Rosen & Barkin's 5-Minute Emergency Medicine Consult (326 page)

DIAGNOSIS

• Chest pain
  
• Dyspnea
  
• Fever
  
• Weakness
  
• Fatigue
  
• Night sweats
  
• Weight loss
  

• Inquire about prior lung, renal, or valvular heart disease
  
• History of cigarette smoking
  
• Chemical, asbestos, or infectious exposure
  
• Travel history (consider parasitic or fungal infectious etiology)
  
• Aspirin, NSAID, or anticoagulant use
  
• Consider Goodpasture syndrome if a history of hematuria is present.
  
• Recurrent or chronic hemoptysis raises suspicion of arteriovenous malformations, bronchiectasis, and cystic fibrosis.
  

• Clubbing of the fingers (chronic inflammatory lung diseases)
  
• Cutaneous ecchymosis (blood dyscrasia or anticoagulants)
  
• Aphthous ulcers (Behcçet disease)
  
• Nasal septal perforation (Wegener granulomatosis)
  
• Hematuria (Goodpasture syndrome)
  
• Unilateral lower extremity edema may indicate DVT.
  
• Suggestive of pseudohemoptysis:
  
  • Sinusitis, epistaxis, rhinorrhea, pharyngitis, upper respiratory infection, aspiration
    

• Thorough head, eyes, ears, nose, and throat exam to exclude nonpulmonary source of bleeding
  
• Pulmonary exam is often normal.
  
• Wheezing may suggest obstruction (e.g., foreign body).
  
• Crackles may indicate an underlying pulmonary etiology (e.g., pneumonia, hemothorax, heart failure).
  
• Telangiectasias or hemangiomas raise suspicion of arteriovenous malformations.
  

• Differentiate between hemoptysis and pseudohemoptysis:
  
  • Note any precipitating factors, duration of symptoms, quantity and quality of blood.
    
  • Pulmonary source:
    
    • Bright red blood
      
    • Frothy in appearance
      
    • Sputum mixed with blood is likely pulmonary
      
    • pH > 7
      
  • GI source:
    
    • Dark red or brown blood
      
    • Accompanied by gastric contents
      
    • Worsens in the setting of nausea/vomiting
      
    • pH < 7
      
    • Gastric lavage may be used to rule out GI source of bleeding; however, nasal or other trauma may cause further bleeding.
      

• CBC with differential
  
• Basic metabolic panel
  
• PT/INR, PTT
  
• Urinalysis
  
• Febrile patient or suspected infectious etiology:
  
  • Blood cultures
    
  • Sputum culture and Gram stain
    
  • Cytology
    
  • KOH prep for fungal causes
    
  • AFB stain for tuberculosis
    
• Hypotensive patient (criteria for massive hemoptysis):
  
  • Type and cross
    
  • Complete metabolic (liver and renal function) panel
    
  • Coagulation profile:
    
    • Fibrin and fibrinogen degradation products (FDP) or antithrombin III if disseminated IV coagulation suspected
      
• Pediatric patient:
  
  • Consider sweat-chloride test if cystic fibrosis is suspected.
    

• CXR:
  
  • Characterizes pathology (e.g., tumor, cavity, effusion, infiltrate, pneumothorax)
    
  • Early pulmonary hemorrhage may present as infiltrate.
    
  • ∼20% will be normal.
    
• CT:
  
  • High-resolution CT has become gold standard for diagnosing bronchiectasis.
    
  • Ideal study for stable patients with hemoptysis and a normal CXR
    
  • Can detect active TB by the presence of cavitary lesions and acinar nodules
    
  • Higher sensitivity for peripheral tumors that may not be apparent on bronchoscopy
    
• CTA:
  
  • Known variability in bronchial arterial supply
    
  • Characterizes origin of bronchial arteries and presence of variants
    
  • May identify a pulmonary artery as a source of bleeding, show a pulmonary or bronchial artery aneurysm
    
  • Characterizes abnormal nonbronchial arterial supply, eliminates nonbronchial arteries as possible sources of bleeding
    
  • identifies pulmonary embolism
    
• V/Q:
  
  • If PE is suspected and patient cannot get CTA
    
  • Limited utility if x-ray is abnormal
    

Bronchoscopy:

• Allows direct visualization of tumors, foreign bodies, granulomas, and infiltration
  
• Valuable for collecting bronchial secretions for cytology and histology
  
• Limited diagnostic yield in lesions outside the bronchial wall, distal to bronchial stenosis or occlusion, or peripheral lesions.
  

Pseudohemoptysis:

• Epistaxis
  
• Pharyngeal bleeding
  
• GI bleeding
  

TREATMENT

• Respiratory and contact precautions
  
• Airway management:
  
  • Oxygen
    
  • Suctioning as needed
    
  • Endotracheal intubation if airway compromised, severe respiratory distress, or hypoxemia
    
• Dual large-bore IV access
  
• Volume resuscitation as needed
  
• Continuous pulse oximetry, close hemodynamic and cardiac monitoring
  

• Airway and breathing:
  
  • Endotracheal intubation for impending respiratory failure
    
  • >8Fr endotracheal tube to facilitate suctioning and subsequent bronchoscopy
    
  • Selective intubation of nonbleeding lung with single- or double-lumen endotracheal tubes may be required.
    
  • Supplemental oxygen as needed
    
  • Continuous pulse oximetry and cardiac monitoring
    
• Massive hemoptysis:
  
  • Principal risk to life is asphyxiation, not exsanguination
    
  • Maintain dual large-bore IV access.
    
  • Volume resuscitation with crystalloid or blood products as needed
    

• Antimicrobial therapy if concern for or diagnosed infectious cause
  
• Correct hypoxemia and/or coagulopathy
  
• If massive hemoptysis:
  
  • Multiple large-bore IVs or central access with volume resuscitation and blood products as needed
    
  • Patient should be positioned upright or in lateral decubitus with affected lung positioned down
    
  • Intubation for airway protection, impending respiratory failure, or to facilitate bronchoscopic evaluation
    
  • Endobronchial tamponade with Foley or Fogarty (<4Fr) catheter, or double-lumen endotracheal tube (temporary measures)
    
  • Bronchoscopy for local therapy including vasoconstrictive agents, stent or balloon tamponade, electrocautery, procoagulants
    
  • Bronchial artery embolization (success rates reported as high as 98%); rebleeding presents in ∼20% of cases
    
  • Surgery:
    
    • Lobectomy or pneumonectomy if unsuccessful embolization or in the presence of thoracic aneurysm, trauma, or arteriovenous malformation
      
    • Surgical resection is most effective for patients with localized lesions and adequate cardiopulmonary reserve
      

Refer to specific etiology

FOLLOW-UP

• ICU:
  
  • Intubation
    
  • Massive hemoptysis
    
  • Hemodynamic instability
    
  • Hypovolemic shock
    
  • Severe or refractory hypoxemia
    
  • Impending respiratory failure
    
  • Impending airway compromise
    
• General ward:
  
  • Mild hemoptysis
    
  • TB (isolation)
    
  • Stable foreign body
    
  • Lung abscess
    
  • Cavitary lung disease
    

• Hemodynamically stable
  
• Mild hemoptysis
  
• No coagulopathy
  
• No supplemental oxygen requirement
  
• History of chronic stable hemoptysis
  
• Close follow-up
  

• PCP within 7–10 days
  
• Specialist if etiology warrants referral
  

• Council patient not to smoke.
  
• Avoid medications that may increase the risk of bleeding, including herbal supplements such as garlic, gingko, or ginseng.
  
• The patient should seek care immediately for:
  
  • Shortness of breath
    
  • Chest pain
    
  • Severe dizziness on standing
    
  • Fainting
    
  • Persistent or worsening hemoptysis
    

• Consider early airway management as clinical picture warrants.
  
• If severe unilateral hemorrhage with hypoxemia, place patient “bad lung” down
  
• Bronchial artery embolization can be very effective. Discuss case early with IR.
  

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