A 44-year-old man with hemoptysis: A review of pertinent imaging studies and radiographic interventions

Cleveland Clinic Journal of Medicine. 2008 August;75(8):601-607

August 1, 2008|Cleveland Clinic Journal of Medicine

Arlene Sirajuddin, MD;Tan-Lucien H. Mohammed, MD

ABSTRACTChest radiography, conventional computed tomography (CT), multidetector CT angiography, and conventional thoracic angiography are all useful in assessing patients with hemoptysis. In this paper we outline our approach to assessing and treating these patients.

KEY POINTS

We recommend chest radiography in the initial stages of evaluation of hemoptysis, whether the hemoptysis is massive or nonmassive.
In cases of hemoptysis that is intermittent (whether massive or nonmassive) in patients whose condition is stable, CT, multidetector CT angiography, and bronchoscopy are all useful.
In cases of hemoptysis that is active, persistent, and massive, multidetector CT angiography, bronchoscopy, and conventional bronchial angiography are all useful, depending on the hemodynamic stability of the patient.
Bronchial artery embolization is the preferred noninvasive first-line treatment for hemoptysis and offers an excellent alternative to surgery for patients who are poor candidates for surgery.

Computed tomography

Figure 3. A computed tomographic scan shows cystic dilatation of the bronchi bilaterally, consistent with cystic bronchiectasis.

Both conventional CT and multidetector CT angiography are quick and noninvasive ways to locate the site of bleeding, determine the cause of bleeding (Figure 3, Figure 4), and create a map to guide further therapy.⁵^,⁶^,¹¹^,¹³

Figure 4. A computed tomographic scan in a 44-year-old man with hemoptysis. The solid mass on the left is a mycetoma within a thin-walled cavity in the left upper lobe.

CT is superior to fiberoptic bronchoscopy in finding a cause of hemoptysis, its main advantage being its ability to show distal airways beyond the reach of the bronchoscope, and the lung parenchyma surrounding these distal airways.⁵^,¹⁵^,¹⁶ In locating the site of bleeding, CT performs about as well as fiberoptic bronchoscopy.⁵

However, while CT imaging is extremely useful in evaluating bleeding from larger vessels, it adds little information beyond that obtained by chest radiography in cases of diffuse alveolar hemorrhage.⁴

Multidetector CT angiography is the optimal CT study for evaluating hemoptysis. In addition to showing the lung parenchyma and airways, it allows one to evaluate the integrity of pulmonary, bronchial, and nonbronchial systemic arteries within the chest. It is at least as good as (and, with multiplanar reformatted images, possibly even better than) conventional angiography in evaluating bronchial and nonbronchial systemic arteries. Multidetector CT angiography is recommended before bronchial artery embolization to help one plan the procedure and shorten the procedure time, if the patient is stable enough that this imaging study can be done first.⁶^,¹²^,¹³

The iodinated contrast material used in CT angiography can cause contrast nephropathy in patients with renal failure. At Cleveland Clinic, we avoid using contrast if the patient’s serum creatinine level is 2.0 mg/dL or greater or if it is rapidly rising, even if it is in the normal range or only slightly elevated; a rapid rise would indicate acute renal failure (eg, in glomerulonephritis). In these cases, we recommend CT without contrast.

CT of the chest has revealed malignancies in cases of hemoptysis in which radiography and bronchoscopy did not.¹⁵^,¹⁷ Although CT is more than 90% sensitive in detecting endobronchial lesions, it has limitations: a blood clot within the bronchus can look like a tumor, and acute bleeding can obscure an endobronchial lesion.⁵ Thus, bronchoscopy remains an important, complementary diagnostic tool in the evaluation of acute hemoptysis.

Bronchoscopy

Bronchoscopy is overall much less sensitive than CT in detecting the cause of the bleeding,¹⁵^,¹⁶^,¹⁸ but, if performed early it as useful as CT in finding the site of bleeding,⁵^,⁹ information that can be helpful in planning further therapy.¹⁹ It may be more useful than CT in evaluating endobronchial lesions during acute hemoptysis, as active bleeding can obscure an endobronchial lesion on CT.⁵ However, the distal airways are often filled with blood, making them difficult to evaluate via bronchoscopy.

In approximately 10% of cases of massive hemoptysis, rigid bronchoscopy is preferred over fiberoptic bronchoscopy, and it is often used in a perioperative setting. However, its use is not usually possible in unstable patients receiving intensive care. Instead, flexible fiberoptic bronchoscopy can be used in patients whose condition is too unstable to allow them to leave the intensive care unit to undergo CT. Flexible fiberoptic bronchoscopy does not require an operating room or anesthesia,¹⁹ and can be done in the intensive care unit itself.

Not only can bronchoscopy accurately locate the site of bleeding, it can also aid in controlling the airway in patients with catastrophic hemorrhage and temporarily control bleeding through Fogarty balloon tamponade, direct application of a mixture of epinephrine and cold saline, or topical hemostatic tamponade therapy with a solution of thrombin or fibrinogen and thrombin.²^,³^,¹⁹ It also provides complementary information about endobronchial lesions and is valuable in providing samples for tissue diagnosis and microbial cultures.

Diagnostic angiography has limitations

Although it is possible to bypass radiography, CT, and bronchoscopy in a case of massive hemoptysis and to rush the patient to the angiography suite for combined diagnostic angiography and therapeutic bronchial artery embolization, this approach has limitations. Diagnostic angiography does not identify the source of bleeding as well as CT does.⁶ It is important to locate the bleeding site first via CT, multidetector CT angiography, or bronchoscopy. Diagnostic angiography can be time-consuming. The procedure time can be significantly shorter if CT, bronchoscopy, or both are done first to ascertain the site of bleeding before bronchial artery embolization.¹^,⁶ Another reason that performing CT first is important is that it can rule out situations in which surgery would be preferred over bronchial artery embolization.⁶

In more than 90% of cases of hemoptysis requiring embolization or surgery, the bleeding is from the bronchial arteries.⁵^,⁶^,⁹^,^11–13 However, bronchoscopy before bronchial artery embolization is unnecessary in patients with hemoptysis of known cause if the site of bleeding can be determined from radiography or CT and if no bronchoscopic airway management is needed.¹⁸

References

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