“Ep 188 Hemoptysis – ED Approach and Management” From Emergency Medicine Cases

Posted on November 15, 2023 by Tom Wade MD

In addition to today’s resource, here are two additional resources:

Today, I reviewed, linked to, and excerpted from Emergency Medicine Cases‘ Ep 188 Hemoptysis – ED Approach and Management.*

*Helman, A. Weingart, S. Tillmann, B. Hemoptysis – ED Approach and Management. Emergency Medicine Cases. November, 2023. https://emergencymedicinecases.com/hemoptysis. Accessed November 15, 2023

All that follows is from the above resource.

Hemoptysis key principles 

  • Patients are poor at identifying the source of bleeding expelled from the mouth and often confuse hemoptysis with an upper airway or GI source; it is imperative to differentiate hemoptysis from pseudohemoptysis
  • Early diagnosis, usually by chest CT with contrast, is important in guiding management
  • Source control of the bleeding, which is usually from bronchial arteries, is the ultimate goal in management, which usually requires early involvement of interventional radiology and/or thoracic surgery and/or respirology; call for help early
  • Once the side of bleeding in the lungs is identified by either chest X-ray, CT or during mainstem bronchus intubation, patients should be positioned bleeding lung down in lateral decubitus to prevent contamination of the contralateral lung
  • Hemorrhage control measures including consideration for nebulized tranexamic acid (TXA) should be employed as a bridge to definitive treatment/source control
  • Death from hemoptysis is most often due to respiratory arrest, akin to drowning, rather than exsanguination, and management should be directed accordingly
  • Patients are generally better at clearing blood from their lungs by coughing compared to suctioning and airway control measures, so keep the patient spontaneously breathing and coughing whenever feasible; definitive airway management should be considered carefully and only when the patient is no longer able to clear blood spontaneously
  • The definition of massive hemoptysis is unclear; more importantly, life-threatening hemoptysis can be identified by signs of respiratory distress, airway obstruction or abnormal gas exchange
  • Suctioning of blood with either a meconium aspirator or Ducanto suction catheter is recommended to allow for adequate visualization during endotracheal intubation; standard suction catheters such as Yankauer catheters may not be adequate
  • Cricothyrotomy should be performed in situations where suction cannot keep up with the volume of blood in the airway (preventing visualization of the chords) and/or failed first attempt at RSI

EM Cases 5 step approach to hemoptysis

Step 1: Differentiate hemoptysis from pseudohemoptysis

Distinguishing hemoptysis from alternative sources of bleeding may be a challenge, as patients are able to accurately identify the source of the bleed only about 50% of the time.

The following table summarizes the key clinical findings that help differentiate hemoptysis from a GI bleed and upper airway bleed.

Pearl:  Nasopharyngoscopy can help rule out an upper airway source if unsure if the source of bleeding is from the lungs or nasopharynx.

Step 2: Is this massive/life-threatening hemoptysis?

The definition of massive hemoptysis is highly variable. The definition of massive hemoptysis by volume over time ranges from 100mL to 600mL over several hours. Clinicians are poor at estimating volume of expectorated blood.

A more practical definition of massive or life-threatening hemoptysis should take the following under consideration:

  • Signs of respiratory distress, signs of airway obstruction or evidence of abnormal gas exchange
  • Hemodynamic instability

Step 3: Early diagnosis guides management

Although the differential diagnosis of hemoptysis is broad,  initial workup should be focused on 3 critical time-sensitive diagnoses that each require specific management:

  1. Tracheo-innominate fistula*
  2. Aortobronchial fistula**
  3. Pulmonary embolism***

*Best Case Ever 36 Tracheo-innominate Fistula from Emergncy Medicine Cases

**An uncommon cause of hemoptysis: aortobronchial fistula  Multidisciplinary Respiratory Medicine volume 13, Article number: 25 (2018)

***Acute Pulmonary Embolism from StatPearls. Last Update: August 8, 2022.

Once the 3 critical time-sensitive diagnoses have been addressed, the broader differential diagnosis should be considered.

BATTLECAMP mnemonic for differential diagnosis of hemoptysis

CT chest with contrast should be the primary investigation modality to work up hemoptysis

A CT Chest with contrast in arterial phase should be our highest priority for workup of hemoptysis as it has a higher diagnostic yield than bronchoscopy and the diagnostic accuracy decreases with accumulation of blood in the lungs. The earlier the CT is done, the better, because as blood accumulates in the lungs, the accuracy of the CT in visualizing the source lesion decreases. Speak to your radiologist about the best contrast CT protocol for hemoptysis as some protocols are able to visualize both bronchial and pulmonary arteries.

The role of bronchoscopy in the work up and management of hemoptysis

Bronchoscopy can be complementary to CT and provide source control measures such as balloon tamponade with bronchial blockers, instillation of endobronchial epinephrine or endobronchial TXA. However, while bronchoscopy has similar efficacy in localizing the site of bleeding, its diagnostic accuracy is inferior to that of CT Chest and as such should not be used as a replacement for CT. Bronchoscopy should be considered an adjunct to be done following the CT scan in intubated patients. In some cases bronchoscopy may be the only option available for patients too unstable for transport to CT.

The role of chest X-ray in the work up and management of hemoptysis

A portable chest X-Ray may be useful to help localize the side of the bleeding in the minority of cases, but has poor diagnostic accuracy (up to 50% of patients with a normal chest X-ray will have contributory findings on CT) and should not be done acutely if it delays time-to-CT.

Pearl: At some hospitals, it may be possible to complete a CT scan with the patient in lateral decubitus position and the bleeding lung downward to avoid contamination of the contralateral lung; speak to your radiology department in advance to request this trick of the trade.

Step 4: Hemorrhage control measures prior to source control

It is important to understand that the primary cause of death in hemoptysis is respiratory, akin to drowning. However, addressing bleeding, similar to other life threatening hemorrhage should concurrently be address in the ED as a bridge to source control. The thrombotic risk associated with reversal of anticoagulants needs to be weighed against the risk of hemoptysis. Considerations for cessation of hemorrhage include:

  • Reversal of anticoagulants with PCCs / direct reversal inhibitors
  • Nebulized / IV TXA
  • FFP if INR >2
  • Cryoprecipitate/fibrinogen concentrate if fibrinogen <2 or suspected
  • Replace platelets if <50 and consider DDAVP in uremic patients
  • Red blood cells transfusion as necessary

Pitfall: A common pitfall is waiting until PE is ruled out before reversing any coagulopathy or administering TXA. In acutely life-threatening hemoptysis, always reverse any coagulopathy. Anticoagulation can be given later in the case of PE.

Episode 89 – DOACs Part 2: Bleeding and Reversal Agents

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