Radiologic approach to hemoptysis in emergency setting: Tackling critical points in patient management

Background / Objective 1. To overview the validity, timing and CT protocols appropriate in examination of hemoptysis. 2. To highlight imaging findings associated with pulmonary hemorrhage, that can help direct patients to suitable treatment. 3. To improve awareness about different types of mechanisms of hemoptysis and their impact to patient management. Methods Hemoptysis is described as coughing up blood from any part of the lungs and must be differentiated from other sources like upper airways or GI tract. It is generally graded into minor or massive and the rate of bleeding is associated with the risk of asphyxiation and blood loss. While chest x-ray may be appropriate in some clinical setting, CT is considered the golden standard in moderate or massive hemoptysis allowing noninvasive, rapid examination of the potential cause, that can aid the choice of further patient management. Results X-ray can help suspect initial diagnosis, however CT is usually appropriate for a stable patient. Scanning protocol includes arterial phase, with an increased coverage and native CT or venous phase can be included case-based suspecting foreign object or the need for tumoral or parenchymal enhancement. Common sources of bleeding can be divided into primary vascular origin like hypertrophied systemic vessels, pseudoaneurysms or AVM’s, direct airway invasion or parenchymal destruction including bronchiectasis, tumor or infection and capillary-level bleeding relating to diffuse alveolar hemorrhage and vasculitis. Findings suggesting hemorrhage are usually nonspecific and appear as ground-glass or consolidation, bronchial plugging, that can be of higher attenuation and in subacute cases septal lines may be thickened, however contrast extravasation is rarely seen. The appearance and distribution of these signs can help direct radiologists to local or diffuse origin of bleeding and accordingly advise management by further examination, bronchoscopy, surgery, endovascular or conservative treatment. Conclusions 1. CT is the modality of choice in detecting source of pulmonary bleeding and protocol should be directed using case-based approach. 2. CT allows visualisation of vascular sources, bronchial invasion, potential areas of parenchymal hemorrhage, in combination with the distribution of secondary findings helps directing targeted therapy. 3. Depending on the mechanism of bleeding including vascular, airway or parenchymal origin accordingly, endovascular treatment, bronchoscopy and conservative management may be appropriate.