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Hemoptysis

Angela Liu, Henry Brems

Background

  • Distinguish between massive (>600cc/24hr or >100cc/hr) and non-massive hemoptysis. Can be difficult to quantify expectorated blood volume and volume that is retained in lungs

  • Massive is potentially life-threatening due to impaired ventilation

  • Remember UGIB (hematemesis) and nasopharyngeal bleeds can easily mimic hemoptysis

  • 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

  • Determine coagulation status: medications, PT/PTT, platelets

  • Labs: CBC, BMP, Coags, UA (for hematuria), ABG (evaluate oxygenation), type and screen

    • Consider ANA, ANCA, anti-GBM, anti-cardiopipin, IFNG release assay, sputum culture (bacteria, fungal, AFB), sputum cytology (if not undergoing bronchoscopy), and RPP depending on clinical context

  • Imaging: CXR first (to evaluate etiology and to localize the source to a side). Chest CT depending on prior workup, severity of bleed, and stability of patient

  • Bronchoscopy is sometimes indicated to localize bleeding source

Management

  • Urgent evaluation if any hemodynamic compromise, hypoxia, hypercarbia, or respiratory distress

  • Ensure a secure airway: massive hemoptysis may require intubation and MICU transfer

  • Reverse underlying coagulopathy if present. Consider trending HCT

  • 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)

  • 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
    • Recurrent hemoptysis is still typically controlled with repeat embolization.