An overview and management tips of hemoptysis in the ED.
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hemoptysis.mp3
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Tags: Critical Care, Pulmonary
Show Notes
Definition:expectoration/ coughing of blood originating from tracheobronchial treeSources:Bronchial arteries (90%): under systemic circulatory pressure to supply supporting structures of the lung → heavier bleedingPulmonary arteries (5%): under low pressure to supply alveoli → milder bleedingNonbronchial arteries (5%): intercostal arteries, coronary arteries, thoracic/ upper/ inferior phrenic arteriesQuantification:Mild: <20mL/ 24hMassive defined anywhere from >300mL-1L/ 24hrMortality: 38% for massive (>500mL/ 24hr) vs 4.5% for nonmassiveEtiology (in adults):Infectious (most common):BronchitisPNA (necrotizing, lung abscess)TBViralFungalParasiticMalignancy:Primary lung cancer vs metastatic diseasePulmonary:BronchiectasisCOPDPE/ infarctionBronchopleural fistulaSarcoidosisCardiac:Mitral stenosisTricuspid endocarditisCHFRheumatological:Goodpasture SyndromeSLEVasculitis (Wegener’s, HSP, Behcet)AmyloidosisHematological:Coagulopathy/ thrombocytopenia/ platelet dysfunctionDICVascular:Pulmonary HTNAAPulmonary artery aneurysmAortobronchial fistulaPulmonary angiodysplasiaToxins:Anticoagulation/ aspirin/ antiplateletsPenicillamine, amiodaroneCrack lungOrganic solventsTrauma:Tracheobronchial rupturePulmonary contusionOther:bronchoscopy/ lung biopsyPulmonary artery or central venous catheterizationForeign body aspirationPulmonary endometriosis (catamenial hemoptysis)Idiopathic (up to 25% of cases)Pseudohemoptysis: SinusitisEpistaxisRhinorrheaPharyngitisURIAspirationGIBHPI:CP, SOBB symptoms: fever, weight loss, chills, night sweatsLymphadenopathyTimeframe: acute vs chronicPrior lung/ renal/ cardiac diseaseRecreational drug/ cigarette/ chemical exposurestravel/ infectious exposureMedicationsAny other sites of bleedingPrecipitating factorsDescription of blood clotsPatients are unable to accurately estimate degree of bleedingPE:Petechiae, edema, ecchymosis, ulcers, clubbing (chronic lung disease)CardiopulmonarySputum samplesLabs:CBC w/ diff, BMP, LFTs, coags, T&SABGUAInfectious workup if suspected: cultures, grain stainsImaging:CXR: 20% will be normal. May see tumour, cavity, effusion, infiltrate, PTX. Early pulmonary hemorrhage may present as infiltrateCT: only for stable patients! May see bronchiectasis, cavitary lesions, acinar nodules, tumoursCTA: bronchial arteries, aneurysms, PEECHO: identify valvular abnormalities, signs of PE, aortic aneurysmBronchoscopy:Not often performed in ED, but therapeutic & diagnosticAllows direct visualization of tumours, foreign bodies, granulomas, infiltration, as well as local therapy (vasoconstrictive agents, stent/ balloon tamponade, electrocautery, procoagulants)Goals:Control airwayProtect healthy lungIdentify and treat underlying causeStabilize hemodynamics with volume resuscitationProvider precautions (respiratory & contact)ABCs, close monitoringEarly airway management: massive hemoptysis, respiratory compromise, hypoxia, risk factors (elderly, AMS, coagulopathic)2 x suction, preoxygenation, patient positioned upright, >8Fr ETT to facilitate suctioning/ bronchIf bleeding side can be identified, consider “selective intubation” into nonbleeding lung to minimize further aspiration of blood and to provide ventilationLife threat = asphyxiation, not exsanguination. ~Only 150cc anatomic dead space in major airways2 x large bore IVsMTP prn vs volume resuscitation“Bad lung down” in lateral position: theoretical belief to minimize reflux of blood into normal lungCorrect coagulopathyConsider nebulized TXA for nonmassive hemoptysis (500mg w/ NS per neb)Double-blind, randomized controlled trial in 2018Nebulized TXA (500mg TID) vs placebo (normal saline) in hemodynamically stable adult patients admitted with mild hemoptysis (<200 mL/ 24hr) and no respiratory instabilityAdditional exclusion criteria included those with renal failure, hepatic failure, or coagulopathyAssessed mortality and hemoptysis recurrence rate at 30 days and 1 year25 patients randomized to receive TXA nebs, 22 randomized to receive normal saline nebsResults: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 groupAntibiotics if infectiousBronchoscopy: local therapy (vasoconstrictive agents, stent/ balloon tamponade, electrocautery, procoagulants)Rigid bronch for unstable patients to evacuate clots vs fiberoptic bronch for stable patientsBronchial artery embolization (call IR early!)May require lobectomy or pneumonectomy (consult thoracic surgery)Low threshold for higher level of care: only mild, hemodynamically stable hemoptysis on floorDischarge: only if certain regarding etiology in healthy, hemodynamically stable patients with scant, resolved hemoptysis, no coagulopathy, and reassuring workupEnsure patients have reliable follow up and avoid smoking. Strict return precautions!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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