Hemoptysis resident survival guide

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For hemoptysis chapter, click here.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Teresa Stahl, M.D. [2]

Overview

Hemoptysis is the medical term for expectorating blood from the trachea, larynx, bronchi or lungs. It can be confused with hematemesis. There are many causes for hemoptysis including bronchiectasis, respiratory infections, iatrogenic. Massive hemoptysis can be a life-threatening condition and should be treated immediately.

Causes

Life Threatening Causes

  • Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
  • Hemoptysis may be a life-threatening condition depending on the severity of bleeding and must be treated as such irrespective of the causes.

Common Causes

Management

 
 
 
 
 
 
 
Characterize the symptoms[1]

❑ Coughing up blood
Chest pain
Tachypnea
Dyspnea
Fever
Obtein detailed history
❑ Recent travel H/O
❑ Recent drug H/O
❑ Family H/O

❑ Systemic illness H/O
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asses volume stauts

❑ General condition
Heart rate
Blood pressure
Respiratory rate
Mucosa
Pulmonary reserve

Examine the patient

❑ Exclude hemorrhagic sites from nasopharynx and gastrointestinal tract

Skin (pallor)

Respiratory system (use accessory respiratory muscles, murmur)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order lab

Complete blood count

Arterial blood gas

Coagulation profile

Electrolytes

Blood typing and crossmatch

Liver and renal function test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hemoptysis
 
 
Upper gastrointestinal bleeding
 
 
Nasopharynx bleeding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow Upper gastrointestinal bleeding resident survival guide
 
 
Refer to otolaryngologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of Mild to Moderate Hemoptysis

The algorithm is based on the American Family Physician Journal of hemoptysis: Diagnosis and Management [2]

 
 
 
 
 
 
 
 
 
 
 
 
Hemoptysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild hemoptysis
❑ <30 cc in 24 hours [3]
 
 
 
 
 
 
 
 
 
 
 
 
Moderate hemoptysis
❑ 30-200 cc in 24 hours [4]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest X-ray (CXR)
 
 
 
 
 
 
 
 
 
 
 
 
Chest X-ray and CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnose found
 
 
 
 
 
Diagnose unknown
 
 
 
 
Diagnose found
 
 
 
 
 
Diagnose unknown
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat underlying disease
 
 
 
 
 
Risk of malignancy[5]

Smoking

❑ Occupational exposure

❑ Family history

❑ Previous cancer treatment
 
 
 
 
Treat underlying disease
 
 
 
 
 
Bronchoscopy to find diagnosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
Diagnose found
 
 
 
 
 
Diagnose unknown
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT or bronchoscopy to find diagnosis
 
 
 
 
 
Close monitoring
 
 
 
 
Treat underlying disease
 
 
 
 
 
Close monitoring
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnose found
 
 
 
 
 
Diagnose unknown
 
If hemoptysis persist consult with pneumonologist
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat underlying Disease
 
 
 
 
 
Close monitoring
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of Massive Hemoptysis

The algorithm is based on the Society of Critical Care Medicine Journal of clinical assessment and management of massive hemoptysis. [6]


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Massive hemoptysis
❑ 200-600cc or more in 48 hours [7]

AND/OR
❑ Signs of hypovolemia: [8]

  • Postural pulse increment of > 30 beats/min
  • Supine tachycardia (>100 beats/min)
  • Supine hypotension

❑ Symptoms of hypovolemia:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Monitor patient in the intensive care unit

❑ Secure airway permeability to avoid aspiration

❑ Place patient in lateral decubit towards site of bleeding (if only one lung is bleeding)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Right away transfuse O- positive blood type.

❑ If the patient has a life-threatening hemoptysis and/or a hypovolemic shock and/or hypoxemia; intubate with a 8-mm or larger endotracheal tube to allow subsequent bronchoscopy.[9] [10]

❑ Make a thoracic surgery consult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bronchoscopy
 
 
 
 
 
 
 
 
 
 
 
Diagnose not found
 
 
 
 
 
Diagnose found
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding localised
 
Bleeding not localized
 
 
 
 
 
 
 
 
 
 
 
Intersticial,
reticular pattern
 
Infiltrate
 
Cavity
 
Nodular,
cystic lesion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endobronchial taponade
 
Pulmonary angiography
 
 
 
 
 
 
 
 
 
 
 
Search for interstitial lung diseases
 
Give appropriate antibiotics
 
Search for tuberculosis, aspergilloma, lung abscess
 
Give appropriate antibiotics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding localized
 
Bleeding not localized
 
 
 
 
 
 
 
 
 
Treat underlying disease
 
 
 
 
 
Give appropriate antibiotics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bronchial artery embolization (BAE)
 
Conservative therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat underlying disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Do's

  • Investigate profusely the patient's medical history for possible diagnosis.
  • Intubate patient with massive hemoptysis to protect airway. [11]
  • Determine volume and rate of blood. [12]
  • Supply all patients with oxygen to maintain oxyhemoglobin saturation.[13]
  • Place the patient with massive hemoptysis in lateral decubit towards side of bleeding (if bleeding is located in one lung). [14]
  • Treat massive hemoptysis in a ICU. [15]
  • Place patient in isolation when tuberculosis is suspected, until the septum is analysed. [16]

Dont's

References

  1. Parrillo, Joseph E.; Dellinger, R. Phillip. (2014). Critical care medicine : principles of diagnosis and management in the adul. Philadelphia, PA: Elsevier/Saunders. ISBN 978-0-323-08929-6.
  2. name="pmid16225028">Bidwell JL, Pachner RW (2005). "Hemoptysis: diagnosis and management". Am Fam Physician. 72 (7): 1253–60. PMID 16225028.
  3. name="pmid12243312">Fidan A, Ozdoğan S, Oruç O, Salepçi B, Ocal Z, Cağlayan B (2002). "Hemoptysis: a retrospective analysis of 108 cases". Respir Med. 96 (9): 677–80. PMID 12243312.
  4. name="pmid12243312">Fidan A, Ozdoğan S, Oruç O, Salepçi B, Ocal Z, Cağlayan B (2002). "Hemoptysis: a retrospective analysis of 108 cases". Respir Med. 96 (9): 677–80. PMID 12243312.
  5. Parkin DM, Boyd L, Walker LC (2011). "16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010". Br J Cancer. 105 Suppl 2: S77–81. doi:10.1038/bjc.2011.489. PMC 3252065. PMID 22158327.
  6. name="pmid10834728">Jean-Baptiste E (2000). "Clinical assessment and management of massive hemoptysis". Crit Care Med. 28 (5): 1642–7. PMID 10834728.
  7. name="pmid12243312">Fidan A, Ozdoğan S, Oruç O, Salepçi B, Ocal Z, Cağlayan B (2002). "Hemoptysis: a retrospective analysis of 108 cases". Respir Med. 96 (9): 677–80. PMID 12243312.
  8. name="pmid15726060">Sinert R, Spektor M (2005). "Evidence-based emergency medicine/rational clinical examination abstract. Clinical assessment of hypovolemia". Ann Emerg Med. 45 (3): 327–9. doi:10.1016/j.annemergmed.2004.09.021. PMID 15726060.
  9. Parrillo, Joseph E.; Dellinger, R. Phillip. (2014). Critical care medicine : principles of diagnosis and management in the adul. Philadelphia, PA: Elsevier/Saunders. ISBN 978-0-323-08929-6.
  10. Nilsson, Kent R.; Piccini, Jonathan. (2006). The Osler medical handbook / the Osler Medical Service, The Johns Hopkins Hospital ; editors, Kent R. Nilsson, Jr., Jonathan Picci. Philadelphia: Saunders/Elsevier. ISBN 978-0-323-03748-8.
  11. Parrillo, Joseph E.; Dellinger, R. Phillip. (2014). Critical care medicine : principles of diagnosis and management in the adul. Philadelphia, PA: Elsevier/Saunders. ISBN 978-0-323-08929-6.
  12. name="pmid16225028">Bidwell JL, Pachner RW (2005). "Hemoptysis: diagnosis and management". Am Fam Physician. 72 (7): 1253–60. PMID 16225028.
  13. Parrillo, Joseph E.; Dellinger, R. Phillip. (2014). Critical care medicine : principles of diagnosis and management in the adul. Philadelphia, PA: Elsevier/Saunders. ISBN 978-0-323-08929-6.
  14. Parrillo, Joseph E.; Dellinger, R. Phillip. (2014). Critical care medicine : principles of diagnosis and management in the adul. Philadelphia, PA: Elsevier/Saunders. ISBN 978-0-323-08929-6.
  15. Nilsson, Kent R.; Piccini, Jonathan. (2006). The Osler medical handbook / the Osler Medical Service, The Johns Hopkins Hospital ; editors, Kent R. Nilsson, Jr., Jonathan Picci. Philadelphia: Saunders/Elsevier. ISBN 978-0-323-03748-8.
  16. Nilsson, Kent R.; Piccini, Jonathan. (2006). The Osler medical handbook / the Osler Medical Service, The Johns Hopkins Hospital ; editors, Kent R. Nilsson, Jr., Jonathan Picci. Philadelphia: Saunders/Elsevier. ISBN 978-0-323-03748-8.
  17. Parrillo, Joseph E.; Dellinger, R. Phillip. (2014). Critical care medicine : principles of diagnosis and management in the adul. Philadelphia, PA: Elsevier/Saunders. ISBN 978-0-323-08929-6.
  18. name="pmid10834728">Jean-Baptiste E (2000). "Clinical assessment and management of massive hemoptysis". Crit Care Med. 28 (5): 1642–7. PMID 10834728.
  19. name="pmid10834728">Jean-Baptiste E (2000). "Clinical assessment and management of massive hemoptysis". Crit Care Med. 28 (5): 1642–7. PMID 10834728.



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