Hemoptysis

• Definition-Expectoration of blood from the respiratory tract below the level of the larynx.
• The amount can vary from blood-tinged sputum to mild (< 5 ml in 24 h) to moderate (5-600 ml in 24 h) to severe (>600 ml in 24 h).
• Mortality is often a result of hypoxemia secondary to impaired gas exchange and also depends upon the underlying disease process (see Table 3E.1).

  Etiology

• Neoplasm and TB are responsible for a significant number of cases but there are many causes of hemoptysis (see Table 3E.1).

  Diagnosis

• History should include symptom acuity, and quality/quantity of expectorate, presence of associated symptoms (i.e., weight loss, fever, etc), past medical history, risk factors for pulmonary disease (i.e., cigarette smoking), and recent travel history.
• Patients present with varying degrees of respiratory and/or circulatory compromise depending upon the severity of bleeding and the underlying cause. In cases of massive hemorrhage, the patient may present with the affected side recumbent to prevent blood from filling the uninjured lung.

  Table Etiology of hemoptysis
  

  Infectious	Chronic bronchitis Tuberculosis Fungal and parasitic infections Necrotizing pneumonia Pulmonary abscess
  Neoplasia	Bronchogenic carcinoma Pulmonary metastasis Bronchial adenoma
  Cardiopulmonary	Mitral valve stenosis
  Vascular	Pulmonary embolus Alveolar arteriovenous malformation
  Other	Trauma Foreign body Bronchiectasis Wegener’s granulomatosis Goodpasture’s syndrome Systemic lupus erythematosus Coagulopathy and use of anticoagulant medications Idiopathic hemosiderosis

• Both the pulmonary and extra pulmonary exams help identify the cause of the bleeding. Pulmonary findings may include rhonchi, rales, decreased breath sounds, ego phony, or a pleural effusions, pleural rub. Extra pulmonary findings may include a diastolic murmur of mitral valve stenosis, supraclavicular adenopathy suggestive of cancer, or digital clubbing in patients with chronic lung disease. Also look for mucosal or cutaneous changes in patients with vasculitic pathology.
• Diagnostic Studies
• CXR is indicated in all cases and often aids identification of the etiology.
• Sputum examination-True hemoptysis is identifiable by its characteristic bright red appearance and alkaline pH. Hematemesis is usually darker, has an acidic pH, and may contain food particles. However, aspiration of gastric hemorrhage may create confusion. An AFB stain and culture is mandatory in all patients for whom TB is suspected.
• Laboratory studies-CBC with differential is the most important and commonly ordered test. Others including PT, electrolytes, glucose, BUN, creatinine, and blood type and screen may be performed depending upon the patient’s history and presentation.
• An EKG should be obtained in patients with suspected valvular or congestive heart disease.
• Specialized radiography such as computerized tomography (CT) and ventilation/ perfusion (V/Q) scans are ordered as needed for suspected neoplasm, bronchiectasis or PE.
• Bronchoscopy is the gold standard for diagnosis and allows for clot removal and retrieval of material for biopsy and culture. This is often not possible with severe, uncontrolled bleeding.

Treatment

• Management of the patient’s airway, breathing and circulatory status are paramount. Supplemental oxygen as well as crystalloid and/or blood product administration should be administered as needed. Patients with respiratory failure or difficulty maintaining a patent airway mandate intubation. Orotracheal intubation with a large (=8.0) endotracheal tube is preferred. This facilitates suctioning and allows for subsequent bronchoscopy.
• Temporizing Measures for Hemorrhage Control in those with Severe Bleeding
• Bronchoscopic balloon tamponade by a pulmonologist
• Selective bronchus intubation
• If the bleeding source is the left lung, selective intubation of the right mainstem bronchus is accomplished by advancing the tube 4-5 cm beyond the usual position.
• Intubation of the left mainstem bronchus is more difficult. Rotating the endotracheal tube 90 degrees counter-clockwise so the tube concavity faces the left during intubation is sometimes successful. If available, a double-lumen endotracheal tube can be used although there are often complications and most physicians have little to no experience with the product.
• Definitive Hemorrhage Control
• Treatment should address any underlying condition such as infection, vasculitis, or coagulopathy.
• Patients with moderate to severe bleeding warrant emergent evaluation by a pulmonary specialist for bronchoscopy. Arterial embolization by interventional radiology is an option for those with uncontrolled hemorrhage or when bronchoscopy is not possible or not successful.
• Some disease processes are amenable to surgical therapy and a thoracic surgery consult is indicated if other modalities fail to control bleeding.

Disposition

• All patients with respiratory compromise or unstable hemodynamics should be admitted to an intensive care unit. There is a high incidence of recurrence in patients with self-limiting massive hemoptysis and these patients also require intensive care admission.
• Patients with suspected TB should be admitted and kept in respiratory isolation until appropriate testing is completed.
• Patients with minor, self-limiting hemoptysis can be considered for discharge. Outpatient treatment should address the underlying etiology. All discharged patients should follow-up with their primary care provider or a pulmonologist.

Massive Hemoptysis

• Expectoration of blood from lower respiratory tract (systemic bronchial vessels and low pressure pulmonary vessels) >50 ml per episode or 600 ml/24 h. It may be differentiated from hematemesis and bleeding from a ENT source ( such as epistaxis) during the course of resuscitation, which must proceed emergently in severe cases.

Primary Survey

Airway:	Endotracheal intubation with RSI technique is indicated.A large diameter ET tube should be used (8.0 or larger if possible) to provide pulmonary toilet and facilitate bronchoscopy The ET tube should be advanced to the mainstem bronchus of nonbleeding lung, if there is persistent bleeding. The right mainstem is easily entered, the left requires specialized technique and/or equipment. Until the airway is secured with endotracheal intubation, personnel should take precautions against respiratory spread of tuberculosis.
Breathing:	Both before and after intubation, the patient should be positioned with bleeding lung dependent to maximize gas exchange and minimize the filling of the unaffected side with blood. Sedation and paralysis should be considered to prevent coughing and retching that may dislodge clot and worsen hemorrhage.
Circulation:	IV fluid resusciation may be initiated with normal saline through large bore IV access, followed by emergent blood transfusion as needed. Blood type and crossmatch is critical. Fresh frozen plasma and platelets should both be considered when there is suspected coagulopathy or severe thrombocytopenia. Massive, uncontrolled hemoptysis may require a spectrum of emergent specialty consultation, including cardiothoracic surgery, interventional radiology and pulmonary medicine.
Disability:	A cursory neurological examination should be sought prior to paralysis and endotracheal intubation so the need to image the head for intracranial pathology can be assessed.

Resuscitation Phase

Critical Questions: Other coexistent conditions that may require other critical actions in the setting of massive hemoptysis:

Conditions	Actions
Advanced malignancy	Consider level of intervention Seek advance directives, family conference
Pneumonia	Sputum cultures and IV antibiotics
Valvular heart lesion	Emergent cardiac surgery consultation
Critical investigations: These may also include:
Emergent bronchoscopy	To localize and treat source of bleeding
Emergency bronchial arteriography
CT Chest

Suggested Reading

1. Cahill BC, Ingbar DH. Massive hemoptysis: Assessment and management. Clin Chest Med 1994; 15(1):147.
2. Dweik RA, Stoller JK. Role of bronchoscopy in massive hemoptysis. Clin Chest Med 1999; 20(1):89.
3. Goldman JM. Hemoptysis: Emergency assessment and management. Emerg Med Clin North Am 1989; 7(2):325.
4. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28(5):1642.
5. Marshall TJ, Flower CDR, Jackson JE. The role of radiology in the investigation and managment of patients with haemoptysis. Clin Radiol 1996; 51:391.