Hemoptysis

Jessica Reed

Background 

  • Quantification: Must distinguish between massive and non-massive. May be difficult, clinical definition is more important than objective measurements 
    • Massive Hemoptysis: >600cc/24hr, >100cc/hr, OR clinically, any bleeding causing respiratory compromise
    • Massive is life-threatening from airway obstruction impairing ventilation and causing asphyxiation, not exsanguination

Pathogenesis and associated etiologies

presentation varies based on source and etiology of bleed 

  • Bronchial artery: Usually a process erodes through parenchyma/airway into an artery 
    • Bronchitis/bronchiectasis, malignancy, infection (bacterial/fungal PNA, abscesses, aspergilloma, TB), trauma/foreign body, AVMs 
  • Pulmonary artery: Typically occlusions cause pulmonary infarction rather than an erosion into the vessel itself, however malignancy and infections can rarely erode into the PAs 
    • PE, malignancy, infections, trauma/foreign body 
  • Pulmonary microcirculation: leaky capillaries as a result of inflammation surrounding or originating in the vessels
    • Rheumatologic (vasculitis, CAPS, Goodpasture's), Cardiac (CHF, mitral stenosis), AVMs/fistulas, cocaine/drug-induced, coagulopathy

Evaluation 

  • Goal is to identify the source of bleeding: bronchial arteries vs pulmonary arteries vs pulmonary microcirculation 
  • Immediate assessment of ABCs: Airway, Breathing (oxygenation/ventilation, respiratory distress), Circulation (hemodynamic instability), and designation of massive vs non-massive bleeding 
  • Rule out Mimics: UGIB (hematemesis) and nasopharyngeal 
  • Determine coagulation status: medications, PT/INR, PTT, platelets 
  • Labs: CBC, Type & Screen, BMP, ABG (evaluate oxygenation) 
    • Consider ANA, ANCA, anti-GBM, anti-cardiolipin, IFNG release assay, UA (hematuria), sputum culture (bacteria, fungal, AFB), sputum cytology (if not undergoing bronchoscopy), and RPP depending on clinical context 
  • Imaging: 
    • CXR first (to evaluate etiology +/- lateralization) 
    • Chest CT unless very low volume 
    • CTA PE if highest suspicion for PE 
    • CTA bronchial artery protocol if brisk bleeding present 
  • Bronchoscopy is sometimes indicated to localize bleeding source 
    • Management 
  • Non-massive hemoptysis: Consider Nebulized Tranexamic acid (TXA) (500mg TID) 
    • Treat underlying cause 
  • Massive hemoptysis: 
    • If concerned for airway compromise page MICU Fellow for consideration of transfer, intubation +/- bronchoscopy (diagnostic and therapeutic) 
    • CT bronchial artery protocol (CTA and specify bronchial artery protocol in the comments, NOT CTPE (timing will be incorrect for CTPE) 
    • This imaging is required for embolization planning 
  • Based on imaging, consider IR consult for consideration of Bronchial Artery Embolization (BAE is recommended for majority of massive hemoptysis cases) 
  • Consider reversing underlying coagulopathy 
    • Positioning: For unilateral bleeding, place bleeding-side DOWN! (e.g., left bleed -> left lateral decubitus) If applicable, this should be in your sign-out 
    • Recurrent hemoptysis is often managed with repeat embolization and addressing the underlying cause
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