Physical examination

The primary initial diagnostic aim in massive hemoptysis is to identify the source of bleeding. The clinician must confirm that the origin of the hemorrhage is, in fact, the respiratory tract below the level of the vocal cords rather than the gastrointestinal tract. Although the distinction is often obvious, it is not invariably so, inasmuch as vomited blood can spill into the tracheobronchial tree and induce coughing. This can also occur if the bleeding is of pharyngeal origin. In hematemesis the blood is generally darker, has an acidic pH, and may contain particles of partially digested food.

Once the pulmonary origin of bleeding is verified, attention should be focused on determining the side from which bleeding emanates. Patients themselves often cannot accurately localize the source of hemoptysis as being one lung or the other. Physical findings, such as localized rales, rhonchi, or wheezing are often not helpful, inasmuch as they may reflect pneumonitis or bronchial reaction to aspirated blood rather than denoting the bleeding site.

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