Difference between revisions of "Hemoptysis"

(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...")
 
(References)
 
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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==
 +
*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
 +
**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
 +
**[[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]
  
5) UA (autoimune)
+
===Massive===
 
+
*Angle head down with affected lung low
6) ECG (pulm HTN/PE)
+
*Consider angio embolization
 
+
*Consider [[intubation]] with >8.0 (for bronch)
7) CXR (30% will be nl)
 
 
 
8) Consider D-Dimer/Spiral CT
 
 
 
9) IVF/blood/correct coagulop as nec
 
 
 
 
 
 
==DDx==
 
 
 
 
 
I. Airway
 
 
 
    A. Bronchitis (acute/chronic)
 
 
 
    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 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

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[1]

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. 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