Horses and Zebras is back after a brief absence!
Today we talked about a patient with new onset hemoptysis and an otherwise normal physical exam, screening blood work and CXR.
Here's a short and focussed review article from AFP on hemoptysis. It includes a very easy to follow algorithm and a good differential diagnosis.
A couple of key take-home points:
1) Always start with the ABCs. While we worry about dropping hemoglobin and hypotension, remember that one of the biggest risks in patients with hemoptysis is airway compromise and hypoxia.
2) Decide if this is actually hemoptysis! Blood from the GI tract or above the vocal cords (pseudohemoptysis) can mimic hemoptysis.
3) Infection and cancer are the most common diagnoses.
4) Evaluate for massive hemoptysis (>200-600cc/24 hours). This may suggest a diagnosis but also implies a much higher risk of airway compromise and need for aggressive airway management.
5) Reverse the reversible - correct coagulopathies, thrombocytpenia, etc.
6) After routine bloodwork - get a CXR. Go on to bronchoscopy or a high resolution CT scan of the chest in patients with massive hemoptysis, persistent bleeding, CXR findings or risk factors for lung cancer.
7) Call for help sooner rather than later - ICU, respirology, thoracic surgery - if the bleeding is not resolving or is getting worse. Specialized airway skills may be needed.
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