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
- Neoplastic
- Lung cancer
- Metastatic cancer
- Cardiovascular
- Pulmonary embolism
- Congestive heart failure
- Pulmonary hypertension
- AV malformation
- Mitral stenosis
- Alveolar hemorrhage syndromes
- Hematologic
- Uremia
- Platelet dysfunction (ASA, clopidogrel)
- Anticoagulant therapy
- Traumatic
- Foreign body aspiration
- Ruptured bronchus
- Inflammatory
- 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
- CXR
- 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
- Coagulopathy
- Emergent bronchoscopy or embolization for life-threatening hemorrhage
- Nebulized TXA 500 mg tid[2]
- Pediatric: used in report
- IV TXA may reduce in-hospital mortality, length of stay, and total healthcare costs[3]
- Absolute in-hospital mortality reduction was 2.5% in the retrospective study of nearly 20,000 patients
- No particular dosing regimen, but in this study, no association was found between TXA and seizures, in part per the authors, due to most patients receiving no more than 2 g of TXA total
Massive
- Angle head down with affected lung low
- Consider angio embolization
- Consider intubation 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
- ↑ Gottlieb M, Sharma V, Field J, Rozum M, Bailitz J. Utilization of a gum elastic bougie to facilitate single lung intubation. Am J Emerg Med. 2016 Dec;34(12):2408-2410. doi: 10.1016/j.ajem.2016.08.057. Epub 2016 Aug 27. PMID: 27614374.
- ↑ Wand O, et al. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. DOI: https://doi.org/10.1016/j.chest.2018.09.026
- ↑ Kinoshita T, Ohbe H, Matsui H, Fushimi K, Ogura H, Yasunaga H. Effect of tranexamic acid on mortality in patients with haemoptysis: a nationwide study. Crit Care. 2019;23(1):347. Published 2019 Nov 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6836388/