Hemoptysis - Diagnosis and Management Summary
DEFINITION: Expectoration of blood from lower respiratory tract
• Airway: bronchitis, bronchiectasis, malignancy (usually primary lung CA), trauma (incl. foreign body)
• Pulmonary parenchyma: infection (PNA, abscess, TB, aspergilloma), ANCA-associated vasculitis (GPA), immune-complex mediated vasculitis (SLE, cryo, HSP), Goodpasture syndrome (anti-GBM), drug-induced vasculitis (cocaine, PTU, TNFi), coagulopathy, endometriosis, inhalation injury, sarcoid
• Pulmonary vascular: PE, CHF, mitral regurgitation, bronchovascular fistula, aneurysm, AVM
1) Consider other sources (GI or nasopharyngeal)
2) CXR (most important), CBC/coags, UA (screen for vascultits), sputum Cx, CT chest (if stable)
3) In select pts: NT-proBNP (if CHF on ddx), ESR/CRP, C3/C4, ANA, ANCA, anti-GBM, APLA (anti-cardiolipin, beta-2 GP1, LA), IGRA/AFB to r/o TB, D-dimer (if PE on ddx)
MASSIVE HEMOPTYSIS (>500mL/day or >100mL/hr) is a life-threatening emergency with mortality rate 50-80%. Source is often arterial. Asphyxiation NOT exsanguination is mechanism of death.
1) Control airway: STAT RICU consult (x63333); consider bronchoscopic intubation; use largest ET-tube (>8mm) possible
2) LIE PATIENT ON SIDE WHERE BLEEDING IS SUSPECTED (preserve gas exchange in unaffected lung)
Call IP→bronch to localize bleeding source to lobe/segment and treat (topical vasoconstriction, coagulant, electrocautery, laser, balloon tamponade);
Call IR→CTA (embolization of bleeding site); correct coagulopathy
Consider c/s thoracic surgery. Consider pulse dose methylprednisolone if vasculitis is suspected cause.
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