Managing Hemoptysis: Strategies and Recent Findings

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