An overview and management tips of hemoptysis in the ED.
Hosts:
Brian Gilberti, MD
Audrey Bree Tse, MD
Core EM - Emergency Medicine Podcast 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.
14:26
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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
Rosen and Barkin’s 5-Minute Emergency Medicine Consult
Rosen and Barkin’s 5-Minute Emergency Medicine Consult
5th Edition
S. Hayden
A. Kiraly
P. Rosen
R. Barkin
A. Barkin
R. Wolfe
P. Pang
N. Cheema
J. Schaider
P. Shayne
Rosen and Barkin's 5-Minute Emergency Medicine Consult is a concise, quick-reference guide for emergency medicine professionals. It provides succinct summaries of key clinical information, diagnostic approaches, and treatment strategies for a wide range of emergency conditions. The book is designed for rapid access to essential details during busy shifts, aiding in efficient decision-making. It is frequently updated to reflect the latest advancements in emergency medicine. The book is highly regarded for its practicality and time-saving features.
Tintinalli's Emergency Medicine
A Comprehensive Study Guide
Donald M. Yealy, MD, FACEP
Judith E. Tintinalli, MD, MS
Garth D. Meckler, MD
J. Stephan Stapczynski, MD
David M. Cline, MD
Tintinalli's Emergency Medicine is a landmark text in the field of emergency medicine, providing in-depth coverage of prehospital care, disaster management, basic and advanced resuscitative techniques, and all significant medical, traumatic, and environmental conditions requiring emergency treatment. The book is essential for physicians, residents, students, advanced practice providers, emergency nurses, EMTs, and paramedics. It includes full-color design, extensive updates, online access to videos, and comprehensive sections on pediatric care, gynecologic and obstetric emergencies, and more.
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
- 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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