EM@3AM: Hemoptysis

Author: Sean O’Hara, MD (EM Attending Physician, San Antonio, TX) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 55-year-old male presents with chief complaint of shortness of breath, cough, and blood-tinged sputum. He states that he has been fighting off a cold over the past week, but noticed increasing cough over the past several hours, sometimes tinged with blood. He states he’s had no fevers, chills, chest pain, leg swelling, or other symptoms other than the cough and shortness of breath when he ambulates. He has a history of atrial fibrillation, takes atenolol and coumadin, and is a two pack per day smoker.

Initial VS include T 36.2, HR 95, BP 100/68, RR 22, SpO2 95% RA.

Exam reveals a well-appearing male in no apparent distress, but is notable for mild tachypnea and atrial fibrillation. Exam is otherwise unremarkable, with clear lungs.

What do you think is going on with this patient? What are the next steps in management?

Answer: Hemoptysis

• Background:
  • Expectoration of blood from lung parenchyma or airways below the larynx.
  • Incidence of 1/1000 patients per year.
  • Typically benign and self-limited, but can be severe.
  • Bronchitis is most common cause in U.S.; tuberculosis most common cause worldwide.
  • Can be related to cancer, especially in those with risk factors.
  • Severe forms may result in airway compromise.
  • Types of hemoptysis: Massive vs. Non-massive
    • Massive (1.5-5% of all hemoptysis cases) – Acutely life threatening bleeding, with death from asphyxiation. No consensus for exact volume, but sufficient volume that causes airway obstruction. Greater than 50 ml per cough, 100mL/hr, or greater than 600mL in 24 hrs is generally accepted as the cutoff. If you as the physician are fearful of the amount, consider it massive.
    • Non-Massive – Everything else. Some patients need infectious/cancerous etiology workup.
  • Massive Hemoptysis bleeding source:
    • 90% from bronchial arteries (high pressure).
    • 5% from aorta, non-bronchial systemic circulation (high pressure).
    • 5% from pulmonary arteries (low pressure).
  • Typically occurs in adults, but rarely can occur in children. Management principles are similar, but etiology changes. Cutoff for massive hemoptysis is lower, greater than 240 mL in 24 hr period is considered massive.
• Evaluation: Key is determining non-massive vs massive hemoptysis.
  • History: Important to differentiate hemoptysis from pseudohemoptysis (bleeding from upper airways or upper GI tract). Ask regarding recent epistaxis, pharyngitis, gastritis symptoms, or history of esophageal varices. Important to quantify timing, duration, quantity of hemoptysis, and how frequently it is occurring. Elicit potential B-symptoms—fever, night sweats, weight loss. Obtain past medical history (history of cystic fibrosis, bronchiectasis, COPD, TB, CHF, trauma), surgical history (recent immobilization; hx. aorta repair), medication lists (anticoagulation), family history (clotting disorders; genetic predispositions), and social history (smoking, alcohol, drug use history; employment history for environmental exposures).
  • Exam: Most patients will appear healthy in those with non-massive hemoptysis. Screen for signs of massive hemoptysis – decreased blood pressure, hypoxia, and tachycardia. Detailed cardiac exam listening for murmurs. Assess lung sounds for asymmetry or decreased lung sounds, which help localize bleeding source. Detailed HEENT and abdominal examination to assess for alternative bleeding sources. Assess for signs of lymphadenopathy, which can suggest malignancy as cause of hemoptysis. Extremity exam important to evaluate for signs of deep venous thrombosis.
  • Obtain:
    • Labs – CBC, BMP, LFTs, PT/PTT/INR, Type/Rh, Lactic Acid. D dimer may be needed in evaluating for PE.
    • Imaging studies – CXR is recommended. +/- CTPE if concerned for PE. If massive, need CT with IV contrast to localize bleeding source.
  • Differential Diagnosis:
    • Adults: Bronchitis, respiratory tract malignancies, bronchiectasis, pneumonia, foreign bodies, fistulas, pulmonary embolism, tuberculosis, aspergilloma, iatrogenic, vasculitis, coagulopathy, cocaine-induced pulmonary hemorrhage, catamenial hemoptysis, congestive heart failure, pulmonary AVMs, trauma, cryptogenic.
    • Children: Respiratory infection, aspirated foreign bodies, bronchiectasis, congenital heart disease, vasculitis, congenital lung malformations, coagulopathy, pulmonary masses, trauma, cryptogenic.
    • Cryptogenic – Up to 30% of hemoptysis patients – no clear cause after evaluation with CT, bronchoscopy.
  • Management:
    • Non-Massive Hemoptysis:
      • Treat underlying disorder.
      • If normal CXR, typically able to observe without treatment.
      • If consolidation, appropriate to treat with antibiotics if infection suspected.
      • If CXR and risk factors/history concerning for malignancy, obtain CT.
      • Evaluate for potential pulmonary embolism if history/physical suggestive.
    • Massive Hemoptysis:
      • Protect airway first!
        • Early intubation if signs of respiratory distress, impending obstruction.
        • Largest single lumen endotracheal tube (ETT) possible (8.0 preferred).
        • Turn ETT 90 degrees towards lung desired to selectively ventilate.
        • Double lumen tubes typically become dislodged easily, complicated to place, and are typically placed by anesthesia.
      • Selectively ventilate
        • If unilateral bleeding, place patient in lateral decubitus with bleeding lung down.
        • If bilateral bleeding, place patient in Trendelenburg.
      • Treat underlying cause
        • Antibiotics if infectious process.
        • Steroids if inflammatory/auto-immune process.
      • Correct coagulopathy if present, transfuse blood products as needed
        • Fresh frozen plasma (FFP), vitamin K, prothrombin complex concentrate (PCC), tranexamic acid (TXA), DDAVP in patients with uremia.
        • Transfuse RBCs and platelets if decreased Hgb/PLT counts.
      • Localize/Stop Bleeding
        • Patients with massive hemoptysis should undergo high resolution CT chest with IV contrast to assist in localizing bleeding.
        • Bronchoscopy typically performed following CT chest. This can be completed in the ICU.
          • Flexible bronchoscopy can be performed at bedside, quickly localize source, fit into distal airways. Unfortunately is unable to suction large volume hemoptysis.
          • Rigid bronchoscopy typically performed in OR, has greater suctioning capabilities, but cannot visualize distal airways. Typically performed if flexible not successful, or if angiography not successful.
          • Bronchoscopic interventions include balloon tamponade, topical vasoconstrictive agents, laser therapy, and iced saline lavage.
        • If persistent bleeding status post bronchoscopy, or unable to control with bronchoscopy, interventional radiology can perform arterial endovascular embolization. Typically performed on bronchial arteries. Can cause spinal cord ischemia, as anterior spinal artery arises from a bronchial artery in 5% of the population.
        • If all else fails and there is a localized bleeding source, thoracic surgery can be consulted to perform resection of bleeding source. Typically performed in cases where there is iatrogenic PA rupture, chest trauma, or aspergilloma. Emergency resections are associated with increased mortality (around 35%).
  • Disposition:
    • Non-Massive Hemoptysis:
      • Discharge home with PCM follow-up.
      • Most patients will have resolution of their symptoms without intervention.
      • Patients at risk for malignancy (age > 40, hx smoking, mass on CXR, adenopathy, etc.) need close follow-up, high resolution CT scan chest to evaluate for malignancy.
      • If persistent hemoptysis with normal CXR and normal CT chest, patient needs bronchoscopy.
    • Massive Hemoptysis:
      • Admit to ICU.
      • Consultations to pulmonary, interventional radiology, and thoracic surgery depending on clinical course.
    • In Hospital Mortality Score:
      • Published by Fartouhk et al. in 2012. Attempts to risk stratify patients with hemoptysis; predict which patients will benefit from early interventions as opposed to observation. Has not been validated.³
      • Patients given points based on history/physical findings:
        • Radiography with hemorrhage from >1 segment of lung (1 pt)
        • Chronic Alcoholism (1 pt)
        • Pulmonary artery involvement (1 pt)
        • Aspergillosis (2 pts)
        • Malignancy (2 pts)
        • Mechanical ventilation required (2 pts)
      • Score 0-1 – Step Down unit appropriate (1-2% mortality)
      • Score 2-4 – ICU with probable IR intervention (6-34% mortality)
      • Score >4 – ICU with urgent IR intervention (58-91% mortality)

A 68-year-old man with a 50 pack-year history of smoking presents with massive hemoptysis and respiratory distress. On examination, he is afebrile with a heart rate 106 beats/minute, blood pressure 130/76 mm Hg, respiratory rate 25 breaths/minute and oxygen saturation 87% on room air. His chest radiograph shows scattered alveolar infiltrates on the left. What is the next best step in management?

A) Emergent bronchoscopy

B) Emergent interventional angiography

C) Place in left lateral decubitus position while preparing for emergent intubation

D) Rapid sequence intubation of the left mainstem bronchus

Answer: C

Massive hemoptysis is generally defined as hemorrhage of 100-600 mL of blood from the respiratory tract in a 24-hour period. As always, rapid assessment and management of the airway should be the first concern. This patient has signs of respiratory distress and hypoxia and should be placed in the left lateral decubitus position (based on his findings on chest radiograph) while preparing for emergent rapid sequence intubation. Placing the presumed affected lung in the dependent position helps limit the amount of spillage of blood into the unaffected lung and may improve oxygenation. The patient should be intubated with a large-bore (8.0 French or larger) endotracheal tube in preparation for possible bronchoscopy.

Emergent bronchoscopy (A) and emergent interventional angiography (B) are both effective steps in localizing and controlling the source of bleeding in patients with massive hemoptysis, but airway management is required first. Unilateral intubation of the unaffected lung helps protect the lung from spillage of blood from the presumed side of bleeding. This patient has evidence of bleeding from the left lung on chest radiograph, so he should undergo rapid sequence intubation of the right mainstem bronchus (D), not left.

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