Hemoptysis: Difference between revisions
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===Evaluation=== | ===Evaluation=== | ||
*Massive = A single expectoration of ≥ 50cc '''OR''' >600cc/24h | *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== | ==Management== | ||
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*Coagulopathy | *Coagulopathy | ||
**[[FFP]] | **[[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] | |||
===Massive=== | ===Massive=== | ||
*Angle head down with affected lung low | |||
*Consider angio embolization | |||
*Consider [[intubation]] with >8.0 (for bronch) | |||
==Disposition== | ==Disposition== | ||
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<references/> | <references/> | ||
[[Category:Pulmonary]] | [[Category:Pulmonary]] | ||
[[Category:Symptoms]] |
Revision as of 16:06, 12 October 2019
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
- Coughing up blood
Differential Diagnosis
- Epistaxis
- Oropharynx bleeding
- Hematemesis
Hemoptysis
- Infectious
- Neoplastic
- Lung cancer
- Metastatic cancer
- Cardiovascular
- Pulmonary embolism
- Congestive heart failure
- Pulmonary hypertension
- AV malformation
- Mitral stenosis
- Alveolar hemorrhage syndromes
- Hematologic
- Uremia
- Platelet dysfunction (ASA, clopidogrel)
- Anticoagulant therapy
- Traumatic
- Foreign body aspiration
- Ruptured bronchus
- Inflammatory
- Miscellaneous
- Cocaine inhalation (crack lung)
- Catamenial pneumothorax
- Goodpasture syndrome
- Cystic fibrosis
- Epistaxis
- Blood-laced mucus from the sinus or nose area
- Upper GI bleeding
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
- CXR
- 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[1]
- Pediatric: used in report
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
- ↑ 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