Hemoptysis

"Vincenzo Grimaldi has tuberculosis. His physician and several female relatives tend to him in his home while a family member prays to the Martyred Saints Alfio, Cirino,and Filadelfo for his swift recovery" - from US National Library of Medicine website

Today we discussed hemoptysis. Some issues that came up:

"Massive" is defined as >600cc in 24h (100-600cc depending on source). In these cases, souce of bleeding in most cases is bronchial artery (not pumonary)

Differential

For non-massive, bronchitis, bronchogenic carcinoma, and bronchiectasis are most common in North America. Frequency of different causes depends on the population (i.e. high prevalence area for TB, etc.)

1) Infection
Bacterial- community or hospital-acquired pneumonia with blood-tinged sputum (as opposed to massive), lung abscess, necrotizing pneumonia (St. aureus, klebsiella, anaerobes)
Mycobacterial- TB
Fungal- aspergillosis, coccidiomycosis

2) Neoplastic
Primary- Endobronchial tumor (carcinoma, adenoma), carcinoid
Secondary - Note that hemoptysis in metastatic ca is rare

3) Bronchiectasis

4) Pulmonary vascular
PE, Pulmonary HTN, AVM (as in HHT)

5) Vasculitis
Goodpasture's, Wegener's, Microscopic polyangiitis

6) Cardiac
Mitral stenosis, severe LV failure

7) Others:
trauma, post-procedural, drugs

Management of massive hemoptysis:

-Hemodynamic support, reverse coagulopathy
-R/O epistaxis or UGIB
-Position with bleeding side down
-Call anesthesia, respirology, thoracic surgery
-Determine which side is source; anesthesia can do bronchial isolation
-Rigid bronchoscopy with suction catheter, lavage with cold epi-saline
-Bronchial artery embolization by interventional radiology

Links:
Click here for a good review of massive hemoptysis management from Thorax
Click here for NEJM clinical-pathological conference on hemoptysis