Hemoptysis Medical Emergency Handout PDF

Hemoptysis Definition: Expectoration of blood it may occur in the form of blood-streaked, blood tinged or frank hemoptysis. Two types: 1. True hemoptysis: Bleeding originating from below the vocal cords. 2. False or spurious hemoptysis: Bleeding originating from ab...

Hemoptysis Definition: Expectoration of blood it may occur in the form of blood-streaked, blood tinged or frank hemoptysis. Two types: 1. True hemoptysis: Bleeding originating from below the vocal cords. 2. False or spurious hemoptysis: Bleeding originating from above the vocal cords. Etiology:  Larynx disorders: e.g., laryngitis, foreign body, tumors, ulcers.  Tracho-Bronchial disorders: Acute infections. Chronic bronchitis. Violent coughing. Inhaled foreign body. Bronchiectasis. Bronchogenic carcinoma.  Pulmonary disorders Infections: Pulmonary TB. Massive pulmonary embolism. Lung abscess. Trauma. Pneumonia. Pulmonary haemosiderosis. Aspergilloma. Pulmonary A-V malformation. Diffuse alveolar hemorrhage: caused by:  Vasculitis e.g., Wegener's granulomatosis.  Systemic lupus erythematosus.  Anti-glomerular basement membrane disease( Goodpasture's syndrome).  Cardiovascular disorders Acute left heart failure. Pulmonary oedema. Mitral stenosis. Severe hypertension.  Hematologic disease, anticoagulants, endometriosis 86 Differential diagnosis: I- Haemoptysis & hematemesis: Hemoptysis Hematemesis Causes Pulmonary or cardiac Digestive system Previous symptoms Cough, chest tightness Nausea, vomiting Spit up Cough up Vomited Color Bright red & frothy Dark red Mixture Sputum, frothy Gastric contents pH Alkaline Acidic Tarry stools - or + + Post-bleeding Sputum with blood No sputum II- True or false Haemoptysis: Examination of upper respiratory tract usually reveals the cause of false Haemoptysis. Approach for Haemoptysis and Clinical assessment: History:  Should determine whether the bleeding source is likely the respiratory tract or an alternative source (e.g., nasopharynx, upper GI tract).  History of previous hemoptysis episodes and cigarette smoking should be ascertained.  Fever and chills should be assessed as potential indicators of acute infection.  Recent inhalation of illicit drugs and other toxins should be determined.  Drug history as anticoagulants.  DVT. 87 Amount: The quantity of expectorated blood should be estimated because it influences the urgency of evaluation and treatment. The amount varies from blood-strained sputum to several hundreds' ml pure blood:  Mild: 100 ml/day.  Moderate: 100 - 500 /day.  Severe: >500 ml/day, or 100-500/time. Character:  Blood – stained: Blood + sputum are mixed in all acute inflammatory condition and in bronchogenic carcinoma.  Blood – streaked: streaks of blood are present in sputum as in pulmonary TB. chronic bronchitis, pulmonary infarction.  Frank blood: pulmonary TB, bronchiectasis, tumors. Physical examination:  Assessment of the nares for epistaxis.  Evaluation of the heart and lungs.  Lowe limb edema could indicate congestive heart failure if symmetric, and deep-vein thrombosis with pulmonary embolism if asymmetric.  Clubbing could indicate lung cancer or bronchiectasis.  Assessment of vital signs and oxygen saturation can provide information about hemodynamic stability and respiratory compromise. Investigations: Radiographic evaluation:  Chest x-ray.  Chest CT may be helpful to assess for bronchiectasis, pneumonia, and lung cancer. 88   CT angiography, pulmonary embolism and location of bleeding may be determined. Laboratory studies:  Complete blood count and coagulation studies.  Electrolytes, renal function, and urinalysis.  Arterial blood gas.  Antineutrophil cytoplasmic antibody (ANCA), anti-GBM (glomerular basement membrane), and ANA if diffuse alveolar hemorrhage is suspected.  Sputum should be sent for Gram’s stain and routine culture as well as acid- fast bacillus (AFB) smear and culture. Bronchoscopy. Bronchography. Cardiac investigations: ECG & echocardiography. Treatment: Airway:  Clear and secure (coughing/suction).  Put on a face mask if maintaining the airway or intubating.  Ensure nearby high flow suction. Breathing:  Provide O 2 to maintain saturations at 94–98 %.  Massive hemoptysis may require endotracheal intubation and mechanical ventilation to provide airway stabilization. Circulation:  Insert a large bore (14G) IV cannula (use 2 if hypovolemic).  Give IV fluids/blood/clotting factors as clinically indicated. Treatment of the cause (e.g., LVF, PE, infection, coagulopathy). If the source of bleeding can be identified: 89   Isolating the bleeding lung with an endobronchial blocker or double-lumen endotracheal tube is optimal.  Pts should be positioned with the bleeding side down. If bleeding persists, bronchial arterial embolization by angiography may be beneficial. As a last resort, surgical resection can be considered to stop the bleeding. 90