Hemoptysis Edited

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      Hemoptysis

       Introduction:

    To have hemoptysis is the most frightened experience, even worse than hematemesis or

    bleeding 1 litter or more from other part of the body. It is a frightening event to both:

    Health- care Providers and Patients & families.

     Definition: 

    As doctors, we should differentiate hemoptysis from other type of bleeding. Heamoptysis is

    the expectoration (or coughing up) of blood from the lung and the airways. Patients always

    describe it in different ways. Some patients will describe it as mucus with blood streaks, or

    mucus with dots, Pink sputum, Frank blood (with or without clots), Others will describe it as

    fresh blood, or black blood.

     Site of bleeding: 

    If we go back to the physiology of blood circulation in the lung, we will find that we have 2

    circulations:

    1- The bronchial circulation: this is high pressure (Bronchial arteries & collaterals originate

    from the aorta ) ,also known as systemic circulation.

    2- The pulmonary circulation: this is low pressure :

    systolic BP= 15-20mmHg.

    diastolic BP= 5-10mmHg .

    Most of the time, Hemoptysis comes from the low pressure circulation – which is close to the

    venous system- & that’s why it is always watery and low amount. In contrast, if the bleeding i

    from high pressure circulation -the arterial system - , there will be massive hemoptysis.

    *In the slides : bronchial circulation is The source of bleeding in most cases. 

    This lecture

    include all the

    slide :D

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     Mechanism of bleeding: 

    Hemoptysis occurs as a result of:

    1- Inflammation with erosion of blood vessels.

    2- Increase pressure in the vessels, which lead to dilatation & aneurysm formation ,and finally

    it will rupture

     Severity of hemoptysis: 

    Depends on 3 factors:

    1- Amount & rapidity of bleeding:

    It’s very important point to understand that, severity of hemoptysis is not only related to the

    amount of blood expectorated in 24h. In the past, they thought that the severity is

    proportional to the amount of blood. But nowadays, they find that the severity of the case is much more related to the rapidity of bleeding. E.g. patient with rapid but small amount

    bleeding is more critical than patient with slow but huge amount bleeding.

    2- Cardio-respiratory reserve:

    So patients with low cardio-respiratory reserve –as in COPD, lung fibrosis or

    Bronchiectasis - will have much more severe hemoptysis than one with healthy high

    reserve.

    3- The effect on gas exchange:

    We must conceder the effect of bleeding on gas exchange. In other word, we should ask: does

    the bleeding affect the gas exchange? & what does it cause in the respiratory tract?!!

    Sometimes, small amount of blood can cause a major obstruction that will lead to

    Asphyxiation or flooding of tracheo-bronchial tree and finally respiratory arrest (Medical

    Emergency: Occur in 1-5% of patients).

    *In medical emergency the amount reported to range from

    [ > 100 – 250 – 500 – 600 – 1000 ] cc / 24 hrs.

    So , we should look for all these 3 factors to assess the severity.

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     Etiology: 

    It’s important to define the etiology & the cause of hemoptysis to be able to deal with it and

    treat the patient. We can classify the etiology according to:

    1- the site of bleeding:

    It might be from tracheobronchial

    tree, lung parenchyma, lung

    vasculature, or related to systemic

    problem – read the table- slide#6-.

    - Bronchogenic carcinoma, Bronchitis, & Bronchiectasis are

    common cause for tracheobronchial

    bleeding.

    - TB is most common cause for lung parenchymal bleeding

    - Other causes are rare cases.

    2- The cause of bleeding:

    It might be infection, foreign body, trauma,

    malignancy, cardio-pulmonary causes, connective

    tissue disorders, factitious, or cryptogenic.

    Note: First make sure it is hemoptysis. Because there are lots of

    patients have nesopharengeal bleeding and cough which looks like

    hemoptysis & will give wrong diagnosis. So, you should ask about

    history of Hematemesis, Epistaxis, or other nasopharyngeal bleeding. 

    Look at the table

    Factitious disorders: are conditions in which

    a person acts as if he or she has an illness by

    deliberately producing, feigning, or

    exaggerating symptoms. 

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    3- Incidence & frequency:

    It varies in different study populations. The

    most common cause worldwide is Bronchitis.

    Pneumonia is 2 nd

    most common cause, then TB , Bronchiectasis, & lung CA.

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     Approach to Patient with Hemoptysis: 

    When a patient comes to the ER with hemoptysis, we needto: 

    - Take good history.

    - Assess the severity, Urgency, amount, duration & extent of bleeding.

    - Assess the Cardio-Respiratory reserve whither he/she has HF, IHD, or previous lung

    problem.

    - Ask about Prior Episodes of bleeding.

     Clues from the history: 

    These clues can help us to define the cause of hemoptysis. It’s not 100% true, but it can

    help.

    - If the patient has blood streaking of mucopurulent or purulent sputum, then think of

    Bronchitis.

    - If he has Blood streaking of purulent sputum + fever & chills, think of Pneumonia.

    - If he has chronic cough & sputum production + Recent change in quantity or

    appearance, think of Acute Exacerbation of COPD.

    - If he comes with foul smell of purulent sputum, check for Lung abscess.

    - If the chief complaint is sudden chest pain with SOB, think of pulmonary embolism.

    - In patient with Bronchiectasis, we expect to have Copious secretions & recurrent

    respiratory infections.- It’s very important to recognize the color of the sputum for

    Bronchiectasis, & that’s why the DR. put it in separated slide#14 –  - In a patient with positive Hx of asbestosis or smoking, we should think of Bronchogenic

    CA.

    - Alcoholic patient, or patient with recurrent coma or with poor dental hygiene are at

    high risk for lung abscess.

    - +ve Hx of drug abuse, or blood transfusion, or sexual practice may indicate HIV

    infection.

    - If hemoptysis is combined with renal disease – or hematuria- , think of Goodpasture

    syndrome or Wegener disease. - SLE patients may come with Lupus Pneumonitis 

    - Hx of other cancers – as renal cell carcinoma- with hemoptysis may indicate metastasis.

    - AIDS patients usually have endobronchial Kaposi sarcoma that may cause hemoptysis.

    - If patient has +ve Hx of previous bleeding, think of thrombocytopenia or anti-coagulant

    overdose.

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      Diagnostic: 

    For any patient coming with hemoptysis we do: labs, radiologic studies and

    endoscopic studies.

    1. Labs:

     Hemoglobin (the most important one)  PT, PTT & INR to know if the patient has bleeding diathesis.

     Sputum studies when suspect infectious or neoplastic etiologies.

     Cultures.

     KFT (Kidney Function Test) because, as we said, there are some illnesses which are

    associated with renal problems.

     UA (Urine Analysis)

     ABG's (Arterial Blood Gas) to know how much the patient is affected.

     CVD (Collagen Vascular Diseases) like: diabetes, rheumatoid arthritis… etc

     Differential diagnosis of hemoptysis + hematuria: 

     GPS, Goodpasture syndrome

     WG, Wegener disease

     SLE.

     Lung cancer. What is the cause of hematuria in lung cancer patients? Membranous GN.

     Renal cell carcinoma from lung metastasis.  Bleeding diathesis which may cause bleeding from any site.

    Student: what is the meaning of bleeding diathesis?

    Doctor: patients who have bleeding tendency.

    2. Radiologic studies:

     CXR (Chest X-Ray): When a patient comes to with any respiratory illness, you should do x-ray

    to him. In hemoptysis, it may be normal in up to one third of cases and in the other two thirds

    you may see the etiology. If you see an abnormality in one side of the x-ray, it may not reflect

    the exact site of the bleeding. Why? Because the bleeding accumulates in gravity-depending

    areas (the patient may be ambulating or bedridden).So, the infiltrate in the x-ray indicates the

    blood but does not indicate where the blood is coming from.

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     CT scan:It has higher yield and the highest yield is in bronchiactasis.

    Diagnostic clues for chest radiograph: Here, the doctor just talked about some examples: 

     Cardiomegaly: the patient may have heart failure or mitral stenosis.

     Hyperinflation: the patient may have COPD.

     Mass lesions, nodules, granulomas: may sug