20. Hemoptysis Flashcards
hemoptysis defn
expectoration of blood from resp tract below vocal cords
massive hemoptysis defn
> 100ml or 1/2 cup blood loss in any 24h period or bleeding rate >/100ml/hour which may result in HD instability, shock or impaired gas exchange and
mortality rate of 80%
How many ml of blood volume is in the tracheopulmonary tree?
150
Highest short term mortality factors in a hemoptysis pt
alcoholism
active cancer
aspergillosis
pulmonary artery involvement
multifocal pulmonary infiltrates
need for mechanical ventilation at time of admission
DDX of hemoptysis
tb
bronchiectasis
lung abscesses
cancer
cf
avm
pneumonia
anticoag use
postprocedural complications
Specific causes of hemoptysis in peds that may be different than adults
infection
chd
cf
bleed from preexisting trach
Minor hemoptysis - where does this typically originate from?
tracheobronchial capillaries disrupted by vigorous coughing, minor bronchial infections
Massive hemoptysis - where does this come from?
bronchial or pulmonary arteries
Why do bronchial arteries cause a big problem as compared to pulmonary?
small caliber but high pressure
pulmonary - large vol of blood at lower pressure, less likely than bronchial to be culprit
How does bronchiectasis cause hemoptysis?
tissue distruction and remoeling can result in bleeding
Diffuse alveolar hemorrhage causes
gpa vasculitis
sle
goodpasture
Name 5 causes of hemoptysis - airway disease
Bronchitis (acute or chronic) Bronchiectasis
Neoplasm (primary and metastatic)
Trauma
Foreign body
Name 4 causes of hemoptysis - parenchymal disease
Tuberculosis (TB) Pneumonia, lung abscess Fungal infection Neoplasm
Name 4 causes of hemoptysis - vascular disease
Pulmonary embolism
Arteriovenous malformation
Aortic aneurysm
Pulmonary hypertension
Vasculitis (Wegener’s granulomatosis, systemic lupus erythematosus
[SLE], Goodpasture syndrome)
Name 4 causes of hemoptysis - hematologic disease
Coagulopathy (cirrhosis or warfarin therapy) Disseminated intravascular coagulation (DIC) Platelet dysfunction
Thrombocytopenia
Name 3 causes of hemoptysis - cardiac disease
Congenital heart disease (especially in children) Valvular heart disease
Endocarditis
Name 4 causes of hemoptysis - miscellaneous
cocaine
postprocedural injiury
tracheal arterial fistula
sle
PE for massive hemoptysis
vitals
abc
ensure not coming from gi/mouth/pharynx
assess for vasuclitis/skin changes
Key hx questions for hemoptysis
hx of disease
amount/rate/appearance
coming from?
cancer sx
etoh, fungal infection hx
tb/travel hx
Key labs for pt with hemoptysis
cbc
cr
urea
urea:cr ratio
coag test
t+screen _–> crossmatch
cxr poor, likely ct vs unknown cta
when is cta first line for hemoptysis?
bronchial a hemorrhage suspected
angio assiste embolization tx to be performed
cause of hemoptysis unknown (ie malignancy)
Name 5 critical diagnoses in patients presenting with hemoptysis:
Disseminated intravascular coagulopathy (DIC) Tracheo-innominate artery fistula (TIF) Aortobronchial fistula
Iatrogenic (postprocedural) hemoptysis Pulmonary embolism
Name 5 emergent diagnoses in patients presenting with hemoptysis:
Trauma
Bronchiectasis
Pneumonia
Abscess/fungal infection Oral anticoagulant overdose Endocarditis
If patient with hemoptysis presents with hx of tracheostomy new within -4 weeks, concern for ?
tracheoinnominate a fistula
If ct chest is not diagnostic, what other test can you consider?
bronchoscopy
Basic position for hemoptysis patient if hypoxic or HD unstable?
bleeding lung down
IV, IVF/blood,ffp, cardiac minor, pulse ox, intubation
concern for bronchial a hemorrhage? –> call cardiothoracic surgery, pulmonary/IR consult
TIF suspected - what can emerg do?
overinflate trach balloon to try to tamponade
if fails, remove trach and oral intubate pt or place and apply pressure
what size ett?
8 or larger
How to perform a R mainstem intubation
advance tube in neutral pos
use 90 deg rotation techn in direction of desired placement and adv until resistance is met
if life threatening hemoptysis or cannot intubate on first try, who to call?
anesthesia for double lumen ETT
Complications of double lumen tubes
unil and bilat ptx
pneumomediastinum
carinal rupture
lobar collapse
tube malposition
What is the most common cause of trace hemoptysis (blood-tinged sputum)?
a. Bronchiectasis
b. Bronchitis
c. Cancer
d. Congestive heart failure e. Pulmonaryembolism
b
Disruption of which of the following vessels is responsible for the
vast majority of cases of massive hemoptysis? a. Aorta
b. Bronchial arteries
c. Pulmonary arteries
d. Pulmonary veins
e. Tracheobronchial capillaries
b
A 50-year-old man presents after an episode of hemoptysis. He describes coughing up several large clots of dark blood. During his evaluation, he coughs and expectorates approximately 5 mL of clotted blood. The patient’s vital signs are normal, and no abnor- malities are noted on physical examination. His chest radiograph is normal. Which of the following is the most appropriate next step in the management of this patient?
a. Admission to an observation unit
b. Consultation for bronchoscopy
c. Consultation for percutaneous embolization
d. Discharge home with follow-up in 24 hours
e. Obtain chest high-resolution computed tomography (HRCT)
scan
e
Which of the following statements regarding the evaluation of
hemoptysis is true?
a. Chest x-ray localizes the site of bleeding in nearly 90% of cases of
patients with large volume hemoptysis.
b. Conventional angiography is the preferred diagnostic test to
detect both bronchial and nonbronchial arterial causes of mas-
sive hemoptysis.
c. High-resolution CT, even with recent advances in technology,
remains diagnostically inferior to angiography.
d. Patients with fever, cough, and blood-tinged sputum should
receive a chest x-ray even if the vital signs are normal.
b
A 58-year-old man with a single lung transplant presents to the
emergency department (ED) with what appears to be large-volume hemoptysis. He was just discharged from the endoscopy suite, where he had a number of surveillance biopsies performed. He looks pale and diaphoretic with an initial oxygen saturation of 71%. After placement of an intravenous line and supplemental oxygen, the next most appropriate step is:
a. Bloodtransfusion
b. High-resolution computed tomography scan of the chest c. Intubation
d. Thoracic surgery consultation
c
