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    Hemoptysis – Diagnosis & Treatment

    Cardinal Presentations / Presenting Problems, Respiratory

    Last Updated Jan 17, 2022
    Read Disclaimer
    By Floyd Besserer, Shayne Hopwood

    Context

    • Hemoptysis is defined as the expectoration of blood from the lower respiratory tract.
    • Overall annual incidence of 0.1% in ambulatory patients and 10% of patients with chronic lung disease.
    • Traditionally classified as massive and non-massive hemoptysis.
      • Massive hemoptysis has significant mortality without appropriate management (up to 80%).
    • Causes include:
      • Cardiovascular
        • Pulmonary embolism, vascular malformations, pulmonary hypertension, CHF, mitral stenosis.
      • Pulmonary parenchyma
        • TB, Pneumonia, lung abscess, lung contusion, pulmonary edema, mycetoma/ fungal infection, cocaine inhalation, vasculitis (GPA, Goodpasture syndrome).
      • Tracheobronchial
        • Bronchiectasis, neoplasm, bronchitis, foreign body, airway trauma.
      • Pseudohemopytsis
        • Upper airway source, upper GI bleed, Serratia marcescens (red pigment producing bacteria).
      • Other
        • Idiopathic, coagulopathy, iatrogenic (e.g. lung biopsy, thoracentesis).
      • Clinical presentation
        • Hemoptysis of variable quantity, ranging from blood tinged sputum to active hemorrhage.
        • Severe cases may present with hypoxemia or respiratory failure.
        • Average age of patients is 62.
        • 2:1 male to female ratio.
        • 50% will have cryptogenic cause despite investigation.

    Diagnostic Process

    • The approach to diagnosis is based on first establishing the severity of hemoptysis.
      • Massive hemoptysis = >100-1000 cc of blood in 24 hours and/or signs of respiratory failure or hemodynamic instability.
        • Look for hypoxemia, cyanosis, dyspnea, and signs of respiratory distress.
        • Requires immediate stabilization and likely inpatient admission.
      • Non-massive = Generally <100 cc of blood and hemodynamically stable.
    • Next step is to establish the source of the bleeding based on history and physical exam.
      • True hemoptysis will present with alkaline pH, bright red, foamy blood, and other respiratory signs such as dyspnea or increased work of breathing.
      • Rule out pseudohemoptysis.
        • Upper GI bleeding will generally present with coffee ground appearance, hematinized blood, acidic pH, food particles, abdominal discomfort, nausea or vomiting.
          • On exam, look for abdominal tenderness and signs of liver disease.
        • Upper respiratory bleeding will present with epistaxis, bleeding gums, mild to no cough.
          • On exam, look for gingivitis, mouth ulcers, or other sources of bleeding in the pharynx.
    • Recommended investigations
      • CXR
        • First line, recommended for all patients.
        • If CXR normal and underlying cause identified, no further testing needed.
          • Exception is for those high risk of malignancy (30 pack years, aged 40 or older).
        • Determines site in 45-65% of cases.
        • Determines etiology in 25-35% of cases.
        • Sensitivity limited, may miss 10% of malignancies.
      • CT
        • Utilized for those where CXR abnormal, recurrent episodes, high risk for malignancy, or in cases of massive hemoptysis.
        • Not feasible for unstable patients.
        • Determines site in 70-88% of cases.
        • Determines cause in 86% of cases.
      • Bronchoscopy
        • Advantage over CT is that it can be performed at the bedside, does not require transport, and the bleeding site can be treated via bronchoscopy.
        • Disadvantage is that it may promote coughing and thus bleeding, requires specialist.
        • Generally performed after CT.
        • Determines site in 73-93%.
        • Identifies cause in only 2.5-8%.
      • CBC, chemistry, renal function, coagulation status, CRP
        • Rule out thrombocytopenia, evaluate for anemia and microcytosis, renal function for CT, rule out coagulopathy, identify inflammation.
      • Autoimmune workup
        • Generally second line investigation, consider when where there is clinical suspicion or no clear etiology found on initial investigations.
        • ANCA, ANA, ds-DNA-ab.
      • Sputum testing
        • Recommended in massive hemoptysis or to rule out infection.
      • Blood type and cross match
        • Recommended for massive hemoptysis with hemodynamic instability.

    Recommended Treatment

    • Initial management is based on clinical status and type of hemoptysis.
    • Massive hemoptysis.
      • Initial focus should be on ABCs and immediate stabilization.
      • Patient should be positioned lateral decubitus with their bleeding side down if known to prevent aspiration in the unaffected lung.
      • Consider intubation based on respiratory status and security of airway.
        • Intubation into unaffected mainstem bronchi may be necessary based on status of bleeding; this can be done with bronchoscopy or blind advancement into the right mainstem bronchus given its anatomical location with confirmatory radiograph afterwards.
        • Additional strategies include using a bougie with angulated tip facing the unaffected lung mainstem bronchus as well as rotating the patient’s head to the contralateral side (i.e., the bleeding lung).
        • When ventilating single lung, use smaller tidal volumes (3-4 ml/kg predicated body weight to avoid barotrauma).
        • Intubate with a large diameter tube for possible bronchoscopy (8 mm or more).
        • Massive hemoptysis patients need inpatient monitoring and possible ICU involvement.
      • Bronchoscopy can be used to:
        • Free airways of blood to allow better gas exchange.
        • Introduce local agents such as cold saline and epinephrine to assist with bleeding.
        • Tamponade or cauterize sites of active bleeding.
      • Bronchial artery embolization may be used as soon as possible after CT or bronchoscopy.
        • Success rate is 82-100%.
      • Surgery is indicated for bleeding from necrotizing tumors, cavernous TB, refractory aspergilloma, iatrogenic causes, and where bronchial artery embolization is unsuccessful.
    • Non-massive mild to moderate hemoptysis.
      • Can be managed conservatively.
      • Treatment should be based on the suspected etiology
        • e.g., antibiotics if infection is suspected.
    • Tranexamic acid (TXA) may be used systemically or locally for bleeding control as part of initial resuscitation.
        • Nebulized TXA 500 mg q8h for 5 days, OR
        • TXA IV 1 g loading dose then 1 g over 8 h
    • Any coagulopathy should be treated.
      • If on anticoagulant, use reversible agent.
        • For warfarin use Vitamin K 10 mg IV with fresh frozen plasma or prothrombin complex concentrate.
        • Specific reversible agent for DOACs.
        • DDAVP 0.4 μg/kg in 30 mL saline IV x 30 min infusion for uremic platelet dysfunction (BUN >35 mg/dL).
        • Massive bleeding may require massive transfusion protocol.

    Quality Of Evidence?

    Justification

    Overall low quality as there is limited specific evidence. Many recommendations are expert opinion based on observational studies or extrapolated from limited studies of non-massive hemoptysis. There a lack of meta-analyses on treatment options or definitive guidelines.

    Low

    Low evidence for TXA. Research so far suggests it helps bleeding in cases of non-massive hemoptysis and given relatively low risk safety profile has been proposed to be used during initial resuscitation in both massive and non-massive hemoptysis.

    Low

    Related Information

    Reference List

    1. Atchinson PRA, Hatton CJ, Roginski MA, Backer ED, Long B, Lentz. 2021. The emergency department evaluation and management of massive hemoptysis. Am J Emerg Med. 50: 148-155.


    2. Earwood JS, Thompson TD. 2015. Hemoptysis: Evaluation and Management. AAFP. 91(4): 243-249.


    3. Ittrich H, Bockhor M, Klose H, Simon M. 2017. The diagnosis and treatment of hemoptysis. Dtsch Arztebl Int. 114: 371-381.


    4. Gagnon S, Quigley N, Dutau H, Delage A, Fortin M. 2017. Approach to hemoptysis and the modern era. Can Resp J. 1565030: 1-11.



    Print Summary

    RESOURCE AUTHOR(S)

    Dr Floyd Besserer

    DISCLAIMER

    The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.

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