Haemoptysis

Pink froth (heart failure) or mildly blood-streaked infected sputum (chest infection) will settle with management of the underlying condition. Of concern here is the patient who is currently coughing up fresh blood, or has a history of recently coughing up blood quantifiable by volume (e.g. ‘half a cup’, ‘a basin full’). Trying to define a cut-off volume for massive haemoptysis is a pointless exercise; a potentially more useful division is between mild and life-threatening disease – in the former it is a manifestation of another process, in the latter it is a condition needing management in its own right

Ensure, with a very careful history, that it is truly haemoptysis and not haematemesis.

Consider a clotting problem (is the patient on warfarin? Does he or she drink heavily?) If in any doubt, do an INR when you take blood for the FBC.

Most massive haemoptysis in resource-constrained settings is due to bleeding from a pulmonary vessel in a lung damaged by previous or current tuberculosis. In the setting of tuberculosis early surgery is not easy and a pneumonectomy may be required to stop the bleeding. If the contralateral lung is also affected by tuberculosis, this may lead to critical respiratory compromise. For this reason there is a case to be made for initial conservative management of this condition, but this should be done in close collaboration with a thoracic surgeon.

Therapeutics in this area is short on science and rich in anecdotes and there is practically no randomised controlled data on which to rely for many of the touted therapeutic recommendations.

There seems to be consensus on the following:

1. Keep up a large bore intravenous cannula and drip.
2. Put the patient on bedrest in hospital.
3. Ensure that blood loss is measured and recorded.
4. Replace blood loss with packed cells and FFP as appropriate.
5. Start broad-spectrum parenteral antibiotics (e.g. ampicillin).
6. If there is a strong clinical suspicion of active tuberculosis, start TB treatment even in the absence of positive AFBs.

There is little consensus on anything else. Many people argue vigorously, for the use of cough suppressants. If you are going to use something like codeine in the doses required to actually suppress cough (30-60 mg 4 hourly) remember to add a laxative as the patient will become constipated, and the raised intrathoracic pressure associated with straining is undesirable.

Truly sedating the patient to the level of reduced consciousness is only acceptable in situations of impeccable monitoring.

Persistent/recurrent severe haemoptysis warrants thoracic surgical input for possible lobectomy (if sufficient pulmonary reserve). Also consider selective bronchial vessel embolization, if an actively bleeding source can be identified.

Perspective – tranexamic acid

Tranexamic acid is sometimes used, but without good data on efficacy. It may reduce bleeding duration (by <1 day), but may increase thromboembolic risk.¹. A further systematic review² found (in 4 RCTS, total 168 patients) found that tranexamic acid had no effect on bleeding duration or haemoptysis resolution but reduced expectorated volume by about 50 ml and hospital stay by 1.6 days… This evidence is simply too preliminary to interpret; there is certainly no convincing evidence of efficacy.

Nebulised tranexamic acid has the theoretical advantage of a lower probability of thromboembolic complications. The RCT evidence is limited³ – some benefit in a trial of 47 patients, and patients were excluded if the produced more than 200 ml of expectorated blood per day. If used, (off label!) 500 mg of the IV solution can be diluted with 4 mil of saline and given 6 hourly.

Perspective – outcomes in patients with haemoptysis

Results are skewed by cohorts of patients collected by thoracic surgeons and interventional radiologists in developed world countries where the prevalence of post-tuberculous lung disease is falling. A relatively small retrospective study⁴ of patients with massive haemoptysis in a high TB prevalence area without bronchoscopic or embolisation facilities portrays a more familiar scenario, with a mortality rate of only 6% (4/63) over a 2.5 year period. About 65% of patients had either active tuberculosis or post-tuberculous destructive changes with presumed secondary infection. An even smaller study⁵ from Singapore suggested that the ratio of new to previous tuberculous disease might be 1:1.

Perspective – cough suppressants

Although cough suppressants are almost universally recommended in treatises on haemoptysis,⁶ there is little evidence for their efficacy in general, with one systematic review being unable to demonstrate benefit from over the counter preparations in acute cough.⁷ Bearing this in mind, the size of trial necessary to demonstrate a small but clinically meaningful effect in haemoptysis would be large, and unlikely to be conducted in developed world settings, where the management of choice is now embolisation or surgery.

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1. Moen CA, Burrell A, Dunning J. Does tranexamic acid stop haemoptysis? Interactive Cardiovasc and Thoracic Surg.  2013;17:991-994 ↩

2. Tsai YS, Hsu LW, Wu MS, Chen KH, Kang YN. Effects of Tranexamic Acid on Hemoptysis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Drug Investig. 2020 Sep;40(9):789-797. doi: 10.1007/s40261-020-00946-y. PMID: 32661913 ↩

3. Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018 Dec;154(6):1379-1384. doi: 10.1016/j.chest.2018.09.026. Epub 2018 Oct 12. PMID: 30321510. ↩

4. Van Kralingen KW, van Kralingen-Heijboer AC, Zimmerman M. Management of haemoptysis in a Third World city hospital: a retrospective study. Tubercle & Lung Dis. 1995;76:344-8. ↩

5. Stebbings AE, Lim TK. Cause, treatment and outcome of patients with life-threatening haemoptysis. Singapore Med J. 1999;40:67-9 ↩

6. Johnson JL. Manifestations of hemoptysis. Postgrad Med 2002;112:101-13 ↩

7. Schroeder K. Systematic review of randomised controlled trials of over the counter cough medicines for acute cough in adults. BMJ. 2002;324:329 ↩

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