Hemoptysis

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DIFFERENTIAL DIAGNOSIS
NON CARDIOPULMONARY epistaxis, upper GI bleed, coagulopathy
CARDIAC HF, mitral Stenosis
PULMONARY
AIRWAY bronchitis (acute, chronic), bronchiec tasis, malignancy, foreign body, trauma
PARENCHYMA
MALIGNANCY lung cancer, metastasis
INFECTIONS necrotizing pneumonia (Staphy lococcus, Pseudomonas), abscess, septic emboli, TB, fungal
ALVEOLAR HEMORRHAGE Wegener’s granuloma tosis, Churg Strauss, Goodpasture disease, pul monary capillaritis, connective tissue disease
VASCULAR pulmonary embolism, pulmonary hypertension, AVM, iatrogenic
PATHOPHYSIOLOGY
MASSIVE HEMOPTYSIS 100 600 mL blood in 24 h. Patients may die of asphyxiation (rather than exsanguination)
CLINICAL FEATURES
HISTORY characterize hemoptysis (amount, fre quency, previous history), cough (productive), dyspnea, chest pain, epistaxis, hematemesis, weight loss, fever, night sweats, exposure, travel, joint inflammation, rash, visual changes, past medical history (smoking, lung cancer, TB, thromboembolic disease, cardiac disease), medi cations (warfarin, ASA, NSAIDs, natural supplements)
PHYSICAL vitals, weight loss, clubbing, cyanosis, lymphadenopathy, Horner’s syndrome, respiratory and cardiac examination, leg swelling (HF or DVT), joint examination, skin examination
INVESTIGATIONS
BASIC
LABS CBCD, lytes, urea, Cr, INR, PTT, urinalysis
MICROBIOLOGY blood C&S, sputum Gram stain/ AFB/fungal/C&S/cytology
IMAGING CXR, CT chest (warranted in most patients unless obvious explanation)
BRONCHOSCOPY warranted in most patients unless obvious explanation
SPECIAL
ETIOLOGY WORKUP ANA, p anca (myeloperoxi dase MPO antibodies), c anca (antiproteinase 3 PR3 antibodies), anti GBM antibody, rheumatologic screen
ABG if respiratory distress
MANAGEMENT
ACUTE ABC, O2, IV, intubation to protect airway if significant hemoptysis
SYMPTOM CONTROL cough suppressants, seda tives, stool softeners. Transfusions. Urgent interven tional bronchoscopy (topical epinephrine, cold sal ine, cautery). Angiographic arterial embolization. Lung resection
TREAT UNDERLYING CAUSE correct coagulopa thy (vitamin K 10 mg SC 1 dose or FFP); antibiotics; radiation for tumors; diuresis for HF; immunosup pression for vasculitis
SPECIFIC ENTITIES
GOODPASTURE DISEASE
PATHOPHYSIOLOGY antibasement membrane antibodies ! attack pulmonary and renal base ment membrane
CLINICAL FEATURES hemoptysis and hematuria, with respiratory and renal failure if severe
DIAGNOSIS lung/kidney biopsy
TREATMENTS steroids, cyclophosphamide, plasma pheresis

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