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



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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