Hemoptysis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Definition

Hemoptysis is the medical term for expectorating (coughing up) blood from the trachea, larynx, bronchi or lungs; and can be confused with hematemesis (vomiting up blood). Massive hemoptysis can be a life-threatening condition and should be treated inmediatley.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Hemoptysis may be a life-threatening condition depending on the severity of bleeding and must be treated as such irrespective of the causes.

Common Causes

• Bronchiectasis
• Coagulopathy: Von Willebrand's disease, haemophilia, thrombocytopenia
• Cystic fibrosis
• Iatrogenic: anticoagulation
• Infection: tuberculosis, aspergilloma
• Lung abscess
• Lung cancer: bronchial carcinoma,adenoma, metastasis
• Pulmonary embolism
• Pulmonary hypertension
• Sarcoidosis
• Trauma
• Vasculitis: Wegener's granulomatosis, Behcet's disease

Management

Characterize the symptoms ❑ Coughing up blood ❑ Chest pain ❑ Tachypnea ❑ Dyspnea ❑ Fever Obtein detalled history ❑ Recent travel H/O ❑ Recent drug H/O ❑ Family H/O ❑ Systemic illness H/O

Asses volume stauts ❑ General condition ❑ Heart rate ❑ Blood pressure ❑ Respiratory rate ❑ Mucosa ❑ Pulmonary reserve Examine the patient ❑ Exclude hemorrhagic sites from nasopharynx and gastrointestinal track ❑ Skin (paleness) ❑ Respiratory system (use accessory respiratory muscles, murmur)

Order lab ❑ Complete blood count ❑ Arterial blood gas ❑ Coagulation profile ❑ Electrolytes ❑ Blood typing and cross match ❑ Liver and renal function test

Hemoptysis

Upper gastrointestinal bleeding

Nasopharynx bleed

Follow Upper gastrointestinal bleeding resident survival guide

Refer to otolaryngologist

Management of Mild to Moderate Hemoptysis

The algorithm is based on the American Family Physician Journal of hemoptysis: Diagnosis and Management

Hemoptysis

Mild hemoptysis ❑ <30 cc in 24 hours

Moderate hemoptysis ❑ 30-200 cc in 24 hours

Chest X-ray (CXR)

Chest X-ray and CT

Diagnose found

Diagnose unknown

Diagnose found

Diagnose unknown

Treat underlying disease

Risk of malignancy ❑ Smoking ❑ Occupational exposure ❑ Family history ❑ Previous cancer treatment

Treat underlying disease

Bronchoscopy to find diagnosis

Yes

No

Diagnose found

Diagnose unknown

CT or bronchoscopy to find diagnosis

Close monitoring

Treat underlying disease

Close monitoring

Diagnose found

Diagnose unknown

If hemoptysis persist consult with pneumonologist

Treat underlying Disease

Close monitoring

Management of Massive Hemoptysis

The algorithm is based on the Society of Critical Care Medicine Journal of clinical assessment and management of massive hemoptysis.

Massive hemoptysis ❑ 200-600cc or more in 48 hours AND/OR ❑ Signs of hypovolemia: Postural pulse increment of > 30 beats/min Supine tachycardia (>100 beats/min) Supine hypotension ❑ Symptoms of hypovolemia: Dizz Faint Nausea Very thirsty

❑ Monitor patient in the intensive care unit ❑ Secure airway permeability to avoid aspiration ❑ Place patient in lateral decubit towards site of bleeding (if only one lung is bleeding)

Unstable patient

Stable patient

❑ Right away transfuse O- positive blood type. ❑ If the patient has a life-threatening hemoptysis and/or a hypovolemic shock and/or hypoxemia; intubate with a 8-mm or larger endotracheal tube to allow subsequent bronchoscopy. ❑ Make a thoracic surgery consult

CT

Bronchoscopy

Diagnose not found

Diagnose found

Bleeding localised

Bleeding not localized

Intersticial, reticular pattern

Infiltrate

Cavity

Nodular, cystic lesion

Endobronchial taponade

Pulmonary angiography

Search for interstitial lung diseases

Give appropriate antibiotics

Search for tuberculosis, aspergilloma, lung abscess

Give appropriate antibiotics

Bleeding localized

Bleeding not localized

Treat underlying disease

Give appropriate antibiotics

Bronchial artery embolization (BAE)

Conservative therapy

Treat underlying disease

Do's

• Investigate profusely the patient's medical history for possible diagnosis.
• Intubate patient with massive hemoptysis to protect airway.
• Determine volume and rate of blood.
• Supply all patients with oxygen to maintain oxyhemoglobin saturation.
• Place the patient with massive hemoptysis in lateral decubit towards side of bleeding (if bleeding is located in one lung).
• Treat massive hemoptysis in a ICU.
• Place patient in isolation when tuberculosis is suspected, until the septum is analysed.

Dont's

• Don't perform chest CT before bronchoscopy or bronchial artery embolization in unstable patients.
• Don't use invasive therapeutic in patients with anticoagulant therapy, blood dyscrasia or goodpasture syndrome.
• Don't operate in patients with lung carcinoma invading the trachea, mediastinum, heart, great vessels, and parietal pleura; in patients with terminal diseases or advanced pulmonary disease.

References

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