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Hemoptysis

Matthew DeLaney, MD and Scott Irvine, MD
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Patients with significant or massive hemoptysis should be send to the ED for further evaluation.Patients with non-massive hemoptysis should be evaluated with initially with a chest x-ray.

Pearls:

  • Most causes of hemoptysis that present to the Urgent Care are secondary to an infectious process.

  • X-ray is the initial study of choice for evaluating a patient with hemoptysis.

  • Patients who present with hemoptysis but have a negative chest x-ray should be referred for close outpatient follow up due to the high risk of malignancy.

 

BACKGROUND

  • In one study in the primary care setting, the incidence of hemoptysis was approximately one case per 1,000 patient years or about 4-5 patients presenting in a single year. Of those, only 5-15% present with massive hemoptysis.

  • Hemoptysis can be  divided into two categories massive versus non-massive.

  • Massive hemoptysis is characterized by large volume hemoptysis including:

    • Hypoxia

    • Hemodynamic instability and shock

    • Inability to protect their airway

 

CAUSES

  • Massive hemoptysis:

    • Lung cancer

    • Tuberculosis

    • Rheumatologic conditions

    • Post-radiation patients

    • Any postoperative patient who has had a recent surgical procedure

  • Non-massive hemoptysis:

    • Upper respiratory infection

    • Asthma

    • COPD

    • Malignancy

    • Bronchiectasis

  • In one study, almost two-thirds of patients with hemoptysis that presented to the primary care setting had some form of acute respiratory tract infection.

  • Tuberculosis as a cause of hemoptysis among US born residents who have no history of travel or weight loss and have never been in jail is extremely low.

  • Only 7% of patients with pulmonary embolism will present with hemoptysis as their primary complaint.

 

DIAGNOSIS & MANAGEMENT

  • A thorough history and physical exam is the first step in working up a patient with hemoptysis.

  • Determine if this is true hemoptysis or if the bleeding is coming from an oral or GI source.

  • For pediatric hemoptysis it is important to rely more heavily on objective data such as the physical exam, hemoccult testing or presence of blood in the diapers.

  • A chest x-ray is the first and most important step that guides management:

    • Pneumonia - Requires antibiotics and outpatient follow up to repeat imaging in 6-8 weeks to ensure that the consolidation resolves and is not malignancy.

    • Lung mass - Patients with a probable lung mass on x-ray need to be sent to the emergency department for a CT of the chest and higher level of care.

    • Negative -10% of patients with hemoptysis and a normal chest x-ray develop a malignancy within the next three years.

      • If the patient's symptoms are most consistent with an infectious cause (i.e. fever, cough, abnormal breath sounds) treat as pneumonia.

      • If the patient has a risk factors for malignancy consider CT-chest and outpatient follow up with pulmonology for bronchoscopy.

  • Patients with a negative chest CT be referred to pulmonology for bronchoscopy as malignancy is only found on CT imaging in 96% of patients who go on to have cancer.

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Hacking Up A Lung Full episode audio for MD edition 176:04 min - 83 MB - M4AHippo Urgent Care RAP - April 2018 Written Summary 365 KB - PDF

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