Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.

HEMOPTYSIS

Definition

• Expectoration of blood or blood-stained sputum from below the vocal cords

• Massive is >100 cc/d (1 cup) or disrupting ability to breathe. High mortality 2/2 asphyxiation.

• Recall that bronchial arteries are high pressure, pulmonary arteries are low pressure

Approach to Patient

History

• Onset (sudden vs. progressive); quantity of blood; differentiate from GI or ENT source

• ROS: Fever, SOB, CP, weight loss, epistaxis (Wegener’s, bleeding diathesis), melena

• Identify hx or RFs for COPD, PE, TB, CHF, cancer, autoimmune dz, coagulopathy

Physical Exam

• Assess airway first, if compromised, proceed directly to stabilizing airway

• Lung exam may show signs of COPD, PNA, edema; cardiac exam for signs of CHF

Diagnostics

• Labs: CBC, PT, PTT; type & screen. Consider AFB, D-dimer.

• Imaging: CXR; if stable, chest CT much more helpful ±bronchoscopy

Treatment

• Airway: HOB >45°; lean to side of bleeding (if known). If intubation necessary, large-bore ETT & consider placing ETT in unaffected lung. Double-lumen ETT if skilled operator.

• Definitive management: Minor hemoptysis can usually be managed conservatively, but if massive requires bronchoscopy or IR embolization, surgical resection if all else fails

Disposition

• Healthy, minimal bleeding: Get CXR; if negative: Home, outpt f/u

• High-risk pt, minor bleeding: Get CT, consider admit for observation, bronchoscopy

• Massive: ICU, consult pulmonology, interventional radiology, thoracic surgery