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: 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 sali

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