Hemoptysis in Older Adults: Etiology, Diagnosis, and Management
Samir Gupta, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.
Robert Hyland, MD, FRCPC, Division of Respirology, Department of Medicine, St. Michael’s Hospital, University of Toronto, Toronto, ON.
Hemoptysis is an important clinical problem that is especially ominous when seen in older patients. The main causes of hemoptysis in first world nations are bronchogenic carcinoma, bronchitis, and bronchiectasis. In older patients cancer remains the main concern, especially if there is a smoking history. The diagnostic approach to nonmassive hemoptysis starts with a chest x-ray, followed by a CT scan and then fibre optic bronchoscopy, which is well tolerated by older adults. In massive hemoptysis, chest x-ray is usually followed immediately by fibre optic or rigid bronchoscopy. Older patients require closer monitoring due to poor cardiopulmonary reserve; management options include endoscopic interventions, bronchial artery embolization,
surgery, and radiation.
Key words: hemoptysis, etiology, management, older adults, bronchiectasis.
Hemoptysis is defined as the coughing up of blood derived from the airways or the lungs; it is a term that can be traced back to its ancient Greek roots, haima (blood) and ptysis (spitting). As a clinical symptom, it is important not only in that it creates anxiety for both the patient and the physician but also because it can often portend a truly life-threatening condition, especially in the older population.
Etiology of Hemoptysis
The traditional list of the causes of hemoptysis is long and diverse (Table 1), but only a handful of causes account for the majority of clinically encountered cases. The distribution of these primary etiologies has changed over the last few decades and still varies among different populations. Most American case series from the 1940s and 1950s showed tuberculosis (TB), bronchiectasis, and bronchogenic carcinoma as the leading causes, each accounting for approximately 20% of cases. More contemporary series from first world medical centres have shown bronchogenic carcinoma, bronchitis, and bronchiectasis to be the leading causes, with 15–30% of cases remaining undiagnosed (“cryptogenic hemoptysis”) and with TB being a rarity.1 On the other hand, reports from inner city New York and several centres across Africa continue to show TB as the leading cause,2 clearly reflecting the high prevalence of TB in these populations.
Few studies have specifically addressed the etiology of hemoptysis in the older population, but retrospective studies have consistently shown a higher prevalence of lung cancer in older smokers presenting with hemoptysis, and this remains the principal concern in this population. The largest retrospective study in the United States showed that the most important predictors of cancer in the population presenting with hemoptysis was age >50, a smoking history >40 pack-years, and male sex.3 Today, with the aging population of female smokers and the alarming increases in female lung cancer rates, clinical suspicion of malignancy should be high in females with a smoking history. Furthermore, in a study of patients initially diagnosed with cryptogenic hemoptysis on the basis of a normal chest x-ray and bronchoscopy, seven out of 115 patients (six percent) developed bronchogenic carcinoma within three years of initial presentation, all of whom were smokers aged greater than 40.4 The only prospective evaluation of the causes of hemoptysis in older patients was performed by Wong et al. in Malaysia; they compared the causes of hemoptysis in a series of patients aged 60 or more to those in younger patients. In the older age group, bronchogenic carcinoma was the leading cause, accounting for 49.3% of cases; in the younger individuals, active pulmonary TB was the leading cause, accounting