus, and Pleura (Radiographics, 2006) [MEDLINE]
      • The Bronchial Arterial Circulation Accounts for Only 2% of the Total Vascular Supply to the Lung
    • Bronchial Arteries are Very Plastic, Potentially Increasing Their Blood Flow from 1% to 30% of the Cardiac Output in Response to a Pulmonary Insult
      • Consequently, Bronchial Artery Hypertrophy and Dilatation of Thin-Walled Distal Bronchial-to-Pulmonary Artery Anastomoses May Occur
  • Size/Pressure
    • Bronchial Arteries Have a Smaller Caliber than the Pulmonary Arteries
      • On Contrast-Enhanced CT, They are Very Thin and Difficult to Detect
      • Normal Caliber of the Bronchial Arteries is <1.5 mm Near the Origin and <0.5 mm Distally, as They Branch in the Pulmonary Hila
      • When Bronchial Artery Hypertrophy Occurs, Their Diameter Can Exceed 2 mm, and They Tend to Have a More Tortuous Course
    • Bronchial Arteries are a High-Pressure System (Under Systemic Arterial Pressure)
  • Anatomy
    • Orthotopic Origin
      • The Bronchial Arteries Most Commonly Originate from the Descending Thoracic Aorta, Usually at the T5-T6 Vertebral Plane, 1–2 cm Above or Below the Level of the Carina
      • The Orthotopic Right Bronchial Artery Originates Preferentially from the Posteromedial Aortic Wall (Directly or or More Commonly from a Short Intercostal-Bronchial Trunk), Running Retrotracheally Towards the Hilum
      • The Orthotopic Left Bronchial Artery Originates Preferentially from the Anterior or Lateral Aortic Wall, Running Retrotracheally Towards the Hilum
      • Most Patients Have 1-2 Bronchial Arteries on Each Side and a Total of 3-4 Bronchial Arteries
    • Ectopic Origin
      • In Up to 36% of Cases, the Bronchial Arteries Ectopically Originate from Aortic Arch, Subclavian Artery, Thyrocervical Trunk, Internal Mammary Artery, or Coronary Arteries (J Thorac Imaging, 2003) [MEDLINE] (Eur Radiol, 2007) [MEDLINE]
        • Ectopic Bronchial Arteries are Recognized Due to Their Adjacent Course with the Associated Bronchi
    • Bronchial Arteries Have Distal Microvascular Anastomoses Connecting to the Pulmonary Arterial System (Chest, 1972) [MEDLINE]
  • Source of Hemoptysis
    • Despite the Bronchial Arteries Accounting for Only 2% of the Total Vascular Supply to the Lung, the Bronchial Arteries are the Predominant Source of Hemoptysis in 90% of Cases of Massive Hemoptysis (Crit Care Med, 2000) [MEDLINE]
      • Other Sources Include
        • Pulmonary Arteries (5% of Cases)
        • Non-Bronchial Systemic Arteries (5% of Cases)

Other Arteries

  • The Non-Bronchial Arterial Circulation (Aorta, Intercostal Arteries, Coronary Arteries, Thoracic Arteries, Axillary Arteries, Subclavian Arteries, Upper and Lower Inferior Phrenic Arteries) Can Supply the Lungs in <5% of Cases (Chest, 2008) [MEDLINE] (Respiration, 2010) [MEDLINE]
    • Many Chronic Inflammatory Lung Lesions are Jointly Supplied by Hypertrophied Bronchial Arteries, as Well as by Collateral Systemic Arteries

Pulmonary Venous Drainage

  • Venous bronchial drainage is mainly through the pulmonary veins, with a smaller contribution of drainage through the superior vena cava, azygos, and hemyazigos systems

Diagnosis

Bronchoscopy (see Bronchoscopy)

  • xxx

Chest CT (see Chest Computed Tomography)

  • xxx

Bronchial Artery Angiogram (see Bronchial Artery Angiogram)

  • Technique
    • Performed by Interventional Radiology (IR)

Pulmonary Artery Angiogram (see xxxx)

  • xxxx

Systemic Artery Angiogram

  • xxxxx

Diagnostic Yield of Procedures for the Evaluation of Hemoptysis


Clinical

Quantification of Hemoptysis (Eur Respir J, 2008) [MEDLINE]

  • Massive/Life-Threatening Hemoptysis: hemoptysis of 150 mL/day (around 1/2 cup blood/day) or at a rate ≥100 mL/hr
    • Life-Threatening Hemoptysis is Defined as Hemoptysis Which Results in Airway Obstruction, Significantly Gas Exchange Abnormalities, or Hemodynamic Instability

Quantification of Hemoptysis (Diagn Interv Radiol, 2017) [MEDLINE]

  • Mild Hemoptysis
    • Hemoptysis <100 mL/Day or <50 mL/Episode
  • Moderate Hemoptysis
    • Hemoptysis ≥100–300 mL/Day or >3 Episodes of >100 mL/Day in a One Week Period
  • Severe/Massive/Life-Threatening Hemoptysis
    • Hemoptysis >300 mL/Day
    • Hemoptysis of Any Volume Resulting in a Decrease in Hemoglobin (Decrease >1g/dL), Hematocrit (Decrease >5%), Respiratory Failure (SpO2 <60%), or Hypotension (Systolic Blood Pressure <90 mm Hg)

Treatment

Antitussives

  • xxx

Correction of Coagulopathy (If Present) (see Coagulopathy)

  • Crucial

Intubation/Airway Protection (see Invasive Mechanical Ventilation)

  • xxxx

Bronchoscopic Techniques (see Bronchoscopy)

  • Balloon Tamponade
  • Iced Saline Lavage
  • Topical Epinephrine (see Epinephrine)
    • XXXXX
  • Topical Vasopressin (see Vasopressin)
  • Laser Therapy
    • May Be Utilized to Control Mucosal Source of Bleeding
    • Preferably Used Via Rigid Bronchoscopy (Due to Superior Suction Capabilities and Visualization)
  • Cautery
    • May Be Utilized to Control Mucosal Source of Bleeding
    • Preferably Used Via Rigid Bronchoscopy (Due to Superior Suction Capabilities and Visualization)
  • Argon Plasma Coagulation
    • May Be Utilized to Control Mucosal Source of Bleeding
    • Preferably Used Via Rigid Bronchoscopy (Due to Superior Suction Capabilities and Visualization)
  • Cryotherapy
    • May Be Utilized to Control Mucosal Source of Bleeding
    • Preferably Used Via Rigid Bronchoscopy (Due to Superior Suction Capabilities and Visualization)

Bronchial Artery Angiogram with Angioembolization (see Bronchial Artery Angiogram)

History

  • Bronchial Artery Embolization for the Control of Hemoptysis was First Described by Remy in 1974 (Ann Radiol-Paris, 1974) [MEDLINE] (Diagn Interv Radiol, 2017) [MEDLINE]
  • Bronchial Artery Embolization Has Bee Used to Control of Hemoptysis Resulting from Both Benign and Malignant Etiologies, as Well as for All Grades of Hemoptysis
  • Bronchial Artery Embolization is Generally Indicated for Persistent, Life-Threatening Hemoptysis Despite Initial Diagnostic/Therapeutic Measures, Such as Bronchoscopy and Chest CT Scan (Radiographics, 2002) [MEDLINE]

Rationale for Studying the Bronchial, Pulmonary, and Systemic Arterial Circulations

  • Bronchial Artery Angiogram
    • The Large Majority of Hemoptysis Cases Arise from the Bronchial Circulation and, Therefore, Bronchial Arterial Embolization is the Initial Procedure of Choice
    • Despite the Fact that the Bronchial Arteries Account for Only 2% of the Total Vascular Supply to the Lung, They are the Predominant Source of Hemoptysis in 90% of Cases of Massive/Life-Threatening Hemoptysis (Crit Care Med, 2000) [MEDLINE]
  • Pulmonary Artery Angiogram
    • Specific Reasons to Initially Perform a Pulmonary Artery Angiogram, Instead of Bronchial Artery Angiogram
      • Suspected Pulmonary Arteriovenous Malformation (AVM)
      • Suspected Pulmonary Artery Pseudoaneurysm (Rasmussen Aneurysm)
      • Suspected Iatrogenic Pulmonary Artery Tear (from Swan-Ganz Catheter, etc)
      • Suspected Pulmonary Embolism (with Infarction) with Associated Coagulopathy
  • Systemic Artery Angiogram
    • The Systemic Circulation is Generally Studied When the Bronchial Arterial Angiogram and Pulmonary Artery Angiogram is Unrevealing and Life-Threatening Hemoptysis Persists (or Recurs After Bronchial Artery Embolization)
    • Some Centers Routinely Perform a Thoracic Aortogram After Bronchial Artery Embolization to Improve the Detection of Bleeding from the Systemic Circulation (AJR Am J Roentgenol. 2003) [MEDLINE]

Technique

  • Pre-Procedure Bronchoscopy and Chest CT are Used to Preliminarily Localize the Site of Hemorrhage
  • Procedure is Performed in an Interventional Radiology Suite
  • Almost All Operators Perform a Prior Flush Aortogram to Identify Abnormal Bronchial and Non-Bronchial Systemic Collaterals (Diagn Interv Radiol, 2017) [MEDLINE]
  • Abnormal Findings on Bronchial Arterial Angiogram Necessitating Embolization (Diagn Interv Radiol, 2017) [MEDLINE]
    • Enlarged or Tortuous Arteries
    • Hypervascularity
    • Parenchymal Blush
    • Active Contrast Extravasation
      • However, Observation of Contrast Extravasation from a Specific Vessel into the Airway is Very Rare, Since the Rate of Bleeding rate is Rarely Sufficient (ie, >1 mL/min) for Detection by Angiogram
    • Bronchopulmonary Shunting
    • Artery-Artery or Artery-Vein Shunting
  • Embolization is Achieved Using Occlusive Material (Spheres, Coils, etc) into the Suspected Bleeding Vessel or the Proximal Vessels Which Supply the Bleeding Vessel
    • No Embolization is Performed if a Culprit Vessel Cannot Be Identified
  • Superselective Catheterization (Diagn Interv Radiol, 2017) [MEDLINE]
    • In This Systematic Review, Superselective Catheterization of abnormal arteries using microcatheters was almost routinely performed by all authors after 2010
    • In This Systematic Review, Superselective catheterization enabled Bypassing Anterior Spinal arteries and catheterization of smaller, more distal, and torturous arteries; thereby providing better overall hemoptysis control and lesser risk of complications

Rate of Success

  • Success Rate of Bronchial Artery Embolization is Approximately 60-90% (Chest, 2002) [MEDLINE] (Radiology, 2013) [MEDLINE] (Am J Med Sci, 2014) [MEDLINE] (Asian Cardiovasc Thorac Ann, 2015) [MEDLINE]
    • In Systematic Reviews, the Technical Success Rate was 81-100% (Diagn Interv Radiol, 2017) [MEDLINE]
      • Causes of Technical Failure Include an Uncooperative Patient, Patient Condition Not Permitting Bronchial Artery Embolization, Artery Tortuosity, Arterial Dissection/Vasospasm, Arterial Ostial Narrowing, Arterial Acute or Multiple Branching
    • Success Rate is Enhanced When the Bronchial, Pulmonary, and/or Systemic Arterial Circulations are Well-Defined During the Procedure
    • Early Technical Failures Occur in 5-10% of Cases
      • Inability to Cannulate the Bronchial Artery
      • Failure to Identify and/or Embolize All of the Collateral Systemic Feeder Vessels (Arising from the Gastric, Intercostal, Internal Mammary, Renal, or Hepatic Arteries)
  • Rate of Rebleeding is 10-20% Over the Next 6-12 mos (Diagn Interv Radiol, 2017) [MEDLINE]
    • Rebleeding May Be Due to Incomplete Embolization, Revascularization, or Recanalization
    • Risk Factors for Rebleeding After Bronchial Artery Embolization
      • Bleeding from Aspergilloma
      • Bleeding from Tuberculosis
      • Bleeding from Bronchiectasis
      • Presence of Non-Bronchial Systemic Collateral Arteries
      • Presence of Bronchopulmonary Shunt

Adverse Effects/Complications

  • Bronchial Wall Necrosis
  • Chest Pain (see Chest Pain)
  • Dyspnea (see Dyspnea)
  • Ischemic Myelopathy/Spinal Cord Infarction (see Spinal Cord Infarction)
    • In Systematic Reviews, the Rate of Complicating Spinal Cord Ischemia was 0.6-4.4% (Diagn Interv Radiol, 2017) [MEDLINE]
    • Due to the Fact that the Anterior Spinal Arteries Arises from a Bronchial Artery in 5% of the Population
      • Cannulation or Embolization of the Bronchial Artery May Compromise Blood Flow to the Anterior Spinal Cord, Resulting in Cord Ischemia/Infarction
    • Risk
      • Risk of Spinal Cord Infarction Has Been Reported to Be <5% ( Semin Intervent Radiol, 2004) [MEDLINE] and <1% with an Experienced Interventional Radiologist
      • Mitigation of Risk
        • Meticulous Technique, the Use of Microcatheters in a Coaxial System and Distal Positioning to the Expected Location of the Spinal Artery Feeders Can Minimize the Risk of Spinal Artery Embolization
        • Small Particles (<200 μm) Should Be Avoided Due to an Increased Risk of Spinal Artery Embolization, as Compared with Larger Particles (>300 μm)
  • Non-Target Embolization of the Brain (Resulting in Cortical Blindness), Esophagus, and Pulmonary Circulation
    • In Systematic Reviews, the Rate of Complicating Transient Ischemic Attack and Cortical Blindness was 0.6-2% (Diagn Interv Radiol, 2017) [MEDLINE]
      • This was Attributed to Manipulation of the Subclavian Arteries or Due to Embolization Agents Crossing Bronchopulmonary Anastomoses

Lobectomy (see Pulmonary Lobectomy)

  • Generally Indicated for Hemoptysis Refractory to Bronchoscopic and Arteriographic Techniques
    • However, Early Surgery is Indicated for the Following Etiologies
      • Chest Trauma
      • Complex Pulmonary Arteriovenous Malformations (AVM) Which Fails Embolization
      • Pulmonary Artery Rupture
      • Refractory Hemoptysis from an Aspergilloma (see Aspergilloma)
      • Tracheoinnominate Artery Fistula (see Tracheoinnominate Artery Fistula)
      • Tracheovascular/Bronchovascular Fistula

Specific Management of Diffuse Alveolar Hemorrhage (DAH) (see Diffuse Alveolar Hemorrhage)

  • Diffuse Alveolar Hemorrhage is Not Amenable to Bronchoscopic Methods or Bronchial Artery Angiogram (Due to the Diffuse Nature of the Bleeding)

Prognosis of Hemoptysis

Prognosis by Degree of Hemoptysis

  • Trivial Hemoptysis
    • Duration of Hospitalization: 8.1 +/- 8 days
    • Surgery: 5% of cases –Death: 2.5% of cases
  • Moderate Hemoptysis
    • Duration of Hospitalization: 9.5 +/- 7.7 days
    • Surgery: 9% of cases
    • Death: 6% of cases
  • Massive Hemoptysis
    • Duration of Hospitalization: 19.3 +/- 21.1 days
    • Surgery: 17% of cases
    • Death: 38% of cases

Predictors of Poor Prognosis (Clin Chest Med, 1999) [MEDLINE] (Respiration, 2012) [MEDLINE] (Eur Respir J, 2015) [MEDLINE]

  • Advanced stage of malignancy
  • Alcohol Abuse (see Ethanol)
  • Aspiration of blood into the contralateral lung
  • Bleeding from the pulmonary artery, cancer, aspergillosis
  • Hypotension (see xxxx)
  • Mechanical ventilation (particularly the need for single lung ventilation)
  • Poor performance status
  • Presence of cavitation or necrosis or lung densities involving two or more quadrants on chest radiograph

References

Etiology

General

  • Life-threatening pulmonary hemorrhage with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia. Chest. 1994;106(5):1387 [MEDLINE]
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Atrial Fibrillation Ablation (see Atrial Fibrillation)

  • Bronchial erosion and hemoptysis after pulmonary vein isolation by cryoballoon ablation. Heart Rhythm. 2011 Sep;8(9):1459 [MEDLINE]
  • Pulmonary hemorrhage after cryoballoon ablation for pulmonary vein isolation in the treatment of atrial fibrillation. Chest. 2014;145(1):156 [MEDLINE]
  • Pulmonary vein intramural hematoma as a complication of cryoballoon ablation of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2013 Jul;24(7):830-1 [MEDLINE]

Broncholithiasis (see xxxx)

  • Broncholithiasis: A Review. Chest. 2019;156(3):445 [MEDLINE]

Drug/Toxin

  • Nitrogen dioxide pneumonitis in ice hockey players. J Intern Med. 1996;239(5):451 [MEDLINE]
  • Paclitaxel-carboplatin alone or with bevacizumab for non-small-cell lung cancer. N Engl J Med. 2006;355(24):2542 [MEDLINE]
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  • Exposure to nitrogen dioxide in an indoor ice arena – New Hampshire, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(8):139 [MEDLINE]
  • Outbreak investigation of epidemic dropsy in Addis Ababa, Ethiopia. Ethiop Med J. 2013;Suppl 2:9 [MEDLINE]
  • Riociguat for the treatment of pulmonary arterial hypertension. N Engl J Med. 2013 Jul;369(4):330-40 [MEDLINE]
  • Hereditary afibrinogenemia and pulmonary-renal hydralazine-induced vasculitis. Proc (Bayl Univ Med Cent). 2019;32(3):397 [MEDLINE]

Bronchial Carcinoid (see Bronchial Carcinoid)

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Bronchial Dieulafoy Lesion (see Bronchial Dieulafoy Lesion)

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  • Dieulafoy’s disease of the bronchus. Am J Respir Crit Care Med. 2012;186(11):1191 [MEDLINE]
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  • Bronchial Dieulafoy’s disease: a retrospective analysis of 73 cases. BMC Pulm Med. 2019;19(1):104 [MEDLINE]

Cryptogenic Hemoptysis

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Diffuse Alveolar Hemorrhage (DAH) (see Diffuse Alveolar Hemorrhage)

  • Pulmonary toxicity of mitomycin. Cancer. 1980 Jan 15;45(2):236-44. doi: 10.1002/1097-0142(19800115)45:2<236::aid-cncr2820450207>3.0.co;2-0 [MEDLINE]
  • Azathioprine-associated interstitial pneumonitis. Am J Clin Pathol. 1984 Aug;82(2):148-54. doi: 10.1093/ajcp/82.2.148 [MEDLINE]
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  • Association of diffuse alveolar haemorrhage with acquired vitamin K deficiency. Respiration. 2000;67(6):697 [MEDLINE]
  • Lung toxicity following fludarabine, cytosine arabinoside and mitoxantrone (flan) treatment for acute leukemia. Haematologica. 2000 Jul;85(7):769-70 [MEDLINE]
  • Fludarabine-related pulmonary toxicity: a distinct clinical entity in chronic lymphoproliferative syndromes. Chest. 2002 Sep;122(3):785-90. doi: 10.1378/chest.122.3.785 [MEDLINE]
  • Clinicopathological and immunohistochemical features of the severe pulmonary form of leptospirosis. Rev Soc Bras Med Trop. 2002; 35:395–399 [MEDLINE]
  • Antiphospholipid antibodies as a cause of pulmonary capillaritis and diffuse alveolar hemorrhage: a case series and literature review. Semin Arthritis Rheum. 2005 Dec;35(3):154-65 [MEDLINE]
  • Diffuse alveolar hemorrhage as a complication of dual antiplatelet therapy for acute coronary syndrome. Cardiovasc Revasc Med. 2011 Nov;12(6):407-11 [MEDLINE] -Valproate associated diffuse alveolar hemorrhage. Eur J Neurol. 2011 Aug;18(8):e98-9. doi: 10.1111/j.1468-1331.2011.03409.x [MEDLINE]
  • Hemodialysis for the treatment of pulmonary hemorrhage from dabigatran overdose. Am J Kidney Dis. 2013 Sep;62(3):591-4 [MEDLINE]
  • A Case of Alveolar Haemorrhage Induced by Iodinated Contrast Medium Use. Eur J Case Rep Intern Med. 2020 Jun 17;7(9):001744. doi: 10.12890/2020_001744. eCollection 2020 [MEDLINE]
  • Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Final Report. N Engl J Med. 2020;382(10):903 [MEDLINE]

Ehlers-Danlos Syndrome (see Ehlers-Danlos Syndrome)

  • Clinical problem-solving. What’s the connection? – A 26-year-old white man presented to our referral hospital with a 1-month history of persistent cough productive of white sputum, which was occasionally tinged with blood. N Engl J Med. 2008;358(6):626 [MEDLINE]
  • A 19-year-old man with relapsing bilateral pneumothorax, hemoptysis, and intrapulmonary cavitary lesions diagnosed with vascular Ehlers-Danlos syndrome and a novel missense mutation in COL3A1. Chest. 2015;147(5):e166 [MEDLINE]

Hamartoma (see xxxx)

  • Giant hamartoma of lung presented with massive hemoptysis: A rare case report and review of the literature. Rare Tumors. 2019;11:2036361318823926 [MEDLINE]

Hematopoietic Stem Cell Transplantation (HSCT) (see Hematopoietic Stem Cell Transplantation)

  • An official American Thoracic Society research statement: noninfectious lung injury after hematopoietic stem cell transplantation: idiopathic pneumonia syndrome. Am J Respir Crit Care Med. 2011;183(9):1262 [MEDLINE]

Infection

  • An unusual exacerbation of chronic obstructive pulmonary disease (COPD) with herpes simplex tracheitis: case report. J Med Case Rep. 2007;1:91 [MEDLINE]
  • Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence–a National Centre’s experience. J Cardiothorac Surg. 2013;8:180 [MEDLINE]
  • 2011 dengue haemorrhagic fever outbreak in Lahore – an account of clinical parameters and pattern of haemorrhagic complications. J Coll Physicians Surg Pak. 2013 Jul;23(7):463-7 [MEDLINE]
  • Surgical therapy of pulmonary aspergillomas: a 30-year North American experience. Ann Thorac Surg. 2014 Feb;97(2):432-8 [MEDLINE]
  • Herpetic tracheitis in association with rituximab therapy. Respirol Case Rep. 2016;4(4):e00158 [MEDLINE]
  • Endobronchial aspergilloma: A case report and literature review. Exp Ther Med. 2017;14(1):547 [MEDLINE]
  • Chronic Pulmonary Blastomycosis Mimicking Pulmonary Tuberculosis. Mil Med. 2018;183(7-8):e332 [MEDLINE]
  • A unique case report of endobronchial cryptococcosis and review of the literature. Respir Med Case Rep. 2018;25:247 [MEDLINE]
  • A case of aggressive atypical anti-GBM disease complicated by CMV pneumonitis. BMC Nephrol. 2019;20(1):2 [MEDLINE]

Malignant Triton Tumor

  • Worsening Hemoptysis in a Rare Intrapulmonary Triton Tumor Mimicking Lung Cancer. Ann Thorac Surg. 2020;109(3):e199 [MEDLINE]

Papillary Thyroid Cancer (see xxxx)

  • Massive hemoptysis: an unusual presentation of papillary thyroid carcinoma due to tracheal invasion. BMJ Case Rep. 2019;12(8) m[MEDLINE]

Pulmonary Arteriovenous Malformation (AVM) (see Pulmonary Arteriovenous Malformation)

  • Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158(2):643 [MEDLINE]

Pulmonary Artery Pseudoaneurysm (Rasmussen Aneurysm) (se ePulmonary Artery Pseudoaneurysm)

  • On Hæmoptysis, Especially When Fatal, in Its Anatomical and Clinical Aspects. Edinb Med J. 1868 Nov;14(5):385-401 [MEDLINE]
  • Rasmussen Aneurysm and Paragonimiasis Presented as Massive Hemoptysis. Chest. 2014;146:S112A
  • Pulmonary Artery Pseudoaneurysms: Clinical Features and CT Findings. AJR Am J Roentgenol. 2017;208(1):84 [MEDLINE]

Tracheovascular/Bronchovascular Fistula

  • Tracheoesophageal fistula and tracheo-subclavian artery fistula after tracheostomy. Eur J Cardiothorac Surg. 2007 Oct;32(4):676-8 [MEDLINE]
  • Aortopulmonary fistula: a rare complication of an aortic aneurysm. Tex Heart Inst J. 2009;36(5):483 [MEDLINE]
  • Tracheo-innominate artery fistula: two case reports and a clinical review. Ann Thorac Cardiovasc Surg. 2013 Feb;19(1):60-2 [MEDLINE]
  • Broncho-vascular fistulas from self-expanding metallic stents: A retrospective case review. Ann Thorac Med. 2013 Apr;8(2):116-20 [MEDLINE]

Trauma

  • Subclavian vein puncture-induced massive pulmonary hemorrhage and hemoptysis during pacemaker implantation. North Clin Istanb. 2018;5(3):254 [MEDLINE]

Anatomy and Physiology

  • Distribution of bronchial arteries in the human lung. Chest. 1972 Oct;62(4):447-51. doi: 10.1378/chest.62.4.447 [MEDLINE]
  • Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000 May;28(5):1642-7. doi: 10.1097/00003246-200005000-00066 [MEDLINE]
  • Radiographic relationship of the origin of the bronchial arteries to the left main bronchus. J Thorac Imaging. 2003 Jan;18(1):27-33. doi: 10.1097/00005382-200301000-00004 [MEDLINE]
  • Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol. 2007 Aug;17(8):1943-53. doi: 10.1007/s00330-006-0576-8 [MEDLINE]

Diagnosis

  • Role of bronchoscopy in massive hemoptysis. Clin Chest Med. 1999;20(1):89 [MEDLINE]
  • Multi-detector row CT of hemoptysis. Radiographics. Jan-Feb 2006;26(1):3-22. doi: 10.1148/rg.261045726 [MEDLINE]
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Clinical

  • Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15:147-167 [MEDLINE]
  • Massive haemoptysis: the definition should be revised. Eur Respir J. 2008;32(4):1131 [MEDLINE]

Treatment

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  • Bronchial artery embolization therapy. J Thorac Imaging. 1990;5(4):60 [MEDLINE]
  • When does bronchial arterial embolization fail to control hemoptysis? Chest. 1990;97(3):515 [MEDLINE]
  • Therapeutic embolization of bronchial artery: a successful treatment in 209 cases of relapse hemoptysis. Angiology. 1993;44(4):295 [MEDLINE]
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  • Percutaneous embolotherapy for life-threatening hemoptysis. Chest. 2002;121(1):95 Percutaneous embolotherapy for life-threatening hemoptysis. Chest. 2002;121(1):95 [MEDLINE]
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  • Robot-assisted ligation of bronchial artery could be an alternative to embolization. Eur J Cardiothorac Surg. 2018 Mar 1;53(3):686-688. doi: 10.1093/ejcts/ezx336 [MEDLINE]
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