Difference between revisions of "Hemoptysis"

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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
  
 
==Clinical Features==
 
==Clinical Features==
 +
*Coughing up blood
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
*Infectious
+
*[[Epistaxis]]
**Bronchitis
+
*Oropharynx bleeding
**[[Pneumonia|PNA]]
+
*[[Hematemesis]]
**Lung abscess
 
**[[Tuberculosis (TB)|TB]]
 
**[[Plague]]
 
*Neoplastic
 
**Lung cancer
 
**Metastatic cancer
 
*CV
 
**[[Pulmonary Embolism (PE)|PE]]
 
**[[Congestive Heart Failure (CHF)|CHF]]
 
**[[Pulmonary Hypertension (Decompensation)|Pulmonary HTN]]
 
**AV malformation
 
*Mitral stenosis
 
*Alveolar hemorrhage syndromes
 
**Goodpasture
 
**Wegener
 
**[[Lupus|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==
+
{{Hemoptysis DDX}}
 +
 
 +
==Evaluation==
 +
===Workup===
 
*Imaging
 
*Imaging
**CXR
+
**[[CXR]]
 
***Nml in 30% (most of whom end up having bronchitis)
 
***Nml in 30% (most of whom end up having bronchitis)
**Chest CT w/ IV contrast
+
**Chest CT with IV contrast
 
***Indicated for gross hemoptysis or suspicious CXR
 
***Indicated for gross hemoptysis or suspicious CXR
 
**Bronchoscopy
 
**Bronchoscopy
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**CBC
 
**CBC
 
**Coags
 
**Coags
**Sputum stain/cx
+
**Sputum stain/culture
**Chem (cr)
+
**Chem (Cr)
 
**T&S/T&C
 
**T&S/T&C
**UA (autoimmune)
+
**[[Urinalysis]] (autoimmune)
**ECG (pulm HTN/PE)
+
**[[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
  
==Treatment==
+
==Management==
*Pt Placement
+
*Patient Placement
**Placing pt w/ affected lung down may actually worsen V-Q mismatch
+
**Placing patient with affected lung down may actually worsen V-Q mismatch
 
**Some advocate for prone positioning
 
**Some advocate for prone positioning
*Intubation
+
*[[Intubation]]
 
**Use 8-0 tube to allow for subsequent bronchoscopy
 
**Use 8-0 tube to allow for subsequent bronchoscopy
 
**If possible can selectively intubate the unaffected bronchus to prevent aspiration
 
**If possible can selectively intubate the unaffected bronchus to prevent aspiration
 
***After tube passes through cords rotate 90degrees left or right and advance
 
***After tube passes through cords rotate 90degrees left or right and advance
 
*Coagulopathy
 
*Coagulopathy
**FFP
+
**[[FFP]]
*Emergenct bronchoscopy or embolization for life-threatening hemorrhage
+
*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>
MASSIVE = A single expectoration of ≥ 50cc OR >600cc/24h
+
**Pediatric: used in [https://www.emrap.org/episode/emrap2018june/case report]
  
*angle head down with affected lung low
+
===Massive===
*consider angio embolization
+
*Angle head down with affected lung low
*intubate with >8.0 (for bronch)
+
*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
  
 
==References==
 
==References==
 
+
<references/>
[[Category:Pulm]]
+
[[Category:Pulmonary]]
 +
[[Category:Symptoms]]

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