Episode 177.0 – Hemoptysis

An overview and management tips of hemoptysis in the ED.

Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD

February 17th, 2020 Download Leave a Comment Tags: ,

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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