Hemoptysis

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

• Epistaxis
• Oropharynx bleeding
• Hematemesis

Hemoptysis

• Infectious
  • Bronchitis
  • Pneumonia
  • Lung abscess
  • Tuberculosis
  • Plague
  • Aspergilloma
  • Coccidioidomycosis
• Neoplastic
  • Lung cancer
  • Metastatic cancer
• Cardiovascular
  • Pulmonary embolism
  • Congestive heart failure
  • Pulmonary hypertension
  • AV malformation
• Mitral stenosis
• Alveolar hemorrhage syndromes
  • Goodpasture syndrome
  • Granulomatosis with polyangiitis (Wegener)
  • SLE
• Hematologic
  • Uremia
  • Platelet dysfunction (ASA, clopidogrel)
  • Anticoagulant therapy
• Traumatic
  • Foreign body aspiration
  • Ruptured bronchus
• Inflammatory
  • Bronchiectasis
  • Cystic fibrosis
• Miscellaneous
  • Cocaine inhalation (crack lung)
  • Catamenial pneumothorax
  • Goodpasture syndrome
  • Cystic fibrosis
  • Epistaxis
  • Blood-laced mucus from the sinus or nose area
  • Upper GI bleeding

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.
• May differentiate from hematemesis with pH litmus paper
  • Hemoptysis tends to be alkaline
  • Hematemesis tends to be acidic, and stomach acid tends to turn bright red blood in stomach to brown/black fragments unless massive

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
  • FFP
• 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)

When all else fails

• Consider Nebulized TXA
  • Adult Patients
    • A 2015 Case Report found that nebulized TXA was a safe, effective, and noninvasive method for controlling/temporizing hemoptysis in select patients.
  • Pediatric Patients
    • An audio case report on the July 2018 episode of EMRAP discussed giving 0.5g of nebulized TXA for a pediatric patient in order to control/temporize hemoptysis.
  • The evidence is limited. However, if you are in the situation where nothing else is working, you might as well try it.

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