Episode 177.0 – Hemoptysis

An overview and management tips of hemoptysis in the ED. Hosts: Brian Gilberti, MD Audrey Bree Tse, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Hemoptysis.mp3 Download One Comment Tags: Critical Care, Pulmonary 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 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. Read More