Difference between revisions of "Hemoptysis"

(Workup)
(References)
 
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{{Hemoptysis DDX}}
 
{{Hemoptysis DDX}}
  
==Diagnosis==
+
==Evaluation==
 
===Workup===
 
===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 with IV contrast
 
**Chest CT with IV contrast
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**Chem (Cr)
 
**Chem (Cr)
 
**T&S/T&C
 
**T&S/T&C
**UA (autoimmune)
+
**[[Urinalysis]] (autoimmune)
**ECG (pulmonary HTN/PE)
+
**[[ECG]] (pulmonary hypertension/PE)
  
 
===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]]
*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>
 +
**Pediatric: used in [https://www.emrap.org/episode/emrap2018june/case report]
  
 
===Massive===
 
===Massive===
#Angle head down with affected lung low
+
*Angle head down with affected lung low
#Consider angio embolization
+
*Consider angio embolization
#[[Intubate]] with >8.0 (for bronch)
+
*Consider [[intubation]] with >8.0 (for bronch)
  
 
==Disposition==
 
==Disposition==
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==References==
 
==References==
 
+
<references/>
 
[[Category:Pulmonary]]
 
[[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