Hemoptysis
Definition: hemoptysis is the expectoration of blood > 100-600 ml over 24 hours
-Be careful to distinguish hemoptysis from hematemesis or blood from gums, throat or nose
-Massive hemoptysis is a medical emergency. Massive hemoptysis can be fatal, with deaths occuring by exsanguination or asphyxiation from flooding of the alveoli with blood and intractable hypoxemia.
-Top 3 causes of massive hemoptysis: TB, bronchiectasis and carcinoma
-Always remember the 3 principles of management 1) maintain airway patency and oxygenation 2) localize the source of bleeding 3) control hemorrhage
Vascular Anatomy
The pulmonary circulation: carries deoxygenated blood from the right ventricle across the pulmonary capillary bed and returns oxygenated blood via the pulmonary veins. This is a low pressure circuit with normal pressures of 15-20/5-10 mmHg. Blood originating from the pulmonary parenchyma can be from an infection such as pneumonia, lung abscess or TB or from diffuse process such as Goodpasture’s syndrome.
The bronchial circulation: is the nutritional source for the structural elements of the lung. Bronchial arteries branch from the aorta and are at systemic pressure. They can bleed profusely when airways are diseased, as seen with bronchiectasis or with endobronchial tumors.
History:
-ask about tobacco history, prior lung, cardiac or renal disease
-ask about any prior episodes of hemoptysis
-productive cough, infection, skin rash, travel history
-ask about chest pain and shortness of breath
-any bleeding disorders
Physical Exam:
-examine skin: look for signs of Kaposi’s sarcoma, vasculitis
-look for splinter hemorrhages as sign of endocarditis
-listen for cardiac bruits or murmurs (large AVM)
-listen for cardiac sounds such as loud P2, TR as signs of pulmonary hypertension
-look for clubbing (nonspecific sign)
-examine legs for signs of DVT
Etiology
Acute: pneumonia, bronchitis, pulmonary embolism
Chronic: tuberculosis, lung cancer, bronchiectasis
Airways disease
Bronchiectasis: is due to destruction of the cartilaginous support of the bronchial wall by infection or bronchial dilatation owing to parenchymal retraction from alveolar fibrosis. This causes bronchial artery hypertrophy and augmentation of anastomoses with the pulmonary artery bed
Carcinoma: 7-10% of patients with bronchogenic carcinoma present with blood streaked sputum; massive hemoptysis is rare. Vast majority of primary lung cancers associated with hemoptysis are squamous in origin. In metastatic lung disease, the lesion is usually endobronchial.
Foreign body and Airway Trauma
Parenchymal Disease:
Bacterial Pneumonia
Tuberculosis: may cause hemoptysis either in active disease (cavitary lesions, rupture of pulmonary artery aneurysms) or as late sequelae (rupture of aneurysms or secondary to bronchiectasis). Rupture of Rasmussen’s aneurysm can occur with active disease or as a late finding. It occurs when there is rupture of ectatic portions of the pulmonary arteries traversing thick-walled cavities.
Fungal Infection: (mycetomas) forms in patients with pre-existing cavitary disease, aspergilloma
Lung abscess: causes hemoptysis, probably because of necrotizing effect of the primary infection on lung parenchyma and vasculature
Autoimmune disorders: Wegener’s, Goodpasture’s, SLE pneumonitis
Coagulopathy: especially in patients with thrombocytopenia
Iatrogenic hemoptysis: from bronchoscopy or biopsy
Vascular:
Pulmonary Embolism
Mitral Stenosis or Congenital heart disease: cause hemoptysis via pulmonary hypertension, which leads to varices in the submucosa of the bronchial walls
Miscellaneous:
Catamenial hemoptysis results from ectopic uterine tissue in lung/pleural. Hemotysis occurs at same time as patients menstrual cycle
Management
-consider TB in anyone with chronic cough and hemoptysis
-Maintain airway patency: asphyxiation is the most frequent complication of massive hemoptysis. ---Obtain chest xray and oxygen saturation if available to assess the status of oxygenation and the amount of blood in the lung. Moniter patient in the ICU. If bleeding site is known, in massive hemoptysis, place the patient in the lateral decubitus position with the affected lung in the dependent position.
-Obtain IV access
-Obtain routine lab date: FBP, BUN/creatinine, PT/PTT and urinalysis
-Localize the source of bleeding: if there is any doubt, the source of the bleeding (pulmonary versus GI versus ENT) should be investigated. Take a thorough history and physical exam.
-in general, bronchoscopy is the diagnostic procedure to identify source of bleeding
-Control the hemorrage: correct coagulopathy, for severe hemoptysis give vitamin K 1 mg IV. Cross match blood if needed. Bronchoscopy can control hemorrhage through vasoconstrictive agents
Pneumonia
Definition = acute infection of lung parenchyma
Clinical manifestations:
Cough, fever, tachycardia, pleuritic chest pain, shortness of breath, sputum production
CXR: infiltrate (can be different patterns i.e. lobar, interstitial, cavitary)
Microbiology:
Typical pathogens: Strep pneumoniae, H. influenzae, Staph aureus, Moraxella catarrhalis
Atypical pathogens: Legionella, Chlamydia pneumoniae, Mycoplasma pneumoniae, Anaerobic bacteria (especially in patients with aspiration or abscess), gram negative bacteria (E. coli, Klebsiella less commonly seen)
Immunocompromised patients: TB, PCP
Treatment:
-Use CURB-65 score to guide treatment: (confusion, BUN>19, RR>30, BP<90/60, Age>65), give 1 point for each that his positive and > 3 points or > 1 with co-morbidity (HIV, diabetes, heart failure, renal disease) is considered sick
-In hospital Ceftriaxone 1 gram IV OD for patients with > 3 points or co-morbidity
-For atypical PNA (especially in HIV patients), add erythromycin
-If patient is hemodynamically unstable, add gentamycin for double gram negative bacterial coverage
-For suspected aspiration pneumonia (especially in stroke patients), add metronadizole 500 mg IV tds for anaerobic coverage
-For suspected PCP pneumonia, add Septrin 1920 mg 8 hourly x 21 days. If pt has hypoxia, add prednisolone 40 mg bd x 5 days, then 40 mg daily x 5 days then 20 mg daily x 11 days
-For suspected TB pneumonia, add 4 drug TB regimen and collect sputum sample for AFB staining
Hemoptysis and pneumonia clinical cases
Case 1
70 year-old F is brought into H2 with cough, fever and chills x 1 week. She has a history of CVA 5 years ago and has had residual L sided weakness and dysarthria since the stroke. Her family has noted she coughs a lot when she is eating and they think she might choke sometimes.
Vital signs are T 39.0, BP 100/60, P 115, RR 28. On exam, she is noted to be in mild respiratory distress. Chest exam is notable for right sided crepitations and increased tactile and vocal fremitus. She had bronchial breath sounds on the right side as well.
She is admitted to the medical ward and IV ceftriaxone is begun empirically.
WBC 14,000 (25% Lymphocytes, 85% Neutrophils)
CXR: dense infiltrate Right middle and lower lobes.
a. Why do you think this patient developed pneumonia? (aspiration is most likely cause))
b. What do you think about the antibiotic selection in this case? Should anything be added? (Add Metronidazole 500 mg 8 hourly for coverage of anaerobic bacteria that are often present in aspiration pneumonia)
c. What should be done to prevent this patient from further episodes of pneumonia? (Keep patient upright as much as possible. For example, when in bed, the head of the bed should be elevated at least 30 degrees. Patients' diets should also be modified. Water/thin liquids and difficult to chew solids are most likely to cause aspiration/choking, events therefore patients at risk for aspiration should be given a thick, pureed diet)
Case 2
29yoM with h/o IDS on ARVs (CD4 unknown) presents to H2 with 5 days of blood-tinged sputum and 1 month history of cough. +fevers, sweats, chills, worsening dyspnea on exertion, weight loss. Denies CP, pleuritic CP, lightheadedness, nausea/vomiting, HA, neck stiffness, diarrhea, urinary symptoms.
PMH:
-Admitted to Bugando 5 months ago for pneumonia and treated with antibiotics. Diagnosed with IDS and started on ARVs.
SH: Married with children. Fisherman. Smokes 3ppd for the last 10 years (=30 Pack years). No ETOH or drugs
Physical Exam: VS Temp 38 BP 100/70 HR 115 RR 22 96% RA; Not orthostatic
Gen: Thin male coughing every 5 minutes and interrupting speech. No respiratory accessory muscle use. NAD
HEENT: no oral thrush
CV: Tachy no murmurs
Pulm: diffuse rhonchi, R>L, no fremitus/dullness to percussion, enlarged chest wall
Abd: Scaphoid soft nontender nondistended normal BS, no organomegaly
Ext: no LE edema
Skin: no rashes
Neuro: alert and oriented, nonfocal
CXR: bilateral interstitial markenings with RUL opacity
Questions:
1. List your top 5 differential diagnoses. (Pulmonary tuberculosis, PCP, bacterial pneumonia, exacerbation of bronchitis/bronchiectasis, Lung cancer, Kaposi's sarcoma)
2. What investigations will you order to determine the cause of hemoptysis? (Chest x-ray, sputum gram stain, culture, sensitivity, AFB and PCP stain, FBP, PT/PTT, Type and cross match, BUN/creatinine, urinalysis, bronchoscopy if available)
3. What should be your immediate next step in management in this case? (Try to secure airway. If site of bleeding known (Right or left), place patient in the lateral decubitus position with bleeding side down. Obtain IV access. Correct any coagulopathy. Start Antibiotics or anti Tb medications if you suspect infection)
On day 3 of admission, the nurse calls you and says the patient vomited 3 cups of blood. No melena. You evaluate the patient and he is coughing so hard that he is unable to speak. VS BP 96/65, HR 130, RR 35 with 91% oxygenation on RA. Patient looks pale and you hear decreased breath sounds on the right with dullness to percussion over the R anterior chest and R lower lobe. Heart exam unchanged and no abdominal tenderness.
1. What should be your next step in the management of the patient? (Administer supplemental oxygen, secure airway/possible intubation, make sure patient has large bore IV access, bolus IV fluids and transfuse blood, send full blood picture. Try to ascertain whether the patient is truly vomiting blood or coughing blood. These can sometimes be difficult to distinguish but it is important. If the nurse is correct, and the patiet is truly vomiting blood, then this patient needs an urgent endoscopy for possible esophageal varices, or peptic ulcer disease. If this is truly hemoptysis, then it may be that there has been rupture of a lung cavity, leading to massive hemoptysis and even hemothorax)
2. Do these changes in his clinical condition change your differential? (In addition to the above mentioned differential, I would consider esophageal rupture as a possibility)
