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Hemoptysis
Aka: Hemoptysis, Bloody Sputum, Massive Hemoptysis, Pulmonary Hemorrhage
- See Also
- Hemoptysis Causes
- Definitions
- Hemoptysis
- Blood expectorated from the lung parenchyma or airways (trachea, Bronchi, Bronchioles)
- Massive Hemoptysis
- Expectoration of >100 ml of blood per 24 hours (or 50 ml in a single cough)
- Various volume criteria have been used ranging from 100 to 600 ml per 24 hours
- Life-Threatening Hemoptysis
- Hemoptysis AND
- Hemodynamic instability, abnormal gas exchange or need for urgent Resuscitation
- Precautions
- Even small volumes of bright red blood (not simply blood tinged Sputum) may herald Massive Hemoptysis
- Evaluate carefully and consider early Endotracheal Intubation in high risk cases
- Patients with Hemoptysis die of asphyxiation, not Hemorrhage
- Epidemiology
- Incidence: 1 in 1000 patients per year
- Only 5-15% of hempotysis cases meet criteria for Massive Hemoptysis
- History
- See Hemoptysis Causes
- Past medical history
- Congestive Heart Failure
- Immunosuppression
- Recent surgery or immobilization (Pulmonary Embolism risk)
- Tobacco Abuse (Lung Cancer, COPD)
- Anticoagulants
- Cough
- Obstructive Lung Disease (e.g. Bronchiectasis, COPD, Asthma)
- Foreign Body Aspiration
- Infection (Pneumonia, Tuberculosis)
- Fever
- Acute Bronchitis (most common cause)
- Pneumonia
- Lung Abscess
- Tuberculosis
- Pulmonary Embolism
- Lung Cancer
- Trauma
- Airway Trauma
- Lung Contusion
- Pulmonary Embolism
- Weight loss
- Chronic Obstructive Pulmonary Disease (COPD)
- Lung Cancer
- Tuberculosis
- Travel or birth in endemic Tuberculosis regions
- Tuberculosis (U.S. Immigrants have 4 fold higher risk)
- Findings: Symptoms and signs
- Hemoptysis
- Frothy Sputum with bright red blood, and alkaline pH
- Contrast with Hematemesis
- Imaging
- Chest XRay
- First-line in most cases
- Test Sensitivity for identifying bleeding site: 33%-82% (and identifies cause in 35% of cases)
- Chest CT with contrast indications
- Test Sensitivity for detecting bleeding site
- Standard Chest CT: 70-88% (and identifies the cause in 60-77% of cases)
- Multidetector Chest CT: 100% for Bronchial arteries (62% for non-Bronchial arteries)
- Identify source of Hemoptysis to direct Intervention Radiology or surgery (Massive Hemoptysis)
- Mass lesion on Chest XRay
- Lung Cancer risk factors (e.g. Tobacco Abuse)
- Failed resolution of Pulmonary Infiltrate on Chest XRay
- Suspected Pulmonary Embolism
- Persistent symptoms despite negative Chest XRay
- Bronchoscopy indications
- Test Sensitivity for identifying bleeding site: 73-93% (and identifies cause in <8% of cases)
- CT chest non-diagnostic
- Mass lesion on Chest XRay
- Recurrent Hemoptysis
- Bronchial artery arteriography
- Used in some cases when Intervention Radiology is planned for embolization
- Differential Diagnosis
- See Hemoptysis Causes
- Distinguish from Pseudohemoptysis (e.g. upper respiratory or gastrointestinal source)
- Evaluation: Non-Massive Hemoptysis
- See labs below
- Step 1: Consider non-lower respiratory cause (Pseudohemoptysis)
- Upper respiratory source (e.g. Sinusitis)
- Upper Gastrointestinal Bleeding (Hematemesis)
- Coffee grounds with acidic pH
- Step 2: Imaging
- See imaging as above
- Step 3: Bronchoscopy Indications
- See imaging above
- Labs: Massive Hemoptysis
- First-line studies
- Complete Blood Count with platelets and differential
- ProTime (PT, INR)
- Partial Thromboplastin Time (aPTT)
- Blood Type and cross-match
- Renal Function tests
- Sputum Gram Stain and culture (including acid-fast bacilli, Fungal Culture, cytology)
- Other studies to consider
- D-Dimer
- HIV Test
- Arterial Blood Gas
- Quantiferon-TB (or PPD)
- Does not replace Sputum testing when acute symptoms are present
- Management: Massive Hemoptysis
- See ABC Management
- Position patient with bleeding lung side down (if known source, e.g. Lung Lesion)
- Patient alert, not hypoxic and able to clear their own airway
- Supplemental Oxygen
- Avoid BIPAP or other positive pressure that interferes with airway clearance of blood
- Observe closely for decompensation
- Bronchial tree will completely fill with 150-200 cc of blood
- Advanced Airway (patient decompensating, hypoxic)
- Attempt awake intubation under Ketamine
- Allows for visualization of cords as patient coughs and clears airway
- Large bore suction or suction via Endotracheal Tube attached to meconium aspirator
- Place as large a bore Endotracheal Tube as possible (e.g. >7.5 up to 8.5)
- Emergency Cricothyrotomy if unable to intubate
- Lung isolation
- Best performed by bronchoscopy if skilled operator available (e.g. pulmonology, thoracic surgery)
- Suspected source of Massive Hemorrhage is on the LEFT
- Pass the Endotracheal Tube into the right mainstem Bronchus (bleeding should stop)
- Suspected source of Massive Hemorrhage is on the RIGHT
- Pull ET Tube back to glottis (but still below Vocal Cords)
- Pass bougie (or bronchoscope) through ET Tube and rotate bougie 90 degrees left
- Pass ET Tube over the bougie and assess bleeding and position (auscultation, Chest XRay)
- Emergent Consultation
- Pulmonology Consultation for bronchoscopy
- Intervention Radiology for directed Bronchial artery embolization
- Cardiothoracic surgery Consultation
- ECMO may be needed
- Manage Coagulopathy
- See Coagulation Bleeding Disorders
- See Emergent Reversal of Anticoagulation
- References
- Swaminathan and Weingart in Herbert (2019) EM:Rap 19(3): 10-11
- Management: Indications for ICU Admission or Tertiary Care Transfer
- Lesions at the highest risk of bleeding (e.g. Aspergillus infection, pulmonary artery involved)
- Respiratory distress or Hypoxia
- Respiratory Rate >30 per minute
- Oxygen Saturation <88% on room air
- Requiring High Flow Oxygen at >8 L/min or Mechanical Ventilation
- Hemodynamic instability
- Hemoglobin < 8 g/dl or more than 2 g/dl drop from baseline
- Disseminated Intravascular Coagulation (DIC) or other consumptive Coagulopathy
- Hypotension requiring intervention (fluid bolus, transfusion, Vasopressors)
- Massive Hemoptysis
- Hemoptysis >200 ml per 24 hours OR
- Hemoptysis >50 ml per 24 hours in a patient with COPD
- Serious comorbidity
- Previous pneumonectomy
- Chronic Obstructive Pulmonary Disease (COPD)
- Cystic Fibrosis
- Ischemic Heart Disease
- References
- Fartoukh (2010) Rev Mal Respir 27(10): 1243-53 +PMID:21163400 [PubMed]
- Management: Non-Massive Hemoptysis
- See Evaluation above
- Consider antibiotic course if symptoms or signs of lower respiratory infection
- Serially re-evaluate
- Consider CT Chest
- Consider pulmonology Consultation for bronchoscopy
- Prognosis: Calculation
- Criteria
- Score 1: Admit Chest XRay with involvement of 2 or more lung quadrants
- Score 1: Chronic Alcoholism
- Score 1: Pulmonary artery involvement
- Score 2: Aspergillosis
- Score 2: Malignancy
- Score 2: Mechanical Ventilation required
- Interpretation
- Admit to ICU for score >2 (see other indications above)
- Consider urgent Intervention Radiology for score >5
- Mortality: In-Hospital
- Total 0: Mortality 1%
- Total 1: Mortality 2%
- Total 2: Mortality 6%
- Total 3: Mortality 16%
- Total 4: Mortality 34%
- Total 5: Mortality 58%
- Total 6: Mortality 79%
- Total 7: Mortality 91%
- References
- Fartoukh (2012) Respiration 83(2): 106-14 +PMID:22025193 [PubMed]
- References
- Bidwell (2005) Am Fam Physician 72(7):1253-60 [PubMed]
- Corder (2003) Emerg Med Clin North Am 21:421-35 [PubMed]
- Earwood (2015) Am Fam Physician 91(4): 243-9 [PubMed]