Hemoptysis & Diffuse Aveolar Hemmorhage

Hemoptysis

First, assess vitals, oxygenation, ability to protect airway
Consider GI or ENT source of bleeding - can often be difficult to distinguish. Careful H+P, +/- endoscopy can be helpful
Can break hemoptysis down into 3 main categories anatomically:

1) Airway - Bronchitis or Bronchiectasis, Tumor, Foreign body, etc
2) Pulmonary Parenchyma - Infectious (PNA, lung abscess, TB, Aspergillus), Autoimmune (Goodpasture's, Wegener's), Toxic (Crack cocaine, XRT)
3) Vascular - Pulmonary embolism, CHF or Mitral stenosis, AVMs

Alternatively, you can remember the mnemonic BATTLE CAMP

Bronchitis, Bronchiectasis
AVMs
Tumor, Trauma
TB
LV dysfunction
Emboli (PE)
Connective Tissue Disease (Wegener's, Goodpasture's,etc), Coagulopathy
Abscess, Aspergilloma, Alveolar hemorrhage
Mitral Stenosis
Pneumonia

Lastly, if patient has massive hemoptysis with respiratory distress, turn patient onto the side where you suspect the bleeding is coming from (so that blood doesn't spill into other side), and ask your anesthesiologist to selective intubate the non-bleeding lung.

Overview of Diffuse Alveolar Hemorrhage

Syndrome resulting from widespread damage to alveolar microcirculation --> blood fills alveoli, leading to impaired gas exchange
Presents as dyspnea, cough, hemoptysis, fever, and nonspecific alveolar infiltrates on CXR/CT
Keep in mind that hemoptysis can be absent in up to 1/3rd of patients
Diagnosis is made with BAL, where you see progressively bloodier aliquots on lavage
Etiologies: Important to exclude infection. Most commonly associated with Autoimmune diseases, Toxins (Crack cocaine), Drugs (including chemotherapy), Radiation therapy, and Bone Marrow Transplants (Auto>Allo).
Treatment - usually cover with antimicrobials empirically, supportive care with lung protective mechanical ventilation, correct any coagulopathies if present..
Steroids are mainstay of treatment once infection excluded, although no demonstrated mortality benefit as of yet

Also can consider other immunosuppressants such as Cytoxan, depending on underlying etiology.

(Chanu Rhee MD, 8/6/10)