Hemoptysis: Difference between revisions

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*Coughing of blood that originates from respiratory tract below level of larynx
*Coughing of blood that originates from respiratory tract below level of larynx
*Death usually occurs from asphyxiation, not exanguination
*Death usually occurs from asphyxiation, not exanguination
*Easy to confuse w/ epistaxis or oropharynx bleeding
*Easy to confuse with [[epistaxis]] or oropharynx bleeding


==Workup==
==Clinical Features==
#Imaging
[[File:Krev na gázových čtvercích.jpg|thumb|Example of hemoptysis from coughing into gauze.]]
##CXR
[[File:Raetchon å sonk.jpg|thumb|Example of hemoptysis upon bronchial lavage.]]
###Nl in 30% (most of whom end having bronchitis)
*Coughing up blood
##Chest CT w/ IV contrast
###Indicated for gross hemoptysis or suspicious CXR
##Bronchoscopy
#Labs
##CBC
##Coags
##Sputum stain/cx
##Chem (cr)
##T&S/T&C
##UA (autoimune)
##ECG (pulm HTN/PE)


==DDx==
==Differential Diagnosis==
#Infectious
*[[Epistaxis]]
##Bronchitis
*Oropharynx bleeding
##PNA
*[[Hematemesis]]
##Lung abscess
##TB
##Plague
#Neoplastic
##Lung cancer
##Metastatic cancer
#CV
##PE
##CHF
##Pulmonary HTN
##AV malformation
#Mitral stenosis
#Alveolar hemorrhage syndromes
##Goodpasture
##Wegener
##SLE
#Hematologic
##Uremia
##Plt dysfunction (ASA, clopidogrel)
##Anticoagulant therapy
#Traumatic
##Foreign body aspiration
##Ruptured bronchus
#Inflammatory
##Bronchiectasis
##Cystic Fibrosis
#Miscellaneous
##Cocaine inhalation (crack lung)
##Catamenial pneumothorax


==Treatment==
{{Hemoptysis DDX}}
#Pt Placement
##Placing pt w/ 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
##FFP
#Emergenct bronchoscopy or embolization for life-threatening hemorrhage


MASSIVE = A single expectoration of ≥ 50cc OR >600cc/24h
==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)


#angle head down with affected lung low
===Evaluation===
#consider angio embolization
*Massive = A single expectoration of ≥ 50cc '''OR''' >600cc/24h
#intubate with >8.0 (for bronch)
**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
****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
**[[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]
*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
===Massive===
*Angle head down with affected lung low
*Consider angio embolization
*Consider [[intubation]] with >8.0 (for bronch)


==Disposition==
==Disposition==
#Gross hemoptysis:
*Gross hemoptysis:
##Admit
**Admit
#Young pt (<40yr) w/ scant hemoptysis, nl CXR, no smoking history:
*Young patient (<40yr) with scant hemoptysis, normal [[CXR]], no smoking history:
##Discharge
**Discharge
#Risk factors for neoplasm (even if CXR nl) or suspicious CXR:
*Risk factors for neoplasm (even if CXR normal) or suspicious CXR:
##Discuss w/ pulmonologist before d/c
**Discuss with pulmonologist before discharge
 
==Source==
Tintinalli


[[Category:Pulm]]
==References==
<references/>
[[Category:Pulmonary]]
[[Category:Symptoms]]

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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