Diagnosis and management of hemoptysis

Hemoptysis is the expectoration of blood that originates from the lower respiratory tract. It is usually a self-limiting event but in fewer than 5% of cases it may be massive, representing a life-threatening condition that warrants urgent investigations and treatment. This article aims to provide a comprehensive literature review on hemoptysis, analyzing its causes and pathophysiologic mechanisms, and providing details about anatomy and imaging of systemic bronchial and nonbronchial arteries responsible for hemoptysis. Strengths and limits of chest radiography, bronchoscopy, multidetector computed tomography (MDCT), MDCT angiography and digital subtraction angiography to assess the cause and lead the treatment of hemoptysis were reported, with particular emphasis on MDCT angiography. Treatment options for recurrent or massive hemoptysis were summarized, highlighting the predominant role of bronchial artery embolization. Finally, a guide was proposed for managing massive and non-massive hemoptysis, according to the most recent medical literature.In clinical practice hemoptysis is a common symptom, which may require further investigation. It is defined as the expectoration of blood that originates from the lower respiratory tract (1). Bleeding from the upper airways is excluded from this definition.In most cases hemoptysis is a self-limiting event but in fewer than 5% it may be severe or massive, representing a life-threatening condition that warrants urgent investigations and treatment (2). Massive hemoptysis usually refers to the expectoration of a large amount of blood and/or to a rapid rate of bleeding. The blood volume expectorated over 24 hours is generally used for distinguishing massive and nonmassive hemoptysis, although the choice of a cutoff value is controversial (3). Volumes of 100 to 1000 mL of blood (4–9) have been described as indicative of massive hemoptysis, but no specific volume has been universally accepted. Furthermore, a large volume of expectorated blood alone should not define massive hemoptysis, but rather an amount of blood sufficient to cause a condition that threatens the patient’s life can be a more correct and functional definition of severe hemoptysis (4, 5).Asphyxia due to the flooding of the airways rather than exsanguination is usually the cause of death, and it is commonly accompanied by cardiovascular collapse. The mortality rate from untreated massive hemoptysis is more than 50% (6). Therefore, prompt recognition of severe hemoptysis and identification of its causes are mandatory to initiate an adequate treatment and to avoid fatal complications (6). Imaging plays a relevant role in managing this clinical condition.This article aims to provide a comprehensive review on massive and nonmassive hemoptysis, with particular emphasis on the pathophysiologic mechanisms, the anatomy of systemic and pulmonary arteries responsible for hemoptysis, and the role of imaging modalities in diagnosing causes and helping treatment. Strengths and limitations of the various diagnostic modalities will be analyzed and a guide for managing hemoptysis, according to the most recent medical literature, will be proposed.