Hemoptysis

Background

  • Coughing of blood that originates from respiratory tract below level of larynx
  • Death usually occurs from asphyxiation, not exanguination
  • Easy to confuse with epistaxis or oropharynx bleeding

Clinical Features

Example of hemoptysis from coughing into gauze.
Example of hemoptysis upon bronchial lavage.
  • Coughing up blood

Differential Diagnosis

Hemoptysis

Evaluation

Workup

  • Imaging
    • CXR
      • Nml in 30% (most of whom end up having bronchitis)
    • Chest CT with IV contrast
      • Indicated for gross hemoptysis or suspicious CXR
    • Bronchoscopy
  • Labs
    • CBC
    • Coags
    • Sputum stain/culture
    • Chem (Cr)
    • T&S/T&C
    • Urinalysis (autoimmune)
    • ECG (pulmonary hypertension/PE)

Evaluation

  • Massive = A single expectoration of ≥ 50cc OR >600cc/24h
    • Rare, occurring in 1-5% of patients.
  • May differentiate from hematemesis with pH litmus paper
    • Hemoptysis tends to be alkaline
    • Hematemesis tends to be acidic, and stomach acid tends to turn bright red blood in stomach to brown/black fragments unless massive

Management

  • Patient Placement
    • Placing patient with affected lung down may actually worsen V-Q mismatch
    • Some advocate for prone positioning
  • Intubation
    • Use 8-0 tube to allow for subsequent bronchoscopy
    • If possible can selectively intubate the unaffected bronchus to prevent aspiration
      • After tube passes through cords rotate 90degrees left or right and advance
  • Coagulopathy
  • Emergent bronchoscopy or embolization for life-threatening hemorrhage
  • Nebulized TXA 500 mg tid[2]
  • IV TXA may reduce in-hospital mortality, length of stay, and total healthcare costs[3]
    • Absolute in-hospital mortality reduction was 2.5% in the retrospective study of nearly 20,000 patients
    • No particular dosing regimen, but in this study, no association was found between TXA and seizures, in part per the authors, due to most patients receiving no more than 2 g of TXA total

Massive

  • Angle head down with affected lung low
  • Consider angio embolization
  • Consider intubation with >8.0 (for bronch)

Disposition

  • Gross hemoptysis:
    • Admit
  • Young patient (<40yr) with scant hemoptysis, normal CXR, no smoking history:
    • Discharge
  • Risk factors for neoplasm (even if CXR normal) or suspicious CXR:
    • Discuss with pulmonologist before discharge

References

  1. ↑ Gottlieb M, Sharma V, Field J, Rozum M, Bailitz J. Utilization of a gum elastic bougie to facilitate single lung intubation. Am J Emerg Med. 2016 Dec;34(12):2408-2410. doi: 10.1016/j.ajem.2016.08.057. Epub 2016 Aug 27. PMID: 27614374.
  2. ↑ Wand O, et al. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. DOI: https://doi.org/10.1016/j.chest.2018.09.026
  3. ↑ Kinoshita T, Ohbe H, Matsui H, Fushimi K, Ogura H, Yasunaga H. Effect of tranexamic acid on mortality in patients with haemoptysis: a nationwide study. Crit Care. 2019;23(1):347. Published 2019 Nov 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6836388/
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