Hemoptysis

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

1. See Also
   1. Hemoptysis Causes
2. Definitions
   1. Hemoptysis
      1. Blood expectorated from the lung parenchyma or airways (trachea, Bronchi, Bronchioles)
   2. Massive Hemoptysis
      1. Expectoration of >100 ml of blood per 24 hours (or 50 ml in a single cough)
      2. Various volume criteria have been used ranging from 100 to 600 ml per 24 hours
   3. Life-Threatening Hemoptysis
      1. Hemoptysis AND
      2. Hemodynamic instability, abnormal gas exchange or need for urgent Resuscitation
3. 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
4. Epidemiology
   1. Incidence: 1 in 1000 patients per year
   2. Only 5-15% of hempotysis cases meet criteria for Massive Hemoptysis
5. History
   1. See Hemoptysis Causes
   2. Past medical history
      1. Congestive Heart Failure
      2. Immunosuppression
      3. Recent surgery or immobilization (Pulmonary Embolism risk)
      4. Tobacco Abuse (Lung Cancer, COPD)
      5. Anticoagulants
   3. Cough
      1. Obstructive Lung Disease (e.g. Bronchiectasis, COPD, Asthma)
      2. Foreign Body Aspiration
      3. Infection (Pneumonia, Tuberculosis)
   4. Fever
      1. Acute Bronchitis (most common cause)
      2. Pneumonia
      3. Lung Abscess
      4. Tuberculosis
      5. Pulmonary Embolism
      6. Lung Cancer
   5. Trauma
      1. Airway Trauma
      2. Lung Contusion
      3. Pulmonary Embolism
   6. Weight loss
      1. Chronic Obstructive Pulmonary Disease (COPD)
      2. Lung Cancer
      3. Tuberculosis
   7. Travel or birth in endemic Tuberculosis regions
      1. Tuberculosis (U.S. Immigrants have 4 fold higher risk)
6. Findings: Symptoms and signs
   1. Hemoptysis
      1. Frothy Sputum with bright red blood, and alkaline pH
      2. Contrast with Hematemesis
7. Imaging
   1. Chest XRay
      1. First-line in most cases
      2. Test Sensitivity for identifying bleeding site: 33%-82% (and identifies cause in 35% of cases)
   2. Chest CT with contrast indications
      1. 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)
      2. Identify source of Hemoptysis to direct Intervention Radiology or surgery (Massive Hemoptysis)
      3. Mass lesion on Chest XRay
      4. Lung Cancer risk factors (e.g. Tobacco Abuse)
      5. Failed resolution of Pulmonary Infiltrate on Chest XRay
      6. Suspected Pulmonary Embolism
      7. Persistent symptoms despite negative Chest XRay
   3. Bronchoscopy indications
      1. Test Sensitivity for identifying bleeding site: 73-93% (and identifies cause in <8% of cases)
      2. CT chest non-diagnostic
      3. Mass lesion on Chest XRay
      4. Recurrent Hemoptysis
   4. Bronchial artery arteriography
      1. Used in some cases when Intervention Radiology is planned for embolization
8. Differential Diagnosis
   1. See Hemoptysis Causes
   2. Distinguish from Pseudohemoptysis (e.g. upper respiratory or gastrointestinal source)
9. Evaluation: Non-Massive Hemoptysis
   1. See labs below
   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: Imaging
      1. See imaging as above
   4. Step 3: Bronchoscopy Indications
      1. See imaging above
10. Labs: Massive Hemoptysis
    1. First-line studies
       1. Complete Blood Count with Platelets and differential
       2. ProTime (PT, INR)
       3. Partial Thromboplastin Time (aPTT)
       4. Blood Type and cross-match
       5. Renal Function tests
       6. Sputum Gram Stain and culture (including acid-fast bacilli, Fungal Culture, cytology)
    2. Other studies to consider
       1. D-Dimer
       2. HIV Test
       3. Arterial Blood Gas
       4. Quantiferon-TB (or PPD)
          1. Does not replace Sputum testing when acute symptoms are present
11. Management: Massive Hemoptysis
    1. See ABC Management
    2. Position patient with bleeding lung side down (if known source, e.g. Lung Lesion)
    3. Patient alert, not hypoxic and able to clear their own airway
       1. Supplemental Oxygen
       2. Avoid BIPAP or other positive pressure that interferes with airway clearance of blood
       3. Observe closely for decompensation
          1. Bronchial tree will completely fill with 150-200 cc of blood
    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)
       4. Emergency Cricothyrotomy if unable to intubate
    5. 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)
    6. Emergent Consultation
       1. Pulmonology Consultation for bronchoscopy
       2. Intervention Radiology for directed Bronchial artery embolization
       3. Cardiothoracic surgery Consultation
       4. ECMO may be needed
    7. Manage Coagulopathy
       1. See Coagulation Bleeding Disorders
       2. See Emergent Reversal of Anticoagulation
    8. References
       1. Swaminathan and Weingart in Herbert (2019) EM:Rap 19(3): 10-11
12. 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]
13. Management: Non-Massive Hemoptysis
    1. See Evaluation above
    2. Consider antibiotic course if symptoms or signs of lower respiratory infection
    3. Serially re-evaluate
    4. Consider CT Chest
    5. Consider pulmonology Consultation for bronchoscopy
14. Prognosis: Calculation
    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]
15. References
    1. Bidwell (2005) Am Fam Physician 72(7):1253-60 [PubMed]
    2. Corder (2003) Emerg Med Clin North Am 21:421-35 [PubMed]
    3. Earwood (2015) Am Fam Physician 91(4): 243-9 [PubMed]