Hemoptysis

Aka: Hemoptysis, Bloody Sputum, Massive Hemoptysis, Pulmonary Hemorrhage

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II. Definitions

  1. Hemoptysis
    1. Blood expectorated from below the Vocal Cords
    2. Sources include the lung parenchyma and airways (trachea, Bronchi, Bronchioles)
  2. Minor Hemoptysis
    1. Self-limited, small volume blood loss (without risk of further bleeding) in otherwise healthy lungs
    2. Stable Vital Signs, adequate oxygenation and ventilation
    3. Originates from tracheobronchial capillaries, due to minor Bronchial infections or coughing
    4. Massive Hemoptysis may begin with minor Hemoptysis (Exercise caution)
  3. Massive Hemoptysis
    1. Functional diagnosis of critically ill patient with impaired airway or hemodynamic compromise
    2. Older criteria included expectoration of >100 ml of blood per 24 hours (or 50 ml in a single cough)
      1. Various volume criteria have been used ranging from 100 to 600 ml per 24 hours
    3. Originates from Bronchial arteries, due to various causes (e.g. Tuberculosis, Bronchiectasis, Bronchogenic Carcinoma)
  4. Life-Threatening Hemoptysis
    1. Hemoptysis AND
    2. Hemodynamic instability, abnormal gas exchange or need for urgent Resuscitation

III. Precautions

  1. Even small volumes of bright red blood (not simply blood tinged Sputum) may herald Massive Hemoptysis
  2. Evaluate carefully and consider early Endotracheal Intubation in high risk cases
  3. Patients with Hemoptysis die of asphyxiation, not Hemorrhage

IV. Epidemiology

  1. Incidence: 1 in 1000 patients per year
  2. Only 1 to 5% of hempotysis cases meet criteria for Massive Hemoptysis
    1. Massive Hemoptysis is associated with a 50% mortality rate
    2. Mortality is due to asphyxia, not acute Hemorrhagic Shock

V. Pathophysiology: Vessel injury mechanisms

  1. Inflammation
    1. Acute (e.g. Acute Bronchitis)
    2. Chronic (e.g. Bronchiectasis, Systemic Lupus Erythematosus)
  2. Infection (e.g. Aspergillosis, Tuberculosis)
    1. Erode Bronchial vessels
    2. Trigger proliferation of fragile vessels
    3. Risk of spontaneous Massive Hemorrhage (esp. Tuberculosis, worldwide)
  3. Infarction (e.g. Lung Infarction, Pulmonary Embolism)
    1. Tissue necrosis
    2. Increased collateral pressure in Bronchial vessels bypassing obstructed main vessels
  4. Trauma
    1. Deceleration injuries (e.g. MVA)
    2. Penetrating Trauma (e.g. Gunshot Wound)
    3. Iatrogenic (lung biopsy, bronchoscopy, right heart catheterization)
  5. Miscellaneous
    1. Fistulization
    2. Malignant invasion

VI. Pathophysiology: Arterial Sources of Bleeding

  1. See Hemoptysis Causes
  2. General
    1. Minor Hemorrhage: Tracheobronchial capillary injury
    2. Severe Hemorrhage: Major Arterial injury (Bronchial artery, Pulmonary artery)
  3. Bronchial Artery
    1. Bronchial artery represents only 1% of lung perfusion (remainder is from pulmonary artery)
      1. However, Bronchial arteries are responsible for 90% of Pulmonary Hemorrhage
      2. Bronchial arteries are the primary arterial supply of intrapulmonary arteries
    2. Bronchial arteries anastomose with pulmonary arteries
    3. Pulmonary artery impaired flow (e.g. Pulmonary Embolism) shunts blood through Bronchial arteries
      1. Bronchial arteries have thin walls and are subject to rupture, with bleeding into alveoli and Bronchi
  4. Pulmonary Artery
    1. Pseudoaneurysms form in pulmonary arteries when adjacent lung parenchyma is chronically inflamed
    2. Chronic inflammation has many causes (e.g. Tb, cancer, Fungal Lung Infection, Lung Abscess)
  5. Non-Bronchial Systemic Artery
    1. Neovascularization and collateral circulation develops in response to chronic inflammation (see above)
    2. Affected vessels anastomose with fragile pulmonary vessels, which on rupture cause Hemoptysis

VII. History

  1. See Hemoptysis Causes
  2. Severity of Hemoptysis
    1. Blood streaked Sputum
      1. Typically appropriate for outpatient evaluation
    2. Gross Hemoptysis
      1. Exercise caution
      2. Even initially small volumes of Hemoptysis may progress to Massive Hemoptysis
  3. Past medical history
    1. Congestive Heart Failure
    2. Valvular heart disease
    3. Obstructive Lung Disease (e.g. COPD, Asthma, Bronchiectasis)
    4. Pulmonary Embolism Risk Factors (e.g. surgery, immobilization, travel, Estrogens, Family History)
    5. Cirrhosis or other Chronic Liver Disease
    6. Renal disease
    7. Personal or Family History of Bleeding Disorders (Coagulopathy, Thrombocytopenia)
    8. History or exposure to Tuberculosis (e.g. international travel to endemic regions)
    9. Cancer history
  4. Medications and toxins
    1. Anticoagulants (e.g. Warfarin, DOACs)
    2. Antplatelet Medications (e.g. Aspirin, Clopidogrel)
    3. Immunosuppression
    4. Tobacco Abuse (Lung Cancer, COPD, Bronchiectasis)
    5. Cocaine Inhalation
  5. Cough
    1. Obstructive Lung Disease (e.g. Bronchiectasis, COPD, Asthma)
    2. Foreign Body Aspiration
    3. Infection (Acute Bronchitis, Pneumonia, Tuberculosis)
  6. Fever
    1. Acute Bronchitis (most common cause)
    2. Pneumonia
    3. Lung Abscess
    4. Tuberculosis
    5. Pulmonary Embolism
    6. Lung Cancer
    7. Rheumatologic Disease
  7. Trauma
    1. Airway Trauma
    2. Lung Contusion
    3. Pulmonary Embolism
    4. Recent respiratory tract instrumentation (e.g. bronchoscopy, Nasolaryngoscopy)
  8. Unintentional Weight Loss
    1. Chronic Obstructive Pulmonary Disease (COPD)
    2. Lung Cancer
    3. Tuberculosis
    4. Rheumatologic Disease
  9. Travel or birth in endemic Tuberculosis regions
    1. Tuberculosis (U.S. Immigrants have 4 fold higher risk)
  10. Miscellaneous
    1. Other sites of bleeding (e.g. Hematuria, melana, Epistaxis, Menorrhagia)
    2. Pseudohemoptysis sources (e.g. Upper GI Bleed, Epistaxis, oropharyngeal bleeding)
      1. Nasal Trauma
      2. Coffee Ground Emesis or Epigastric Pain

VIII. Exam

  1. Complete Vital Signs
  2. Lung Exam (may localize source of bleeding to one segment of the lung)
    1. Focal rales (e.g. Pneumonia)
    2. Wheezing (e.g. COPD)
  3. Examine for bleeding sources
    1. Oropharyngeal lesions or bleeding
    2. Epistaxis
    3. External Trauma to head, neck or chest
    4. Rectal Exam for black stool (upper gastrointestinal Hemorrhage)
  4. Examine for signs of Coagulopathy or other underlying Hemorrhage or inflammation risks
    1. Petechiae or Purpura
    2. Cirrhosis stigmata
    3. Multiple sources of bleeding (e.g. Gingival Bleeding, Rectal Bleeding)
    4. Cachexia
    5. Rheumatologic findings (e.g. synovitis, Cutaneous Signs of Rheumatic Disease)
    6. Unilateral Leg Edema (e.g. Deep Vein Thrombosis)
  5. Hemoptysis
    1. Frothy Sputum with bright red blood, and alkaline pH
    2. Contrast with Hematemesis (coffee grounds with acidic pH)
  6. Findings suggestive of Massive Hemoptysis (respiratory or hemodynamic compromise)
    1. Dyspnea
    2. Tachypnea
    3. Increased work of breathing
    4. Wheezing
    5. Cyanosis
    6. Hypoxia
    7. Altered Mental Status
    8. Hypotension
    9. Tachycardia

IX. Labs

  1. First-line studies
    1. Complete Blood Count with Platelets and differential
    2. Comprehensive Metabolic Panel
    3. ProTime (PT, INR)
    4. Partial Thromboplastin Time (aPTT)
    5. Blood Type and Cross-match (in Massive Hemoptysis)
    6. Sputum Gram Stain and culture
      1. Consider acid-fast bacilli, Fungal Culture, cytology
  2. Other studies to consider
    1. D-Dimer
    2. HIV Test
    3. Brain Natriuretic Peptide (BNP)
    4. Arterial Blood Gas or Venous Blood Gas
    5. Quantiferon-TB (or PPD)
      1. Does not replace Sputum testing when acute symptoms are present
    6. Electrocardiogram (EKG)
    7. Acute phase reactants (e.g. C-RP, ESR)
    8. Rheumatologic studies (e.g. ANCA, FANA, anticardiolipin, xGBM)
    9. Spirometry or Pulmonary Function Tests
      1. Do not perform in acute Hemoptysis (consider once stabilized)

X. Imaging

  1. Chest XRay
    1. First-line in most cases
    2. Normal in 20 to 30% of cases
    3. Test Sensitivity for identifying bleeding site: 33 to 82% (and identifies cause in 35% of cases)
      1. Findings include Pneumonia, cavitary lesions, Lung Abscess, Lung Mass, alveolar Hemorrhage
      2. Lower sensitivity for Lung Cancer (misses up to 10% of Bronchogenic Carcinomas in Hemoptysis)
        1. Thirumaran (2009) Thorax 64(10): 854-6 [PubMed]
  2. Chest CT with Contrast (or CTA)
    1. Typically perform as CTA (with PE timed contrast)
      1. May identify vascular sources of Hemorrhage
    2. Test Sensitivity for detecting bleeding site
      1. Standard Chest CT: 70-88% (and identifies the cause in 60-77% of cases)
      2. Multidetector Chest CT: 100% for Bronchial arteries (62% for non-Bronchial arteries)
    3. Indications
      1. Identify source of Hemoptysis to direct Intervention Radiology or surgery (Massive Hemoptysis)
      2. Mass lesion on Chest XRay
      3. Lung Cancer risk factors (e.g. Tobacco Abuse)
      4. Failed resolution of Pulmonary Infiltrate on Chest XRay
      5. Suspected Pulmonary Embolism
      6. Persistent symptoms despite negative Chest XRay
  3. Bronchoscopy
    1. Test Sensitivity for identifying bleeding site: 73-93% (and identifies cause in <8% of cases)
    2. Indications
      1. CT chest non-diagnostic
      2. Mass lesion on Chest XRay
      3. Recurrent Hemoptysis
      4. Patient too unstable to undergo CT
  4. Bronchial artery arteriography
    1. Used in some cases when Intervention Radiology is planned for embolization
  5. Echocardiogram
    1. Consider (esp. early POCUS) in the evaluation of cardiovascular cause (e.g. CHF)
  6. Consider other diagnostics if suspected Pseudohemoptysis
    1. Upper Endoscopy
    2. Nasopharyngoscopy

XI. Differential Diagnosis

  1. See Hemoptysis Causes
  2. Hemoptysis is with no known cause (cryptogenic) in 20 to 50% of cases
  3. Hemoptysis requiring acute emergent management is from Bronchial arteries in 90% of cases
  4. Pseudohemoptysis
    1. Upper Gastrointestinal Bleeding
      1. Coffee ground Emesis
      2. Low, acidic pH
    2. Upper respiratory source (e.g. Epistaxis, pharyngeal bleeding
      1. Consider Nasolaryngoscopy

XII. Evaluation: Non-Massive Hemoptysis

  1. See labs above
  2. Step 1: Consider non-lower respiratory cause (Pseudohemoptysis)
    1. Upper respiratory source (e.g. Sinusitis)
    2. Upper Gastrointestinal Bleeding (Hematemesis)
      1. Coffee grounds with acidic pH
  3. Step 2: Chest XRay
    1. See imaging as above
    2. Treat suspected causes based on initial findings
  4. Step 3: CT Chest or CTA Chest Indications
    1. Non-diagnostic history, exam, labs and chest x-ray
    2. High suspicion for serious underlying cause (e.g. Pulmonary Embolism, Trauma, cancer)
  5. Step 4: Bronchoscopy Indications
    1. See imaging above

XIII. Management: Massive Hemoptysis

  1. See ABC Management
  2. Position patient
    1. Decubitus position with bleeding lung side down (if known source, e.g. Lung Lesion)
    2. Place in trendelenburg position If bilateral lung Hemorrhage
  3. Patient alert, not hypoxic and able to clear their own airway
    1. Supplemental Oxygen
    2. Consider nebulized Tranexamic Acid
    3. Avoid BIPAP or other positive pressure that interferes with airway clearance of blood
    4. Observe closely for decompensation
      1. Bronchial tree will completely fill with 150-200 cc of blood
      2. Patients with a strong cough, respiratory and cardiovascular stability may not require initial intubation
  4. Advanced Airway (patient decompensating, hypoxic)
    1. Attempt awake intubation under Ketamine
      1. Allows for visualization of cords as patient coughs and clears airway
    2. Large bore suction or suction via Endotracheal Tube attached to meconium aspirator
    3. Place as large a bore Endotracheal Tube as possible (e.g. >7.5 up to 8.5)
      1. Size 8.5 ET Tube allows for flexible bronchoscope passage
      2. Allows for Hemorrhage treatment with balloon tamponade, fogarty catheter or laser treatment
    4. Emergency Cricothyrotomy if unable to intubate
  5. Imaging
    1. Obtain portable Chest XRay
    2. Obtain CT Chest or CTA Chest only when stable
  6. Lung isolation
    1. Best performed by bronchoscopy if skilled operator available (e.g. pulmonology, thoracic surgery)
    2. Suspected source of Massive Hemorrhage is on the LEFT
      1. Pass the Endotracheal Tube into the right mainstem Bronchus (bleeding should stop)
    3. Suspected source of Massive Hemorrhage is on the RIGHT
      1. Pull ET Tube back to glottis (but still below Vocal Cords)
      2. Pass bougie (or bronchoscope) through ET Tube and rotate bougie 90 degrees left
      3. Pass ET Tube over the bougie and assess bleeding and position (auscultation, Chest XRay)
  7. Emergent Consultation
    1. Pulmonology Consultation for bronchoscopy
      1. Indications
        1. Endobronchial lesion
        2. Source unknown
        3. Unstable Patient (increasing Hypoxia, loss of airway protection, Altered Mental Status)
      2. Interventions
        1. Lung isolation
        2. Balloon tamponade (fogarty catheter)
        3. Electrocautery
        4. Argon plasma coagulation
        5. Nd:YAG laser
        6. Other measures (e.g. ice-cold saline, Epinephrine or Norepinephrine)
    2. Intervention Radiology
      1. Directed Bronchial artery embolization (BAE)
        1. Bronchial arteries are source in 90% of Massive Hemorrhage cases
      2. Efficacy in control of Hemorrhage: >70%
      3. Indications
        1. Parenchymal bleeding identified
        2. Non-surgical candidate with vascular injury (e.g. Trauma)
        3. Refractory Hemorrhage despite bronchoscopy or thoracic surgery
      4. Recurrent bleeding risk
        1. Occurs in 10 to 58% of patients
        2. Median onset of rebleeding at 6-12 months (unlikely after 3 years)
        3. Rebleeding Risk Factors
          1. Non-Bronchial collateral vessels
          2. Aspergillosis
          3. Tuberculosis (reactivation or multi-drug resistant)
          4. Cancer
          5. Severe Hemoptysis history
          6. Findings on bronchoscopy (blood clots or active bleeding)
    3. Cardiothoracic surgery Consultation
      1. Indications
        1. Chest Trauma
        2. Vascular injury (e.g. iatrogenic pulmonary artery rupture)
        3. Complex Arteriovenous Malformation
        4. Refractory Hemoptysis to bronchoscopy and Intervention Radiology (e.g. aspergilloma, Lung Abscess)
      2. Surgical Complications
        1. Perioperative bleeding
        2. Asphyxia
        3. Bronchopleural Fistula
      3. High mortality risk
        1. Not actively bleeding: 2 to 18% mortality
        2. Active Hemoptysis: 25 to 50% mortality
    4. ECMO may be needed
  8. Manage Coagulopathy
    1. See Coagulation Bleeding Disorders
    2. See Emergent Reversal of Anticoagulation
    3. Consider Tranexamic Acid (TXA) IV or nebulized (see above)
  9. References
    1. Swaminathan and Weingart in Herbert (2019) EM:Rap 19(3): 10-11

XIV. Management: Indications for ICU Admission or Tertiary Care Transfer

  1. Lesions at the highest risk of bleeding (e.g. Aspergillus infection, pulmonary artery involved)
  2. Respiratory distress or Hypoxia
    1. Respiratory Rate >30 per minute
    2. Oxygen Saturation <88% on room air
    3. Requiring High Flow Oxygen at >8 L/min or Mechanical Ventilation
  3. Hemodynamic instability
    1. Hemoglobin < 8 g/dl (or more than 2 g/dl drop from baseline)
    2. Disseminated Intravascular Coagulation (DIC) or other consumptive Coagulopathy
    3. Hypotension requiring intervention (fluid bolus, transfusion, Vasopressors)
  4. Massive Hemoptysis
    1. Hemoptysis >200 ml per 24 hours OR
    2. Hemoptysis >50 ml per 24 hours in a patient with COPD
  5. Serious comorbidity
    1. Previous pneumonectomy
    2. Chronic Obstructive Pulmonary Disease (COPD)
    3. Cystic Fibrosis
    4. Ischemic Heart Disease
  6. References
    1. Fartoukh (2010) Rev Mal Respir 27(10): 1243-53 +PMID:21163400 [PubMed]

XV. Management: Non-Massive Hemoptysis

  1. See Evaluation above
  2. Serially re-evaluate for signs of more significant Hemoptysis (at risk for Massive Hemoptysis)
  3. Give strict return precautions
  4. Treat the underlying cause of Hemoptysis
    1. Consider Antibiotic course if symptoms or signs of lower respiratory infection (e.g. Pneumonia)
    2. Consider Corticosteroids and/or Bronchodilators (e.g. Asthma, COPD)
    3. Consider Antitussive medications (e.g. Acute Bronchitis)
  5. Additional evaluation
    1. Consider CT Chest
    2. Consider pulmonology Consultation for bronchoscopy

XVI. Prognosis: Moderate to Severe Hemoptysis Mortality

  1. Criteria
    1. Score 1: Admit Chest XRay with involvement of 2 or more lung quadrants
    2. Score 1: Chronic Alcoholism
    3. Score 1: Pulmonary artery involvement
    4. Score 2: Aspergillosis
    5. Score 2: Malignancy
    6. Score 2: Mechanical Ventilation required
  2. Interpretation
    1. Admit to ICU for score >2 (see other indications above)
    2. Consider urgent Intervention Radiology for score >5
  3. Mortality: In-Hospital
    1. Total 0: Mortality 1%
    2. Total 1: Mortality 2%
    3. Total 2: Mortality 6%
    4. Total 3: Mortality 16%
    5. Total 4: Mortality 34%
    6. Total 5: Mortality 58%
    7. Total 6: Mortality 79%
    8. Total 7: Mortality 91%
  4. References
    1. Fartoukh (2012) Respiration 83(2): 106-14 +PMID:22025193 [PubMed]

XVII. Prognosis: Mild Hemoptysis

  1. Mortality: 0.3%
  2. Recurrence in 19% of patients (73% rebleed in first 2 years)
  3. Risks for recurrent bleeding
    1. Aspergillosis
    2. Nontuberculous Mycobacterium infection
    3. Smoking
    4. Findings on bronchoscopy (blood clots or active bleeding)
  4. References
    1. Choi (2018) Am J Emerg Med 36(7): 1160-5

XVIII. References

  1. John, Reeder and Thomas (2023) Crit Dec Emerg Med 37(12): 23-9
  2. Bidwell (2005) Am Fam Physician 72(7):1253-60 [PubMed]
  3. Corder (2003) Emerg Med Clin North Am 21:421-35 [PubMed]
  4. Earwood (2015) Am Fam Physician 91(4): 243-9 [PubMed]
  5. O'Gurek (2022) Am Fam Physician 105(2): 144-51 [PubMed]

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