An overview and management tips of hemoptysis in the ED.

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Brian Gilberti, MD

Audrey Bree Tse, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hemoptysis.mp3



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Tags: Critical Care, Pulmonary





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.
  

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