Episode 177.0 – Hemoptysis

Feb 17, 2020

Explore the ins and outs of hemoptysis, from its definition to critical management tips in the emergency department. Learn about the various sources of bleeding and how to differentiate between mild and massive cases. The hosts share essential strategies for patient stabilization, including lab tests and imaging. Discover recent research on nebulized tranexamic acid and effective positioning techniques. Finally, gain insights into admission criteria and the importance of monitoring hemodynamic stability.

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Intro

00:00 • 2min

Understanding Hemoptysis: Origins and Causes

01:40 • 5min

Hemoptysis Management Essentials

06:48 • 3min

Managing Hemoptysis: Strategies and Recent Findings

10:14 • 2min

Management Strategies for Hemoptysis in Emergency Care

12:20 • 2min

An overview and management tips of hemoptysis in the ED.

Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD

Download One Comment Tags: Critical Care, Pulmonary

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