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Hemoptysis
From WikEM
Contents
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
- CV
- PE
- CHF
- Pulmonary HTN
- AV malformation
- Mitral stenosis
- Alveolar hemorrhage syndromes
- Goodpasture
- Wegener
- SLE
- Hematologic
- Uremia
- Platelet dysfunction (ASA, clopidogrel)
- Anticoagulant therapy
- Traumatic
- Foreign body aspiration
- Ruptured bronchus
- Inflammatory
- Bronchiectasis
- Cystic Fibrosis
- Miscellaneous
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
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
- Emergenct bronchoscopy or embolization for life-threatening hemorrhage
Massive
- Angle head down with affected lung low
- Consider angio embolization
- Intubate 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
