Common misconceptions and mistakes
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Believing that a double-lumen tube is the preferred airway in a patient with massive hemoptysis
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Failing to treat patients with bronchiectasis and hemoptysis with antibiotics (Abx) because there is no fever or elevated white blood cell (WBC) count
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Believing that intubation should be done, preemptively for airway protection, to prevent respiratory failure in patients with massive hemoptysis
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Focusing risk stratification on the amount of blood reported to have been coughed up in the 24 hours before presentation
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Believing that the priority positioning in a patient with massive hemoptysis is “good lung up”
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Being reassured by a stable hematocrit in a patient reporting an episode of massive hemoptysis
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Believing that bronchoscopy is the preferred (gold standard) way to localize bleeding in a patient with massive hemoptysis
Initial assessment/risk stratification
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Hemoptysis is a very common complaint that encompasses a wide spectrum, from reports of blood-tinged oral secretions that “may have been” coughed up to presentations of voluminous, bright-red blood being expelled from the airway
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Risk stratification: massive , at risk for massive , and non–life-threatening hemoptysis ( Fig. 21.1 )
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Massive hemoptysis
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Individuals who actively cough up voluminous, bright-red blood and clot at the time of evaluation are suffering from massive hemoptysis
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These patients need localization via a chest CT (typically with arterial-phase contrast looking for bronchial arteries) and definitive intervention via embolization (interventional radiology) or resection (CT surgery)
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At risk for massive hemoptysis
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Individuals who report (or demonstrate) hemoptysis and who have a known history of bronchiectasis (the most common cause of massive hemoptysis) are at risk for massive hemoptysis
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These individuals should:
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Be admitted for observation
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Be given IV antibiotics with Gram-positive cocci (GPC) and Gram-negative rod (GNR) coverage
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Have their bleeding localized via a chest CT scan
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The majority of the time, bleeding (and sputum) will improve with antibiotics (requiring no further intervention)
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Those with ongoing bleeding, despite antibiotics, should be evaluated by interventional radiology for possible embolization
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Individuals who report (or demonstrate) hemoptysis and who may have bronchiectasis are also at risk for massive hemoptysis
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Common bronchiectasis risk factors in adults include:
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Nontuberculous mycobacterial infection
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Thoracic radiation therapy (ie, external beam radiation therapy for lung cancer)
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Pulmonary fibrosis
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Fibrocavitary tuberculosis
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Less common causes include immunodeficiency (and recurrent lung infection), poorly treated bacterial pneumonia in youth, ciliary dyskinesia syndromes, and partial cystic fibrosis (CF) gene mutations, and immunoglobulin deficiencies
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Patients at risk for massive hemoptysis deserve a chest CT (typically noncontrast) looking for a focal parenchymal explanation for their bleeding (ie, lung cancer, arteriovenous malformation, necrotic pneumonia, or area of bronchiectasis)
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Individuals without known or suspected lung disease who present with a high-risk hemoptysis story (ie, significant hemoptysis without cough, phlegm production, and/or an antecedent respiratory illness) deserve a chest CT scan with contrast (pulmonary arterial phase) looking for pulmonary embolism and/or a parenchymal source to explain their bleeding (ie, lung cancer, arteriovenous malformation, necrotic pneumonia, or an area of bronchiectasis)
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Individuals with a normal CT angiogram of the chest are not at risk of dying from massive hemoptysis and may be treated more conservatively (ie, outpatient pulmonary follow-up and possibly bronchoscopy to look for an endobronchial explanation [ie, early squamous cell cancer])
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Individuals without known or suspected lung disease who present with a low-risk hemoptysis story (ie, blood tinged sputum or clots mixed with phlegm in the setting of a respiratory illness) deserve a PA and lateral CXR looking for reactivation TB, lung cancer, and/or necrotic pneumonia
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Individuals with a low-risk story and a clear CXR should have bronchitis treated with PO antibiotics and cough suppression
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Fig. 21.1
Schematic showing the evaluation and management of hemoptysis. Patients presenting with active voluminous hemoptysis require urgent evaluation by interventional radiology (IR) and possibly CT surgery. Either way, an arterial-phase computed tomography (CT) scan of the chest should be the first step in attempting to localize active hemoptysis (and survey for culprit vessels). Patients with known bronchiectasis typically have recurrent exacerbations or flairs where sputum becomes more purulent and blood clots and streaks appear with phlegm. This is a “low-risk” presentation for an individual with known, symptomatic bronchiectasis and should be evaluated with a noncontrast CT scan (for localization) as part of admission for antibiotics and observation. Patients with known bronchiectasis who have a “high-risk” presentation (ie, no change in cough or phlegm, just sudden hemoptysis) probably deserve a contrast CT scan (arterial phase) and an urgent IR evaluation. Patients with known parenchymal lung disease (ie, pulmonary fibrosis) but no history of clinical bronchiectasis (ie, recurrent lung infections and chronic sputum purulence) should be treated like individuals with no known lung disease (ie, pulmonary embolism should be excluded with a contrast CT timed for pulmonary artery [PA] opacification). If the CT scan demonstrates bronchiectasis or a mass, the patient should be admitted for observation. Patients with bronchiectasis and hemoptysis deserve intravenous antibiotics (even if they deny a change in cough or phlegm). When a new parenchymal mass is discovered, antibiotics should be considered for postobstructive pneumonia or imaging suggestive of a lung abscess (ie, necrosis with an air-fluid level). Individuals reporting hemoptysis who have normal Chest CT angiography (CTA) are not at risk of death by massive hemoptysis (or pulmonary embolism) and can be discharged from the emergency room with outpatient follow-up. Individuals who have a “high-risk” presentation (ie, no cough, phlegm, or respiratory illness) should be followed up in pulmonary clinic to have bronchoscopy considered to exclude an airway mucosal source of bleeding (ie, early squamous cell cancer). Patients without lung disease and with “low-risk” presentation (ie, cough, phlegm, blood-tinged sputum) should be screened for tuberculosis and necrotic pneumonia with a PA and lateral chest x-ray (CXR). A clear CXR confirms the diagnosis of bronchitis, which should be treated with antibiotics and cough suppression (and smoking cessation attempts if applicable). An abnormal CXR in an otherwise healthy person presenting with hemoptysis in the clinical setting of “bronchitis” (ie, cough and phlegm) but not “fever and shaking chills” (ie, pneumonia) warrants a CT scan for better characterization of the abnormality.
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Pathophysiology and management of massive hemoptysis
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Massive hemoptysis kills by large airway obstruction with clot
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Not by hemorrhagic shock or alveolar filling of blood with subsequent hypoxemia
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Massive hemoptysis most commonly occurs when large, ectatic bronchial and intercostal arteries (arising from the aorta) rupture, often in the setting of an acute on chronic bronchiectasis infection or exacerbation
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Bronchiectasis produces abnormal bronchial and intercostal arteries via:
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Poor secretion clearance, leading to chronic lung infection and inflammation, leading to pathologic angiogenesis
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Other common causes of massive hemoptysis include:
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Large proximal lung cancers (especially squamous cell carcinoma)
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Invasive fungal infection
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Pulmonary artery bleeding (as in Rasmussen’s aneurysm [ie, calcified granulomatous lymphoid tissue eroding into the pulmonary artery])
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Diffuse alveolar hemorrhage (< 30% of the time)
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Pulmonary venous bleeding from pulmonary vein stenosis (eg, after ablation for atrial fibrillation [AFIB])
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May require definitive intervention (ie, IR embolization vs CT surgical resection)
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When definitive therapy is required, the pulmonologist localize the bleeding to a region of the lung (eg, right vs left, upper lung zone vs lower lung zone)
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Subsegmental resolution is not required (culprit vessels arise directly from the aorta)
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CXR and CT scan typically show an area of parenchymal abnormality
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If multiple abnormalities exist, the area of most change compared with the prior is presumed to be the area of activity, either the bleeding lesion itself or an area of aspirated blood (close to the bleeding lesion)
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Patients are good at localizing their own bleeding source and should be asked, “Do you have any idea where the bleeding is coming from? Have you had any strange sensations in an area of your chest—popping, bubbling, or gurgling sensations?”
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Often they will point with one finger to the abnormal area identified by imaging (high pretest probability sign)
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Upper lobe fibrocavitary change should prompt consideration of reactivation of TB or chronic fibrosing pulmonary aspergillosis
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Bronchoscopic localization is extraordinarily difficult during active bleeding ( Fig. 21.2 )
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Blood quickly coats all of the airways during active bleeding and coughing
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Blood always appears to be dripping from the upper lobes and pooling in the lower lobes
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Should be reserved for patients who are in respiratory failure, already intubated, or too unstable for CT imaging
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