Hemoptysis

Hemoptysis – Henry Brems

Background

  • Distinguish between massive (>600cc/24hr or >100cc/hr) and non-massive hemoptysis; however, due to practical difficulties quantifying expectorated blood and limitations in quantifying blood in lungs that is not expectorated, verbiage is falling out of favor
  • Massive is potentially life-threatening due to impaired ventilation not necessarily due to hemodynamic compromise
  • Remember UGIB (hematemesis) and nasopharyngeal bleeds can easily mimic hemoptysis and require different management
  • 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

  • Assess anticoagulation status
  • Labs: CBC, BMP, Coags, UA (for hematuria), ABG (evaluate oxygenation), type and screen
    • Also consider ANA, ANCA, Anti-GBM, sputum culture (bacteria, fungal, AFB), sputum cytology as indicated to further evaluate etiology
  • Imaging: CXR first (to evaluate etiology and to localize the source to a side). May likely require Chest CT pending prior workup, severity of bleed, and stability of patient
  • Bronchoscopy is sometimes indicated to localize bleeding source
     

Management

  • Hemoptysis that is non-massive and does not impair ventilation can generally be evaluated and treated non-urgently
  •  Urgent evaluation needed if there is any hemodynamic compromise, hypoxia, hypercarbia, or respiratory distress
  • Reverse underlying coagulopathy if present. Consider trending HCT
  • Make NPO
  • 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)
  • Ensure a secure airway: Massive hemoptysis may require intubation and MICU transfer
  • 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
  • Consider GI and/or ENT evaluation if source of bleed is unclear