Hemoptysis

Background

• Coughing of blood that originates from respiratory tract below level of larynx
• Death usually occurs from asphyxiation, not exanguination
• Easy to confuse w/ epistaxis or oropharynx bleeding
• Mild=<20ml/24° Severe=>600ml/24°

Workup

1. Imaging
   1. CXR
      1. Nl in 30% (most of whom end having bronchitis)
   2. Chest CT w/ IV contrast
      1. Indicated for gross hemoptysis or suspicious CXR
   3. Bronchoscopy
2. Labs
   1. CBC
   2. Coags
   3. Sputum stain/cx
   4. Chem (cr)
   5. T&S/T&C
   6. UA (autoimune)
   7. ECG (pulm HTN/PE)

DDx

1. Infectious
   1. Bronchitis
   2. PNA
   3. Lung abscess
   4. TB
   5. Plague
2. Neoplastic
   1. Lung cancer
   2. Metastatic cancer
3. CV
   1. PE
   2. CHF
   3. Pulmonary HTN
   4. AV malformation
4. Mitral stenosis
5. Alveolar hemorrhage syndromes
   1. Goodpasture
   2. Wegener
   3. SLE
6. Hematologic
   1. Uremia
   2. Plt dysfunction (ASA, clopidogrel)
   3. Anticoagulant therapy
7. Traumatic
   1. Foreign body aspiration
   2. Ruptured bronchus
8. Inflammatory
   1. Bronchiectasis
   2. Cystic Fibrosis
9. Miscellaneous
   1. Cocaine inhalation (crack lung)
   2. Catamenial pneumothorax

Treatment

1. Pt Placement
   1. Placing pt w/ affected lung down may actually worsen V-Q mismatch
   2. Some advocate for prone positioning
2. Intubation
   1. Use 8-0 tube to allow for subsequent bronchoscopy
   2. If possible can selectively intubate the unaffected bronchus to prevent aspiration
      1. After tube passes through cords rotate 90degrees left or right and advance
3. Coagulopathy
   1. FFP
4. Emergenct bronchoscopy or embolization for life-threatening hemorrhage

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

1. angle head down with affected lung low
2. consider angio embolization
3. intubate with >8.0 (for bronch)

Disposition

1. Gross hemoptysis:
   1. Admit
2. Young pt (<40yr) w/ scant hemoptysis, nl CXR, no smoking history:
   1. Discharge
3. Risk factors for neoplasm (even if CXR nl) or suspicious CXR:
   1. Discuss w/ pulmonologist before d/c

Source

Tintinalli