Hemoptysis¶
Henry Brems
Background¶
-
Distinguish between massive (>600cc/24hr or >100cc/hr) and non-massive hemoptysis. Can be difficult to quantify expectorated blood volume and volume that is retained in lungs
-
Massive is potentially life-threatening due to impaired ventilation
-
Remember UGIB (hematemesis) and nasopharyngeal bleeds can easily mimic hemoptysis
-
Presentation based on source of bleed:
| Structure | Etiologies |
|---|---|
| Airways | Bronchitis (common cause of non-massive), bronchiectasis (especially in CF pts), neoplasm |
Alveolar/ Parenchymal |
Infectious (bacterial PNA, abscess, TB, fungal, aspergilloma), Rheumatic (Goodpasture’s, GPA, Behcet’s) |
| Vascular | PE, AVM, CHF, mitral stenosis |
| Other | Coagulopathy, traumatic, foreign-body, iatrogenic, cocaine-induced |
Evaluation¶
-
Check for anticoagulation on med list
-
Labs: CBC, BMP, Coags, UA (for hematuria), ABG (evaluate oxygenation), type and screen
- Consider ANA, ANCA, Anti-GBM, sputum culture (bacteria, fungal, AFB), sputum cytology depending on clinical context
-
Imaging: CXR first (to evaluate etiology and to localize the source to a side). Chest CT depending on prior workup, severity of bleed, and stability of patient
-
Bronchoscopy is sometimes indicated to localize bleeding source
Management¶
-
Urgent evaluation if any hemodynamic compromise, hypoxia, hypercarbia, or respiratory distress
-
Ensure a secure airway: massive hemoptysis may require intubation and MICU transfer
-
Reverse underlying coagulopathy if present. Consider trending HCT
-
If unilateral bleed, place bleeding lung down (i.e. if the source is left lung, place pt on left side) to prevent filling 'good' lung with blood (include this info in sign-out if known)
-
Urgent pulmonary consult if clinical instability: Bronchoscopy is diagnostic and therapeutic
-
Obtain CT Bronchial Artery Protocol if concern for bronchial artery source (especially in CF patients) so embolization can be planned
- Order this at VUMC with a CTA Chest (NOT a CTA PE as that will be timed incorrectly) and include "bronchial artery protocol" in comments for the study
-
Consider IR consult for angiography as diagnostic and therapeutic option
- Consult early if there is massive hemoptysis; If bronchoscopy is attempted but fails to stop the bleed, they can get to angiography fastest if IR has already been made aware