Hemoptysis

Definition & Pathophysiology

• Expectoration of blood or blood-streaked sputum

• Massive hemoptysis: -600cc/24-48 h (though no absolute definition); gas exchange far more important than absolute blood loss

• Massive hemoptysis usually from tortuous or invaded bronchial arteries

Etiologies

Infection/ Inflammation

Bronchitis (most common cause of trivial hemoptysis) Bronchiectasis incl. CF (most common cause of major hemoptysis) Tuberculosis, aspergilloma, pneumonia/lung abscess

Neoplasm

Usually primary lung cancer, sometimes metastasis

Cardiovascular

PE. pulmonary artery rupture (2° to instrumentation). CHF, mitral stenosis, trauma/foreign body, bronchovascular fistula

Other

Vasculitis (Wegener's granulomatosis. Goodpasture's syndrome). AVM. excessive anticoagulation (w/ underlying lung disease), idiopathic pulmonary hemosiderosis, catamenial (lung endometriosis)

Diagnostic workup

• Localize bleeding site

Rule out GI or ENT source by exam, history; may require endoscopy Pulmonary source: determine whether unilateral or bilateral, localized or diffuse, parenchymal or airway by CXR or chest CT. bronchoscopy if necessary

• PT. PTT. CBC to rule out coagulopathy

• Sputum culture/stain for bacteria, fungi, and AFB; cytology to r/o malignancy

• ANCA. anti-GBM. urinalysis to ✓ for vasculitis or pulmonary-renal syndrome Treatment

• Mechanism of death is asphyxiation not exsanguination; maintain gas exchange, reverse coagulation and treat underlying condition; cough supp. may Î risk of asphyxiation

• Massive hemoptysis: put bleeding side dependent; selectively intubate nl lung if needed

Angiography: used for Dx & Rx (vascular occlusion balloons or selective embolization of bronchial circulation) Rigid bronchoscopy, allows more interventional options (electrocautery, laser) than flex. Surgical resection

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