(P18) Hemoptysis

Chief Complaint : A 34-year-old female with no known past medical history presents with coughing up blood for 1 day.

History of Present Illness : She reports occasional hemoptysis over the past three months but consistent episodes today. Today, the patient estimates approximately 5-10 mL of frank bright red blood with each episode of hemoptysis and about 500 mL in total over the past 24 hours. She reports annual trips to Albania. During her most recent trip that was 3 months ago, she had dental implants placed. She denies fever, chest pain, shortness of breath, or trauma.

Pertinent Physical Exam: Vitals: BP 127/88 HR 86 temp 98.8 F RR 18 SpO2 99% RA
General: alert, answering questions appropriately, occasional cough with streaks of bright red blood produced.
Mouth/throat: normal dentition, no lesions, no ulcers, no lacerations.
Heart: S1 and S2 appreciated.
Lungs: clear to auscultation.
Abdomen: soft, nontender.
Derm: no rashes.

Pertinent Laboratory Data: WBC: 16.7
Hgb: 13.6
Hct: 42.5
Plt: 304
BUN: 6

Case Discussion: The initial concern for this patient was airway stability. No immediate intervention was needed as she was only producing streaks of blood, speaking in full sentences, and had no increased work of breathing. However, the patient then began to produce approximately 10 mL of blood per cough with an estimated over 500 mL per 24 hours. The decision was made to obtain a CTA of the chest while the patient was stable. It showed a cavitary lesion in the left lower lobe with an endobronchial opacity concerning for blood. The patient was then intubated via a right mainstem intubation using a large endotracheal tube (size 8.0). Interventional pulmonology was then able to perform a rigid bronchoscopy to place an endobronchial blocker at the site of the lesion in the left lower lobe. She was started on broad spectrum antibiotics. Pathology reports from bronchoscopy showed active tuberculosis for which the patient was treated.

Massive hemoptysis is life threatening hemoptysis with potential for death by asphyxiation. Quantitatively, it is over 50 mL per cough, over 100 mL per hour, or over 600 mL per day. Bleeds are usually from the high pressure bronchial arteries, pulmonary arteries, or aorta. Intubation technique should involve right mainstem intubation when applicable or place the patient in lateral decubitus position with lesion on the dependent side. If mainstem intubation is done, it is important to adjust the ventilator parameters to account for one lung ventilation. When an endobronchial blocker is placed, the patient will have to be re-paralyzed or deeply sedated to minimize movement of the blocker.

Hemoptysis can be a life threatening chief complaint which can worsen quickly during a patient’s emergency department stay. Therefore these patients must be closely monitored and reassessed.

References and Acknowledgements (Optional): O'Hara S. EM@3AM:Hemoptysis. emDocs.net.

Larici AR, et al (2014). “Diagnosis and management of hemoptysis.” Diagnostic and Interventional Radiology. 20 (4): 299-309.

Templeton TW, Piccioni F, Chatterjee D. An update on one-lung ventilation in children. Anesth Analg. 2021;132(5): 1389-99.