Massive haemoptysis DDx

Overview

• Haemoptysis is the symptom of coughing up blood. Massive haemoptysis has no generally accepted definition. Suggested volumes range from 100 mL to more than 1000 mL.
• A more relevant definition of massive haemoptysis is the volume that is life threatening by virtue of airway obstruction or blood loss (anatomical dead space is only 100-200 mL)
• Origin is bronchial circulation in 95%, and pulmonary circulation in 5%.
• Alveolar haemorrhage rarely causes massive haemoptysis

Causes

Chronic inflammatory conditions (including bronchiectasis, tuberculosis, lung abscess) and lung malignancies are the most common causes

Infections

• Mycobacteria, particularly tuberculosis
• Fungal infections (mycetoma)
• Lung abscess
• Necrotising pneumonia (Klebsiella, Staphylococcus, Legionella)

Iatrogenic

• Swan-Ganz catheterisation
• Bronchoscopy
• Transbronchial biopsy
• Transtracheal aspirate

Parasitic

• Hydatid cyst
• Paragonimiasis

Trauma

• Blunt/penetrating injury
• Suction ulcers
• Tracheo-arterial fistula

Neoplasia

• Bronchogenic carcinoma
• Bronchial adenoma
• Pulmonary metastases
• Sarcoma

Children

• Bronchial adenoma
• Foreign body aspiration
• Vascular anomalies

Vascular

• Pulmonary infarct, embolism
• Mitral stenosis
• Arteriobronchial fistula
• Arteriovenous malformations
• Bronchial telangiectasia
• Left ventricular failure

Coagulopathy

• Von Willebrand’s disease
• Haemophilia
• Anticoagulant therapy
• Thrombocytopenia
• Platelet dysfunction
• Disseminated intravascular coagulation

Vasculitis

• Behcet disease
• Granulomatosis With Polyangiitis (GPA, Wegener granulomatosis)

Pulmonary

• Bronchiectasis (including cystic fibrosis)
• Chronic bronchitis
• Emphysematous bullae

Miscellaneous

• Lymphangioleiomatosis
• Catamenial (endometriosis)
• Pneumoconiosis
• Broncholith
• Idiopathic

Spurious

• Epistaxis
• Haematemesis

References and Links

Journal articles and textbooks

• Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax. 2003 Sep;58(9):814-9. PMC1746797.

CCC Differential Diagnosis Series
NEURO	Anosmia, Ataxia, Blepharospasm, Bulbar and Pseudobulbar palsy, Central Pontine Myelinosis, Cerebellar Disease, Chorea, Cranial nerve lesions, Dementia, Dystonia, Exophthalmos, Eye trauma, Facial twitches, Fixed dilated pupil, Horner syndrome, Loss of vision, Meningism, Movement disorders, Optic disc abnormality, Parkinsonism, Peripheral neuropathy, Radiculopathy, Red eye, Retinal Haemorrhage, Seizures, Sudden severe headache, Tremor, Tunnel vision
RESP	Bronchial breath sounds, Bronchiectasis, High airway pressures, Massive haemoptysis, Sore throat, Tracheal displacement
CVS	Atrial Fibrillation, Bradycardia, Cardiac Failure, Chest Pain, Murmurs, Post-resuscitation syndrome, Pulseless Electrical Activity (PEA), Pulsus Paradoxus, Shock, Supraventricular tachycardia (SVT), Tachycardia, VT and VF, SVC Obstruction
GIT	Abdominal distension, Abdominal mass, Abdominal pain, Asterixis, Dysphagia, Hepatomegaly, Hepatosplenomegaly, Large bowel obstruction, Liver palpation abnormalities, Lower GI haemorrhage, Malabsorption, Medical causes of abdominal pain, Rectal mass, Small bowel obstruction, Upper GI Haemorrhage
GUT	Genital ulcers, Groin lump, Scrotal mass, Urine colour, Urine Odour, Urine transparency,
MSK	Arthritis, Shoulder pain, Wasting of the small muscles of the hand
DERM	Palmar erythema, Serious skin signs in sick patients, Thickened Tethered Skin, Leg ulcers, Skin Tumour, Acanthosis Nigricans
ENDO	Diabetes Insipidus, Diffuse Goitre, Gynaecomastia, Hirsutism, Hypoglycaemia, SIADH, Weight Loss
HAEM	Splenomegaly
PAEDS	Floppy infant
MISC	Anaphylaxis, Autoimmune associated diseases, Clubbing, Parotid Swelling, Splinter haemorrhages, Toxic agents and abnormal vitals, Toxicological causes of cardiac arrest
IMAGING	CHEST: Atelectasis, Hilar adenopathy, Hilar enlargement on CXR, Honeycomb lung, Increased interstitial markings, Mediastinal widening on mobile CXR, Pulmonary fibrosis, Pseudoinfiltrates on CXR, Pulmonary opacities on CXR, ABDO: Gas on abdominal X-ray, Kidney mass, BRAIN: Intracranial calcification, Intracranial structures with contrast, Ventriculomegaly, OTHER: Pseudofracture on X-Ray,
LABS	LOW: Anaemia, Hypocalcaemia, hypochloraemia, Hypomagnesaemia,  HIGH: Bilirubin and Jaundice, Hyperammonaemia, Hypercalcaemia, Hyperchloraemia, Hyperkalaemia, Hypermagnesaemia,  ACID BASE: Acid base disorders, Resp. acidosis, Resp. alkalosis, Creatinine, CRP, Dipstick Urinalysis, Laboratory Urinalysis, Liver function tests (LFTs), Pleural fluid analysis, Urea, Urea Creatinine Ratio, Uric acid, Urinalysis, Urine Electrolytes

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