An overview and management tips of hemoptysis in the ED.
Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD
Episode 177.0 – Hemoptysis
Core EM - Emergency Medicine Podcast
00:00
Management Strategies for Hemoptysis in Emergency Care
This chapter delves into the clinical management of hemoptysis, outlining the criteria for patient admission and discharge. It highlights the necessity of monitoring hemodynamic stability and assessing the underlying causes for effective treatment.
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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
- Infectious (most common):
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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