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Hemoptysis
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Hemoptysis
, Bloody Sputum, Massive Hemoptysis, Pulmonary Hemorrhage
See Also
Hemoptysis Causes
Definitions
Hemoptysis
Blood expectorated from the lung parenchyma or airways (trachea,
Bronchi
,
Bronchi
oles)
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
)
Anticoagulant
s
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.
Immigrant
s 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
Bronchi
al arteries (62% for non-
Bronchi
al 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
Bronchi
al 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
Bronchi
al 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
Bronchi
al 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,
Vasopressor
s)
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]
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