Hemoptysis

Definition: Expectoration of blood or blood streaked sputum. True hemoptysis is expectoration of blood from the lower resp tract (below the glottis).

Massive hemoptysis: > 600 ml/24 h (no absolute definition exists). Usually occurs from bronchial arteries.

Gas exchange is more important than blood loss.

Causes:

• • Acute bronchitis, pneumonia, trauma, FB, PE, left heart failure, bronchogenic carcinoma, metastatic lung cancer, bronchiectasis, TB, aspergilloma, lung abscess, AVM, pulmonary endometriosis, bronchial carcinoid, Kaposi's sarcoma, rupture of pulmonary artery 2° instrumentation (Swan-Ganz cath), CF, mitral stenosis, pulmonary HTN, Goodpasture's syndrome, Wegener's granulomatosis, Lupus pneumonitis, excessive anticoagulation (w/ underlying lung disease), DIC, thrombocytopenia, idiopathic pulmonary hemosiderosis, hereditary hemorrhagic telangiectasia.

  • Massive hemoptysis: bronchiectasis, cavitary lung disease (TB, aspergilloma, lung abscess), AVM, malignancy.

  • Meds: anticoagulants, ASA, cocaine.

Tx:

• • ABC

  • Distinguish massive from nonmassive hemoptysis.

    • Stablize

    • Dx and localize

    • Decide on need of therapy.

  • Nonmassive hempotysis: usually tx conservatively and based on underlying d/o:

    • Reverse coagulopathy

    • Antitussives and mild sedatives

    • Bronchoscopy if recurrent

  • Massive hemoptysis requires urgent action:

    • ICU monitoring, early MDT approach (pulmonologist and/or thoracic surgeon, and interventional radiologist).

    • Initial stabilization:

      • Ensure airway patency

      • Put bleeding lung down/dependent, in massive hemoptysis to minimze aspiration into unaffected lung.

      • Selective intubation with single-lumen ETT of unaffected lung.

      • Double lumen ETT for selective ventilation of unaffected lung.

      • Systemic procoagulants: Factor VII, vasopressin, aminocaproic acid.

    • Mechanical vent if necessary

    • Reverse coagulation

    • Angiography: used for Dx and Rx (vascular occlusion balloons or selective embolization of bronchial circulation)

    • Rigid bronchoscopy allows more interventional options (electrocautery, laser - Nd:YAG) than flex-bronch.

    • Surgical resection (lobectomy/pneumonectomy) for emergent therapy of life-threatening hemoptysis that fails to respond to other measures. Also indicated electively for recurrent bleeding where definitive management of localized disease is warranted.

  • Rebleeding is common in up to 20% cases over 1 year.

  • Risks: bronchial, pulmonary infarct, rarely ischemic myelopathy due to inadvertent embolization of a spinal artery.

History:

• • Age, smoking history, prior lung disease, previous malignancy, risk for coagulopathy.

  • Fever, chills, sputum with hemoptysis - pneumonia. Sputum is putrid, malodorous - lung abscess.

  • Chronic, copious sputum production - bronchiectasis

  • Hemoptysis + pleuritic chest pain + tachypnea + tachycardia = PE.

  • H/o renal dz + hemoptysis - Goodpasture's synd, or Wegener's granulomatosis, SLE

  • H/o previous malignancy or treatment of malignancy - recurrent lung cancer or endobronchial metastases from nonpulmonary primary tumor; chemotherapy or bone-marrow transplant.

    • Risk factors for cancer: smoking, asbestos exposure, etc.

  • Pt. with AIDS - endobronchial or pulmonary parenchymal Kaposi's sarcoma

  • Bleeding d/o. Is Pt. on anticoagulants, drugs associated with thrombocytopenia?

Physical ex:

• • VS, oxygen sats, general state of health.

  • Pleural friction rub - PE

  • Crackles - parenchymal process associated with bleeding.

  • Airflow obstruction - bronchitis, endobronchial tumor

  • Rhonchi, wheezing or crackles - bronchiectasis.

  • Diastolic Murmur of mitral stenosis, signs of CHF, pulmonary HTN

  • Skin exam for Kaposi's sarcoma lesions, Osler-Rendu-Weber dz.

Patient with at least two risk factors for bronchogenic CA: male sex, age >40 yrs, >40 pack-year smoking, duration of hemoptysis >1 week, volume expectorated >30 mL.

Lab/Dxtic:

• • CXR (PA/lateral): mass lesions or focal or diffuse parenchymal lesions

  • CBC, PT, PTT, INR, CMP, ABG, ANA, c-ANCA, BNP, anti-GMB antibodies, complement levels, cryoglobulins, etc.

  • UA with microscopy

  • Type and crossmatch blood

  • Sputum for gram stain, C&S, AFB, fungal, cytology

  • ECG

  • Fiberoptic bronchoscopy +/- BAL, and/or Bx.

  • Rigid bronchoscopy preferable for Tx and Dxtic.

  • HRCT

  • Echo

  • Bronchial and pulmonary arteriography in persistent or recurring massive hemoptysis.

    • Embolization within 48 hours of bleeding onset.

Dx of Hemoptysis form H & P