Case Study
The bedside nurse initiated a rapid response event for a patient who developed large volume hemoptysis along with dyspnea. On arrival of the condition team, the patient was coughing bright red blood and visibly dyspneic, using accessory muscles of respiration. Per report from the nurse, the patient was an 80-year-old male with a history of atrial fibrillation, admitted two days ago for exacerbation of chronic obstructive pulmonary disease. Over the last few minutes, the patient developed hemoptysis and had coughed up approximately 50-100 mL of blood.
Vital Signs
Temperature: 100.4 °F, axillary
Blood Pressure: 90/50 mmHg
Heart Rate: 120 beats per min (bpm) – sinus tachycardia on the monitor
Respiratory Rate: 35 breaths per min
Oxygen Saturation: 70% on room air, 90% on 12 L/min (LPM) high flow nasal cannula
Focused Physical Examination
A quick exam showed an older adult who appeared visibly dyspneic and was using accessory muscles of respiration. Crackles were present in the left lower lung field. Heart auscultation was normal except for tachycardia, and his abdomen was soft, non-tender, and non-distended. The remaining examination was unremarkable.
Interventions
A cardiac monitor and pads were attached to the patient. Fifteen LPM oxygen was administered through a non-rebreather mask, which improved oxygen saturation to 96%. Due to concerns for airway protection, and the patient’s continued hemoptysis, he was intubated by the anesthesiologist on call. He was started on intravenous (IV) fluid resuscitation. Stat arterial blood gas was ordered, which showed pH 7.25, pO 2 92 mmHg, pCO 2 60 mmHg, lactate 4.9 mmol/L. Stat chest X-ray, complete blood count (CBC), prothrombin time, and partial thromboplastin time were done. The patient was on warfarin for his atrial fibrillation, which led to an international normalized ratio of 2.9; this was reversed acutely with 4-factor prothrombin complex concentrate (Kcentra) and 5 mg of IV vitamin K. His chest X-ray revealed multiple opacities in the left lung ( Fig. 31.1 ). The patient was placed in the left lateral position (diseased lung down to prevent the gravity-guided blood pooling in the healthy right lung) and was transferred to the intensive care unit (ICU) for further management and intervention.
Final Diagnosis
Acute hypoxic respiratory failure secondary to hemoptysis.
Hemoptysis
Hemoptysis is the spitting up of blood derived from the respiratory system (parenchyma vs. airways) because of pulmonary or bronchial hemorrhage. There are two vascular circulations coursing through the lungs: the pulmonary and the bronchial systems. The low-pressure pulmonary arterial system carries blood from the right ventricle to the lungs. The high-pressure bronchial circulation originates from the aorta and provides arterial blood to the tracheobronchial tree. The bronchial arteries are the site of bleeding in >90% of cases. The components of each of these systems are described in Fig. 31.2 .
It is crucial to differentiate hemoptysis from bleeding originating in the nasopharynx, oropharynx, larynx, and gastrointestinal (GI) tract. Factors that suggest an ear, nose, and throat (ENT) or upper-airway source are blood visualized in the nares and the sensation of blood in the posterior pharynx. ENT physicians can perform nasolaryngoscopy at the bedside in patients with concerns for bleeding in these sites. Coffee ground emesis and a history of vomiting/regurgitation suggest GI source of the bleed.
Traditionally, hemoptysis had been categorized based on volume and blood expectorated over 24 h. More than 600 cc blood loss in less than 4 h has been associated with high mortality rates. Complications are associated with hypoxia rather than exsanguination. The classification of hemoptysis is as follows:
- 1.
Non-massive hemoptysis is defined as <100 mL of blood loss and includes blood-streaked sputum
- 2.
Massive hemoptysis (also called life-threatening hemoptysis) is a term used when hemoptysis results in a life-threatening event, including significant airway obstruction, significant abnormal gas exchange, or hemodynamic instability. Although is it difficult to quantify the amount of blood lost in massive hemoptysis, traditionally, the following cut-offs are used:
- a.
≥ 150 ml blood expectorated in a 24 h period, OR
- b.
Bleeding at a rate of ≥ = 100 mL/h
- a.
Common causes of hemoptysis include:
- 1.
Malignancy (most common cause): Primary lung carcinoma, metastatic carcinoma
- 2.
Infection: Bronchiectasis (such as cystic fibrosis), lung abscess, necrotizing pneumonia, aspergilloma, tuberculosis, and septic pulmonary emboli
- 3.
Vascular: Granulomatosis with polyangiitis, pulmonary artery aneurysm
- 4.
Iatrogenic: Placement of pulmonary artery catheter, transbronchial biopsy, trachea-innominate fistula.
Suggested Approach to a Patient With Massive Hemoptysis
For a patient with life-threatening hemoptysis, we suggest the following approach to evaluate and treat the acute event. The usual sequence of history taking, physical exam, investigations, and resuscitative interventions are often not followed during a rapid response; these measures often run parallel to each other in a code situation. The following components of the rapid response are discussed in the traditional sequence only to ease understanding.
History and Physical Examination
- ◾
Timing of onset and duration of symptoms
- ◾
Past medical history, specifically history of lung disease and malignancy
- ◾
Medication history, specifically use of anticoagulants
- ◾
History of recent procedures
- ◾
Physical exam should begin with the evaluation of airway, breathing, and circulation
- ◾
The presence of bleeding from other sites could indicate a systemic disorder rather than a focal pulmonary problem, although it is unusual to develop life-threatening hemoptysis from coagulopathy
Laboratory Tests
- ◾
CBC – to evaluate for the degree of anemia and to evaluate for infections
- ◾
Coagulation profile – including fibrinogen to evaluate for coagulopathy and DIC
- ◾
Comprehensive metabolic panel, ABG, and lactate – to assess for the degree of acidosis in respiratory failure
- ◾
Blood type and screen
Imaging Studies
- ◾
Chest radiograph: Initial imaging modality, however, limited utility in these cases. These could help lateralize bleeding.
- ◾
Computed tomography (CT) chest with contrast/CT angiography: CT helps identify the bleeding source and underlying etiologies. Angiography can help identify the site of bleeding in case of active bleeding.
- ◾
Bronchoscopy: This is the primary method of identifying the bleeding site and examining the airways. Bronchoscopy is pursued after securing the airway with endotracheal intubation and stabilization of the patient.
Interventions
Management begins with the assessment of the airway, breathing, and circulation. The capability of the patient to maintain the airway should be assessed. In most patients with life-threatening hemoptysis, intubation is required to protect the airway and reduce the risk of aspirating blood. Indications for intubation are ineffective cough (gurgling, inability to clear blood from airway) or worsening respiratory failure. Preferably, large endotracheal tubes should be used to facilitate bronchoscopy. While the team is preparing for intubation, the patient should be continuously suctioned and pre-oxygenated. If the bleeding site is known, intubation into the non-bleeding lung can minimize further aspiration and provide ventilation. Patients should be positioned to ensure that the suspected bleeding lung is in the dependent position, which can be deduced from history, physical examination, and prior imaging. This is to protect the non-bleeding lung since spillage of blood could impair gas exchange. If the bleeding site is unknown or both lungs are bleeding, the patient should be placed head up. Coagulopathy should be reversed appropriately depending on what anticoagulant the patient is taking. Platelet transfusion should be done in those with platelets <50,000 cells/mm 3 .
Once the patient has been stabilized appropriately, efforts should be made to evaluate the cause of hemoptysis. For patients who are intubated, bronchoscopy should be done to identify the bleeding source. In patients who are not intubated and clinically stable, the patient can be taken for CT chest with contrast or angiography. If the bleeding source is identified, the patient could undergo interventional embolization before transferring to the ICU for closer monitoring.
For patients in whom definitive management is delayed, nebulized tranexamic acid can be used. Tranexamic acid is an anti-fibrinolytic agent that has shown some benefit in patients with hemoptysis but has not been studied specifically in life-threatening hemoptysis. The dosage for this medication is 500 mg inhaled through a nebulizer. In these patients, non-invasive ventilation is a high risk for aspirating blood. In patients who refuse intubation, high flow nasal oxygen is an option. The management algorithm can be found in Fig. 31.3 .
