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
  • 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), rheumatologic (Goodpasture’s, GPA, Behcet’s)
Vascular PE, AVM, CHF, mitral stenosis, bronchovascular fistula
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 pt
  • 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. Ex: 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 pts) 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.
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