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

Differential Diagnosis

• Infectious
  • Bronchitis
  • PNA
  • 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

Diagnosis=

• Imaging
  • CXR
    • Nml in 30% (most of whom end up having bronchitis)
  • 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 (autoimmune)
  • ECG (pulm HTN/PE)

Treatment

• 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

• angle head down with affected lung low
• consider angio embolization
• intubate with >8.0 (for bronch)

Disposition

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