Hemoptysis

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Background

  • Coughing of blood that originates from respiratory tract below level of larynx
  • Death usually occurs from asphyxiation, not exanguination
  • Easy to confuse with epistaxis or oropharynx bleeding

Clinical Features

  • Coughing up blood

Differential Diagnosis

Hemoptysis

Evaluation

Workup

  • Imaging
    • CXR
      • Nml in 30% (most of whom end up having bronchitis)
    • Chest CT with IV contrast
      • Indicated for gross hemoptysis or suspicious CXR
    • Bronchoscopy
  • Labs
    • CBC
    • Coags
    • Sputum stain/culture
    • Chem (Cr)
    • T&S/T&C
    • Urinalysis (autoimmune)
    • ECG (pulmonary hypertension/PE)

Evaluation

  • Massive = A single expectoration of ≥ 50cc OR >600cc/24h
    • Rare, occurring in 1-5% of patients.

Management

  • Patient Placement
    • Placing patient with affected lung down may actually worsen V-Q mismatch
    • Some advocate for prone positioning
  • Intubation
    • Use 8-0 tube to allow for subsequent bronchoscopy
    • If possible can selectively intubate the unaffected bronchus to prevent aspiration
      • After tube passes through cords rotate 90degrees left or right and advance
  • Coagulopathy
  • Emergenct bronchoscopy or embolization for life-threatening hemorrhage

Massive

  1. Angle head down with affected lung low
  2. Consider angio embolization
  3. Intubate with >8.0 (for bronch)

Disposition

  • Gross hemoptysis:
    • Admit
  • Young patient (<40yr) with scant hemoptysis, normal CXR, no smoking history:
    • Discharge
  • Risk factors for neoplasm (even if CXR normal) or suspicious CXR:
    • Discuss with pulmonologist before discharge

References