Hemoptysis

General Overview

  • Expectoration of blood from tracheobronchial tree, ranging from blood-streaked sputum to gross blood
  • Severity
    • Mild <50mL/24h
    • Moderate 50-200mL/24h
    • Massive >200mL/24h
  • Cause
    • Pulmonary Parenchyma
      • Infectious
        • Acute/Chronic Bronchitis - 50%
        • Necrotizing pneumonia (Klebsiella = currant jelly sputum)
        • Tuberculosis (most common worldwide)
        • Fungal
        • Parasitic
      • Neoplasm - 20%
      • Vasculitis
        • Granulomatosis with polyangiitis (Wegener's)
        • Goodpasture
        • Behcet disease
      • Asthma/COPD
      • Trauma/Iatrogenic
    • Vascular
      • Pulmonary Embolism
      • AV malformation
    • Cardiac
      • Mitral stenosis with pulmonary edema
    • Coagulopathy
    • r/o Pseudohemoptysis
      • Upper airway (posterior epistaxis, oropharynx)
      • Hematemesis (usually darker/brown blood, pH<7, N/V)
        • Consider NG tube to rule out GI source

History

  • Duration/Quantity
  • Infectious (Fever, cough, sputum)
  • Systemic (rash, hematuria, joint pain/swelling)
  • Prior lung, renal, valvular disease
  • Cigarette smoking
  • Chemical/Asbestos exposure
  • Travel history (TB, parastic, fungal)
  • Aspirin, NSAID, Anticoagulants
  • Previous episodes (AV malformation, cystic fibrosis, bronchiectasis)

Physical Exam

  • Vitals
  • Respiratory distress
  • HEENT
    • Nasal septal perforation (Granulomatosis with polyangiitis)
    • Aphthous Ulcers (Behcets)
  • Lung/Heart auscultation
  • Unilateral leg swelling (DVT/PE)
  • Skin bruising, telangiectasia, purpura

Investigation

  • CXR
  • CBC, Coag, LFT, Electrolytes (renal function)
  • UA (r/o Granulomatosis with polyangiitis)
  • Consider
    • D-dimer (or CT Angio r/o PE)
    • Blood/sputum cultures
    • BNP
  • If massive, consider Type and Cross-match
  • If risk of malignancy, consider CT vs. Bronchoscopy

Treatment

  • ABC - Maintain airway and oxygenation
    • Consider intubation, transfusion
      • Consider 8.0 ETT allow for bronchoscopy and sunctioning
    • Consider tranexamic acid 1.5g QID
    • Consult
      • Pulmonology (Bronchoscopy)
      • Interventional Radiology (Bronchial artery embolization)
      • Thoracic Surgery
  • Mild hemoptysis with negative CXR
    • Consider treating for bronchitis (antibiotics if appropriate, eg. purulent sputum >10 days)
    • Pulmonology consult for persistent hemoptysis r/o occult neoplasm
  • If negative CXR, CT, Bronchoscopy = cryptogenic hemoptysis
    • Can observe for three years