Laboratory testing is also done. Patients usually should have a complete blood count, a platelet count, and measurement of PT prothrombin time and PTT partial thromboplastin time. Anti-factor Xa testing can be used to detect supratherapeutic anticoagulation in patients receiving low molecular weight heparin. Urinalysis should be done to look for signs of glomerulonephritis hematuria, proteinuria, casts.
TB skin testing and sputum culture should be done as the initial tests for active TB, but negative results do not preclude the need to induce sputum or do fiberoptic bronchoscopy to obtain samples for further acid-fast bacillus testing if an alternative diagnosis is not found.
It can be difficult to protect the uninvolved lung because it is often initially unclear which side is bleeding. Prevention of exsanguination involves reversal of any bleeding diathesis and direct efforts to stop the bleeding. Clotting deficiencies can be reversed with fresh frozen plasma and factor-specific or platelet transfusions.
Desmopressin is used to reverse platelet dysfunction associated with uremia and kidney disease. Tranexamic acid is an antifibrinolytic drug being increasingly used to promote hemostasis. Laser therapy, cauterization, or direct injection with epinephrine or vasopressin can be done bronchoscopically. Massive hemoptysis is one of the few indications for rigid as opposed to flexible bronchoscopy Bronchoscopy Bronchoscopy is the introduction of an endoscope into the airways.
Flexible fiberoptic bronchoscopy is used for virtually all diagnostic, and most therapeutic, indications. Flexible bronchoscopes Emergency surgery is indicated for massive hemoptysis not controlled by rigid bronchoscopy or embolization and is generally considered a last resort. Once a diagnosis is made, further treatment is directed at the cause 2, 3 Treatment references Hemoptysis is coughing up of blood from the respiratory tract.
Early resection may be indicated for bronchial adenoma or carcinoma. Broncholithiasis erosion of a calcified lymph node into an adjacent bronchus may require pulmonary resection if the stone cannot be removed via rigid bronchoscopy. Bleeding secondary to heart failure or mitral stenosis usually responds to specific therapy for heart failure.
In rare cases, emergency mitral valvulotomy is necessary for life-threatening hemoptysis due to mitral stenosis. Bleeding from a pulmonary embolism is rarely massive and almost always stops spontaneously.
If emboli recur and bleeding persists, anticoagulation may be contraindicated, and placement of an inferior vena cava filter is the treatment of choice. Because bleeding from bronchiectatic areas usually results from infection, treatment of the infection with appropriate antibiotics and postural drainage is essential. Antifibrolytic drugs such as tranexamic acid are being increasingly used and studied in minor hemoptysis 4 Treatment references Hemoptysis is coughing up of blood from the respiratory tract.
Mal H, Rullon I, Mellot F, et al : Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 4 : —, Illustrative case 7: Assessment and management of massive haemoptysis.
Thorax —, Jean-Baptiste E : Clinical assessment and management of massive hemoptysis. Critical Care Medicine 28 5 : —, Hemoptysis needs to be distinguished from hematemesis and nasopharyngeal or oropharyngeal bleeding.
Bronchitis, bronchiectasis, tuberculosis, and necrotizing pneumonia or lung abscess are the most common causes in adults. Detecting lung cancer as a cause of hemoptysis in patients with a normal chest radiograph: bronchoscopy vs CT. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference.
This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Contact afpserv aafp. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Previous: Management of Spontaneous Abortion. Oct 1, Issue. Hemoptysis: Diagnosis and Management. Hemoptysis is the spitting of blood that originated in the lungs or bronchial tubes. C 5 Patients with normal chest radiograph, no risk factors for cancer, and findings not suggestive for infection should be considered for bronchoscopy or high-resolution CT.
C 5 After extensive initial investigation, closely follow smokers older than 40 years who have unexplained hemoptysis. Algorithm for diagnosing nonmassive hemoptysis. Diagnosing Nonmassive Hemoptysis Figure 1.
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Navigate this Article. Source other than the lower respiratory tract. Upper airway nasopharyngeal bleeding. Gastrointestinal bleeding. Tracheobronchial source. Bronchitis acute or chronic. Pulmonary parenchymal source. Idiopathic pulmonary hemosiderosis. Primary vascular source. Arteriovenous malformation. Elevated pulmonary venous pressure especially mitral stenosis. Miscellaneous and rare causes. Pulmonary endometriosis. Systemic coagulopathy or use of anticoagulants or thrombolytic agents.
Absence of nausea and vomiting. Presence of nausea and vomiting. Gastric or hepatic disease. Sputum examination. Liquid or clotted appearance. Coffee ground appearance. Mixed with macrophages and neutrophils. Mixed with food particles. Medication effect, coagulation disorder. Association with menses.
Congestive heart failure, left ventricular dysfunction, mitral valve stenosis. Fever, productive cough. History of breast, colon, or renal cancers. Endobronchial metastatic disease of lungs. Bronchiectasis, lung abscess. HIV, immunosuppression. Gastritis, gastric or peptic ulcer, esophageal varices. Pleuritic chest pain, calf tenderness. Pulmonary embolism or infarction. Acute bronchitis, chronic bronchitis, lung cancer, pneumonia.
Emphysema, lung cancer, tuberculosis, bronchiectasis, lung abscess, HIV. Bronchogenic carcinoma, small cell lung cancer, other primary lung cancers. Dullness to percussion, fever, unilateral rales. Facial tenderness, fever, mucopurulent nasal discharge, postnasal drainage.
Acute upper respiratory infection, acute sinusitis. Acute exacerbation of chronic bronchitis, primary lung cancer, pneumonia. Heart murmur, pectus excavatum. Mitral valve stenosis. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital.
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Massive hemoptysis in cystic fibrosis. Surgical management of acute necrotizing lung infections. Canadian Respiratory Journal , 13 , — Randomized phase II trial comparing bevacizumab plus carboplatin and paclitaxel with carboplatin and paclitaxel alone in previously untreated locally advanced or metastatic non-small-cell lung cancer.
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Internal Medicine , 40 , —9. Regulation of angiogenesis by hypoxia: role of the HIF system. Nature Medicine , 9 , — Chronic bronchitis is defined as cough productive of sputum for at least three months per year in two consecutive years.
It is considered a type of chronic obstructive pulmonary disease. Bronchiectasis is diagnosed by high resolution computed tomography CT and pulmonary function testing. Malignancies and abscess will have a characteristic radiographic appearance but may be confused with one another. They both require tissue biopsy either by bronchoscopy, radiologically guided needle biopsy, or thoracoscopy to confirm diagnosis. Gram stain may also be helpful. Vascular abnormalities including aneurysms, thoracic aortic dissection and pulmonary embolism, are computed tomographic angiography CTA diagnoses.
Some arterial fistulas may be radiographically apparent but others may require bronchoscopic visualization. Infective endocarditis is defined by modified Duke criteria. Granulomatosis with polyangiitis, whether the ANCA is positive or negative, requires a tissue diagnosis of either lung or renal lesions, but not both.
Systemic lupus erythematosus has specific diagnostic criteria written by the American College of Rheumatology. Pulmonary hypertension, mitral stenosis, and left systolic heart failure are characterized by specific echocardiographic criteria.
Lung injury, whether trauma or inhalant in origin, can be diagnosed by history and clinical examination. Radiography may be of adjunctive help. Due to the perceived association between hemoptysis and acute mortality, patients with hemoptysis are often placed at a higher level of care than needed. They are also subjected to tests that are of minimal benefit. Diagnostic testing should be based on a differential diagnosis developed from a sound history and physical.
Due to the wide number of etiological processes, a stepwise approach to diagnostic testing is preferred. Strongly consider PA and lateral views for chest radiography rather than simply portable films for greater diagnostic yield. CT will often be necessary but not essential for work-up, thus starting with plain chest radiography is appropriate. If CT is deemed necessary consider whether or not the diagnosis requires contrast and if so, what phase contrast will be most diagnostic.
CTA of the arterial phase examines abnormalities in systemic arterial contrast, e. Thus knowing what you are looking for will determine when, after the contrast bolus, the images will be acquired. Bronchoscopy has decreased yield, and is presumably not indicated in patients who are below 40 years old, non-smokers, with less than 1 week of hemoptysis, and who have a normal chest X-ray.
The first clinical decision must be whether to intubate the patient for airway protection. A patient will need intubation if they are unable to clear blood or other secretions, in extremis, failing non-invasive positive pressure support ventilation, or if they have worsening hemodynamics, or a decline in mentation despite interventions. If it is possible to localize the bleed, it may be necessary to perform intubation of main left or right bronchus to isolate bleeding and protect the other lung.
Patients requiring intubation may need more urgent bronchoscopy or arteriography to isolate bleeding. If you suspect tuberculosis, airborne isolation should be ordered empirically to protect other patients and providers.
Continuous positive pressure ventilation may, theoretically, play a role by applying positive pressure i. D-dimer if low to intermediate modified Geneva criteria, if high go immediately to pulmonary embolism imaging. Chest X-ray posterior-anterior and lateral , portable anterior-posterior chest X-ray if patient unable to stand or hemodynamically unstable. Request old records with particular attention to previous pulmonary function testing, CT, and pulmonary function testing.
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