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.

Episode 177.0 – Hemoptysis

Core EM - Emergency Medicine Podcast