Hemoptysis: Difference between revisions

(Created page with "==Workup== 0) Icon 1) CBC 2) Chem 7 3) Coags 4) T&S/T&C 5) UA (autoimune) 6) ECG (pulm HTN/PE) 7) CXR (30% will be nl) 8) Consider D-Dimer/Spiral CT 9) IVF/blood/corre...")
 
 
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==Workup==
==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==
[[File:Krev na gázových čtvercích.jpg|thumb|Example of hemoptysis from coughing into gauze.]]
[[File:Raetchon å sonk.jpg|thumb|Example of hemoptysis upon bronchial lavage.]]
*Coughing up blood


0) Icon
==Differential Diagnosis==
*[[Epistaxis]]
*Oropharynx bleeding
*[[Hematemesis]]


1) CBC
{{Hemoptysis DDX}}


2) Chem 7
==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
*Labs
**CBC
**Coags
**Sputum stain/culture
**Chem (Cr)
**T&S/T&C
**[[Urinalysis]] (autoimmune)
**[[ECG]] (pulmonary hypertension/PE)


3) Coags
===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


4) T&S/T&C
==Management==
 
*Patient Placement
5) UA (autoimune)
**Placing patient with affected lung down may actually worsen V-Q mismatch
 
**Some advocate for prone positioning
6) ECG (pulm HTN/PE)
*[[Intubation]]
 
**Use 8-0 tube to allow for subsequent bronchoscopy
7) CXR (30% will be nl)
**If possible can selectively intubate the unaffected bronchus to prevent aspiration
 
***After tube passes through cords rotate 90degrees left or right and advance
8) Consider D-Dimer/Spiral CT
****Can also use ''coude'' tip of [[bougie]]<ref>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.</ref>
 
*Coagulopathy
9) IVF/blood/correct coagulop as nec
**[[FFP]]
 
*Emergent bronchoscopy or embolization for life-threatening hemorrhage
*Nebulized [[TXA]] 500 mg tid<ref>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</ref>
 
**Pediatric: used in [https://www.emrap.org/episode/emrap2018june/case report]
==DDx==
*IV [[TXA]] may reduce in-hospital mortality, length of stay, and total healthcare costs<ref>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/</ref>
 
**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
I. Airway
===Massive===
 
*Angle head down with affected lung low
    A. Bronchitis (acute/chronic)
*Consider angio embolization
 
*Consider [[intubation]] with >8.0 (for bronch)
    B. Bronchietctasis
 
    C. Neoplasm (primary/met)
 
    D. Trauma
 
    E. Foreign body
 
II. Parenchymal Dz
 
    A. Infectious
 
          1. TB
 
          2. PNA
 
          3. Fungal
 
          4. Abcess
 
    B. Autoimmune
 
          1. Goodpasture's
 
          2. SLE
 
          3. Wegener's
 
          4. Pulmonary Hemosiderosis
 
III. Vascular
 
    A. PE
 
    B. AV malformation
 
    C. Pulm HTN
 
    D. Aortic dissection
 
IV. Hematologic Dz
 
    A. Coagulopathy
 
    B. DIC
 
    C. Platelet dysfx
 
    D. Thrombocytopenia
 
V. Cardiac
 
    A. Mitral stenosis
 
    B. Tricuspid endocarditis
 
VI. Misc
 
    A. Cack cocaine
 
    B. Iatrogenic
 
    C. Tracheal-arterial fistula
 
 
Bold: Most common in US
 
 
==Treatment==
 
 
MASSIVE = >100-500cc/day
 
*angle head down with affected lung low
 
*consider angio embolization
 
*intubate with >8.0 (for bronch)
 


==Disposition==
==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==
ADMISSION
<references/>
 
[[Category:Pulmonary]]
1) Massive
[[Category:Symptoms]]
 
2) Minor + high risk of massive bleed
 
 
==Source==
 
 
3/19/06 DONALDSON (adapted from Rosen)
 
 
 
 
[[Category:Pulm]]

Latest revision as of 17:40, 24 April 2024

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

Example of hemoptysis from coughing into gauze.
Example of hemoptysis upon bronchial lavage.
  • Coughing up blood

Differential Diagnosis

Hemoptysis

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
  • 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
    • Use 8-0 tube to allow for subsequent bronchoscopy
    • If possible can selectively intubate the unaffected bronchus to prevent aspiration
      • After tube passes through cords rotate 90degrees left or right and advance
  • Coagulopathy
  • Emergent bronchoscopy or embolization for life-threatening hemorrhage
  • Nebulized TXA 500 mg tid[2]
  • 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

  1. ↑ 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.
  2. ↑ 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
  3. ↑ 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/
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