Blood In Sputum (Hemoptysis)

Introduction

Hemoptysis is defined as the expectoration of blood or blood-tinged sputum from the lower respiratory tract (below the glottis). It is a frightening symptom for patients and a common presentation in Canadian emergency departments and family practice clinics.

For MCCQE1 preparation, distinguishing between massive (life-threatening) and non-massive hemoptysis, and differentiating true hemoptysis from pseudo-hemoptysis (e.g., epistaxis) or hematemesis, is critical. The management approach prioritizes the CanMEDS role of Medical Expert, focusing on airway protection and hemodynamic stability.

MCCQE1 Objectives

When studying for the MCCQE1, focus on the following objectives related to hemoptysis:

1. Data Acquisition: Differentiate hemoptysis from hematemesis and nasopharyngeal bleeding. Identify risk factors (smoking, travel history, anticoagulation).
2. Problem Solving: Construct a differential diagnosis based on anatomy (airway vs. parenchyma vs. vasculature).
3. Management: Apply the ABCs (Airway, Breathing, Circulation) immediately for massive hemoptysis. Determine the need for referral (respirology, thoracic surgery).

Etiology and Differential Diagnosis

In the Canadian context, while acute bronchitis is the most common cause of mild hemoptysis, malignancy and bronchiectasis are major considerations for recurrent or significant bleeding.

Common Causes (The “BATTLE CAMP” Mnemonic)

Anatomical Classification

Clinical Evaluation

History Taking

Key questions to ask during the MCCQE1 Clinical Decision Making (CDM) or MCQ sections:

• Quantity: “How much blood? Teaspoon or cup?”
• Description: “Is it bright red, frothy, or coffee-ground?” (Differentiates from hematemesis).
• History of Present Illness: Fever, weight loss, night sweats (TB/Malignancy), leg swelling (PE).
• Social History: Smoking pack-years (Cancer), Occupational exposure (Asbestos/Silica), Travel history.
• Medications: Warfarin, DOACs, Aspirin.

Differentiating Hemoptysis

Diagnostic Approach

Follow this stepwise approach, which aligns with Canadian standard of care.

Management Strategies

Management depends entirely on the volume of bleeding and patient stability.

Massive Hemoptysis (Medical Emergency)

1. Protect the Airway:

   • Endotracheal intubation with a large-bore tube (size 8.0 or larger) to facilitate bronchoscopy.
   • Selective intubation of the non-bleeding lung may be required.

2. Positioning:

   CRITICAL CONCEPT: “Bad Lung Down”

   Place the patient in a lateral decubitus position with the bleeding side DOWN. This utilizes gravity to prevent blood from spilling into the healthy lung, preserving gas exchange.

3. Volume Resuscitation:

   • Two large-bore IVs.
   • Crystalloids and blood products (Packed RBCs, Platelets, FFP) as needed.
   • Correct coagulopathy (Vitamin K, reversal agents).

4. Intervention:

   • Rigid Bronchoscopy: Provide better suction and airway control than flexible bronchoscopy.
   • Bronchial Artery Embolization (BAE): The first-line definitive therapy for massive hemoptysis in most Canadian tertiary centers.
   • Surgery: Lobectomy is a last resort if embolization fails.

Non-Massive Hemoptysis

• Treat the underlying cause (Antibiotics for pneumonia/bronchitis).
• Discontinue NSAIDs/Anticoagulants if safe.
• Follow up chest imaging to ensure resolution of infiltrates or to screen for cancer.
• Tranexamic Acid (TXA): May be used (nebulized or IV) to reduce bleeding time, though evidence is variable.

Canadian Guidelines

When answering MCCQE1 questions, keep these Canadian-specific guidelines in mind:

• Canadian Tuberculosis Standards (8th Ed): Hemoptysis in a patient from an endemic area (or Canadian North) requires immediate isolation (Airborne Precautions) until active pulmonary TB is ruled out (usually 3 negative sputum smears).
• Canadian Thoracic Society (CTS) - COPD: In patients with COPD exacerbation presenting with hemoptysis, always consider lung cancer, as the risk is compounded by smoking history.
• Lung Cancer Screening: Canada has implemented low-dose CT screening for high-risk populations (Age 55-74, smoking history). Hemoptysis is a symptom that bypasses screening and moves directly to diagnostic workup.

Medical Abbreviations

CXR    : Chest X-Ray
CT     : Computed Tomography
BAE    : Bronchial Artery Embolization
AFB    : Acid-Fast Bacilli
GPA    : Granulomatosis with Polyangiitis
SLE    : Systemic Lupus Erythematosus
DOAC   : Direct Oral Anticoagulant
INR    : International Normalized Ratio

Key Points to Remember for MCCQE1

• Most common cause: Acute Bronchitis.
• Most feared cause: Bronchogenic Carcinoma.
• Initial Test: Chest X-ray.
• Definitive Test (Anatomy): CT Chest.
• Localization/Biopsy: Bronchoscopy.
• Massive Hemoptysis: >100-600mL/24h. First step: ABCs + Bad Lung Down. Treatment of choice: Bronchial Artery Embolization.
• Systemic causes: Don’t forget Goodpasture’s (Anti-GBM) and Wegener’s (GPA) in young patients with hemoptysis + hematuria.

Sample Question

Scenario: A 62-year-old male presents to the Emergency Department with a 2-day history of coughing up approximately 1 cup (250 mL) of bright red blood per day. He has a 40-pack-year smoking history and mild COPD. On examination, he is alert but anxious. His blood pressure is 110/70 mmHg, heart rate is 105 bpm, respiratory rate is 24/min, and oxygen saturation is 93% on room air. Auscultation reveals crackles in the right lower lobe. A chest X-ray shows a cavitary lesion in the right lower lobe.

Which one of the following is the most appropriate immediate management step?

• A. Order a CT scan of the chest with contrast
• B. Perform flexible bronchoscopy at the bedside
• C. Place the patient in the right lateral decubitus position
• D. Initiate empiric intravenous antibiotics
• E. Administer nebulized epinephrine

Explanation

The correct answer is:

• C. Place the patient in the right lateral decubitus position

Detailed Explanation: This patient is presenting with massive hemoptysis (defined clinically by the volume ~250mL/day and the physiological tachycardia/tachypnea). The immediate priority in massive hemoptysis is Airway protection and maintaining gas exchange.

• Option C is correct: Placing the patient in the right lateral decubitus position (bad lung down) prevents blood from the right lung (where the lesion is) from spilling into the healthy left lung due to gravity. This preserves the functional surface area of the left lung for gas exchange.
• Option A (CT Chest): While a CT angiogram is crucial for diagnosis and planning embolization, the patient must be stabilized and positioned correctly first. Transporting an unstable patient to CT without airway precautions is unsafe.
• Option B (Flexible Bronchoscopy): While diagnostic, flexible bronchoscopy has limited utility in massive bleeding because the view is obscured by blood, and the suction channel is too small to clear large clots. Rigid bronchoscopy is preferred in the OR for massive bleeds.
• Option D (Antibiotics): While the cavitary lesion could be an abscess or TB, antibiotics are not the immediate life-saving intervention required for airway protection.
• Option E (Epinephrine): While topical vasoconstrictors can be used during bronchoscopy, nebulized epinephrine is not the standard immediate management for massive hemoptysis originating from the lower respiratory tract.

References

1. Medical Council of Canada. (2023). MCCQE Part I Clinical Decision-Making and Multiple-Choice Questions Objectives.
2. Canadian Tuberculosis Standards. (8th Edition). Public Health Agency of Canada.
3. Ittrich, H., et al. (2017). Review of Bronchial Artery Embolization in Management of Hemoptysis. Rofo.
4. UpToDate. (2024). Evaluation and management of hemoptysis in adults.
5. Toronto Notes. (2024). Respirology Chapter.