haemoptysis

see also:

• acute cough in the adult

• pseudohemoptysis
  • blood coming from the upper airways eg. posterior epistaxis, sinusitis,
• haematemesis
  • pH < 7, blood is dark red or brown not bright red

• 60% are infective causes - see acute cough in the adult, and remember tuberculosis (TB), aspergilloma, lung abscess
  • pulmonary embolism (PE)
  • neoplastic
  • cystic fibrosis
  • congestive cardiac failure / mitral stenosis
  • arteriotracheobronchial fistula
  • ruptured aneurysms - AAA, bronchial artery aneurysm, pulmonary artery aneurysm
  • pulmonary angiodysplasia
  • pulmonary hypertension
  • bronchiectasis
  • coagulopathy
  • systemic lupus erythematosus (SLE)
  • Goodpastures syndrome
  • Wegener's granulomatosis
  • Behcet disease
  • occupational exposures:
    • isocyanate poisoning in automotive spray painters - immunologic haemorrhagic pneumonia ¹⁾
    • trimellitic anhydride–associated hemoptysis-anemia syndrome occurs after high-dose exposure to fumes

• haemoptysis > 200mL places these patients at high risk of asphyxiation from the haemoptysis and a high mortality, especially so if the cause is a neoplasm
• top 3 causes are tuberculosis (TB), bronchiectasis and lung cancer
• iv cannula
• take bloods for FBE, U&E, LFTs, coagulation profile and DIC screen, cross match,
• oxygen to maintain SaO2
• secure airway via intubation (consider size 8.0 ETT to allow suctioning and bronchoscopy)
  • may need to use selective intubation to only ventilate the non-bleeding lung
  • consider placing a double lumen endotracheal tube (permits ventilation of both lungs, while preventing aspiration from one lung to another)
• CXR - generally picks up 80-90% of neoplastic causes
• correct any coagulopathy
• consider tranexamic acid (Cyclokapron)
• admit ICU
• if bleeding site is known, place pt. in the lateral decubitus position with the affected lung in the dependent position
• consider endobronchial tamponade with a Foley catheter (< 4 Fr)
• consider CT chest if stable
• urgent referral to thoracics for ?bronchoscopy
• may need catheter-directed bronchial artery embolization (BAE) or even lobectomy

• could it be pulmonary embolism (PE)?
• is the patient in acute pulmonary oedema (APO)?
• does the patient need to be isolated for possible active tuberculosis (TB)?
• remember 60% will be due to infection such as acute bronchitis or pneumonia
• iv cannula, bloods for FBE, U&E, coagulation, consider D-Dimer
• CXR
• consider CT chest if CXR abnormal
• consider referral to thoracics for bronchoscopy