Episode 177.0 – Hemoptysis

Show Notes

OVERVIEW:

• Definition:
  • expectoration/ coughing of blood originating from tracheobronchial tree
• Sources:
  • Bronchial arteries (90%): under systemic circulatory pressure to supply supporting structures of the lung → heavier bleeding
  • Pulmonary arteries (5%): under low pressure to supply alveoli → milder bleeding
  • Nonbronchial arteries (5%): intercostal arteries, coronary arteries, thoracic/ upper/ inferior phrenic arteries
• Quantification:
  • Mild: <20mL/ 24h
  • Massive defined anywhere from >300mL-1L/ 24hr
  • Mortality: 38% for massive (>500mL/ 24hr) vs 4.5% for nonmassive

• Etiology (in adults):
  • Infectious (most common):
    • Bronchitis
    • PNA (necrotizing, lung abscess)
    • TB
    • Viral
    • Fungal
    • Parasitic
  • Malignancy:
    • Primary lung cancer vs metastatic disease
  • Pulmonary:
    • Bronchiectasis
    • COPD
    • PE/ infarction
    • Bronchopleural fistula
    • Sarcoidosis
  • Cardiac:
    • Mitral stenosis
    • Tricuspid endocarditis
    • CHF
  • Rheumatological:
    • Goodpasture Syndrome
    • SLE
    • Vasculitis (Wegener’s, HSP, Behcet)
    • Amyloidosis
  • Hematological:
    • Coagulopathy/ thrombocytopenia/ platelet dysfunction
    • DIC
  • Vascular:
    • Pulmonary HTN
    • AA
    • Pulmonary artery aneurysm
    • Aortobronchial fistula
    • Pulmonary angiodysplasia
  • Toxins:
    • Anticoagulation/ aspirin/ antiplatelets
    • Penicillamine, amiodarone
    • Crack lung
    • Organic solvents
  • Trauma:
    • Tracheobronchial rupture
    • Pulmonary contusion
  • Other:
    • bronchoscopy/ lung biopsy
    • Pulmonary artery or central venous catheterization
    • Foreign body aspiration
    • Pulmonary endometriosis (catamenial hemoptysis)
    • Idiopathic (up to 25% of cases)
  • Pseudohemoptysis: 
    • Sinusitis
    • Epistaxis
    • Rhinorrhea
    • Pharyngitis
    • URI
    • Aspiration
    • GIB

WORKUP:

• HPI:
  • CP, SOB
  • B symptoms: fever, weight loss, chills, night sweats
  • Lymphadenopathy
  • Timeframe: acute vs chronic
  • Prior lung/ renal/ cardiac disease
  • Recreational drug/ cigarette/ chemical exposures
  • travel/ infectious exposure
  • Medications
  • Any other sites of bleeding
  • Precipitating factors
  • Description of blood clots
  • Patients are unable to accurately estimate degree of bleeding
• PE:
  • Petechiae, edema, ecchymosis, ulcers, clubbing (chronic lung disease)
  • Cardiopulmonary
  • Sputum samples
• Labs:
  • CBC w/ diff, BMP, LFTs, coags, T&S
  • ABG
  • UA
  • Infectious workup if suspected: cultures, grain stains
• Imaging:
  • CXR: 20% will be normal.  May see tumour, cavity, effusion, infiltrate, PTX.  Early pulmonary hemorrhage may present as infiltrate
  • CT: only for stable patients!  May see bronchiectasis, cavitary lesions, acinar nodules, tumours
  • CTA: bronchial arteries, aneurysms, PE
  • ECHO: identify valvular abnormalities, signs of PE, aortic aneurysm
• Bronchoscopy:
  • Not often performed in ED, but therapeutic & diagnostic
  • Allows direct visualization of tumours, foreign bodies, granulomas, infiltration, as well as local therapy (vasoconstrictive agents, stent/ balloon tamponade, electrocautery, procoagulants)

MANAGEMENT:

• Goals:
  • Control airway
  • Protect healthy lung
  • Identify and treat underlying cause
  • Stabilize hemodynamics with volume resuscitation
• Provider precautions (respiratory & contact)
• ABCs, close monitoring
  • Early airway management: massive hemoptysis, respiratory compromise, hypoxia, risk factors (elderly, AMS, coagulopathic)
  • 2 x suction, preoxygenation, patient positioned upright, >8Fr ETT to facilitate suctioning/ bronch
  • If bleeding side can be identified, consider “selective intubation” into nonbleeding lung to minimize further aspiration of blood and to provide ventilation
  • Life threat = asphyxiation, not exsanguination.  ~Only 150cc anatomic dead space in major airways
• 2 x large bore IVs
• MTP prn vs volume resuscitation
• “Bad lung down” in lateral position: theoretical belief to minimize reflux of blood into normal lung
• Correct coagulopathy
• Consider nebulized TXA for nonmassive hemoptysis (500mg w/ NS per neb)
  • Double-blind, randomized controlled trial in 2018
  • Nebulized TXA (500mg TID) vs placebo (normal saline) in hemodynamically stable adult patients admitted with mild hemoptysis (<200 mL/ 24hr) and no respiratory instability
    • Additional exclusion criteria included those with renal failure, hepatic failure, or coagulopathy
  • Assessed mortality and hemoptysis recurrence rate at 30 days and 1 year
  • 25 patients randomized to receive TXA nebs, 22 randomized to receive normal saline nebs
  • Results:
    • Resolution of hemoptysis within 5 days of admission was significantly higher in TXA-treated patients than placebo patients (96% vs 50%; P < 0.0005)
    • Mean hospital length of stay was shorter for TXA group (5.7 +- 2.5 days vs 7.8 +- 4.6 days; P = 0.046)
    • Fewer patients in TXA group required invasive procedures to control bleeding vs placebo group (0% vs 18.2%; P = 0.041)
    • No side effects were noticed in either group
• Antibiotics if infectious
• Bronchoscopy: local therapy (vasoconstrictive agents, stent/ balloon tamponade, electrocautery, procoagulants)
  • Rigid bronch for unstable patients to evacuate clots vs fiberoptic bronch for stable patients
• Bronchial artery embolization (call IR early!)
• May require lobectomy or pneumonectomy (consult thoracic surgery)

DISPOSITION:

• Low threshold for higher level of care: only mild, hemodynamically stable hemoptysis on floor
• Discharge: only if certain regarding etiology in healthy, hemodynamically stable patients with scant, resolved hemoptysis, no coagulopathy, and reassuring workup
  • Ensure patients have reliable follow up and avoid smoking. Strict return precautions!

REFERENCES:

• Kiraly A, Pang P, Cheema N.  Hemoptysis.  In: Schaider J, Barkin R, Hayden S, Wolfe R, Barkin A, Shayne P, Rosen P.  Rosen and Barkin’s 5-Minute Emergency Medicine Consult.  5th Edition.  Philadelphia, PA: Wolters Kluwer; 2015; 504-505.
• Nickson, C.  Haemoptysis. Life in the Fastlane.  [litfl.com/haemoptysis/]. Updated April 9, 2019.  Retrieved February 10, 2020.
• Wand O, Guber E, Guber A, Schochet GE, Israeli-Shani L, Shitrit D.  Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial.  Chest. December 2018; 154(6): 1379-1384.
• Young WF.  Hemoptysis.  In: Cline, David,eds. Tintinalli’s Emergency Medicine Manual. 7th Edition.  New York : McGraw-Hill Medical; 2011; 473-476.