Massive haemoptysis: the definition should be revised

To the Editors:

Massive haemoptysis represents one of the most challenging conditions in clinical practice. The condition is potentially lethal and, therefore, warrants clear understanding and precise definition. The definition of massive haemoptysis has not been completely agreed upon and varies widely in the literature. It is unfortunate that almost all previous definitions of massive haemoptysis relied only on the volume of expectorated blood. The use of expectorated blood volume alone to define massive haemoptysis is often misleading and confusing for three main reasons. First, no cut-off volume has been agreed upon in the literature. While Amirana et al. 1 proposed an amount of 100 mL of expectorated blood in 24 h to define massive haemoptysis, Corey and Hla 2 defined massive haemoptysis as expectoration of ≥1,000 mL of blood over 24 h. In the middle of the spectrum we find other studies that use 200 mL 3, 240 mL 4, 500 mL 5 or 600 mL 6 as a cut-off volume for the definition of massive haemoptysis. Secondly, in real practice, the quantification of haemoptysis is often difficult and, from a clinical point of view, such criteria are not useful 7. In many instances the amount of expectorated blood may be exaggerated by patients. Furthermore, in a majority of patients, quantification of expectorated blood volume may underestimate the overall amount of blood loss because the volume of blood engulfing the involved lobes or lungs is not quantified and may be significant 8. Thirdly, morbidity and mortality in patients with haemoptysis depend on not only the volume of expectorated blood but also the rate of bleeding, the ability of the patient to clear blood from the airways and the extent and severity of any underlying lung disease 9. The confusion created by the arbitrary use of the volume of expectorated blood to define massive haemoptysis has led other authors to consider the magnitude of effects (namely airway obstruction and hypotension) as the defining factors 10, 11.

I feel that the confusion will persist if we continue to use the word “massive”. The term “massive haemoptysis” is a general term that was originally selected to describe the magnitude of life-threatening bleeding. Over time, this term became a loosely applied descriptor for the condition as the word “massive” necessitates the identification of a specific volume of blood. Therefore, in order to precisely define this serious condition, we should move away from using the word massive. The term “life-threatening haemoptysis” may provide a fascinating and rich understanding of the condition. Thus, life-threatening haemoptysis may be defined as any haemoptysis that: 1) is >100 mL in 24 h; 2) causes abnormal gas exchange/airway obstruction; or 3) causes haemodynamic instability. The cut-off volume of 100 mL per 24 h has been selected because it is the smallest amount of haemoptysis that is reported in literature to threaten the life of the patient.

Statement of interest

None declared.