Case Hemoptysis 1 Dr Ayed

Hemoptysis: The students should consider the following objectives: 1. The definitions of hemoptysis, massive hemoptysis. 2. The dual blood supply (pulmonary and systemic) of the respiratory tract. 3. Define and identify the common causes of hemoptysis. 4. Able to identify the diagnostic clues in hemoptysis. 5. Identify the with hemoptysis.principles of therapeutics and evidence based practice for patient 6. Basis of resuscitation in a patient with massive hemoptysis. Case: A – 50 – year – old Kuwaiti oil refinery worker, comes to emergency room complaining of cough productive of yellowish sputum a long with left sided chest pain. In addition he has noticed lately blood stained sputum with increasing the amount of blood in the sputum during the last 4 days. Clues from the history 50 yrs old, oil refinery worker[exposure to chemicals], Lt. sided chest pain, productive cough, increasing the amount of blood in the sputum, short duration, coming to ER[means the problem is very sever and he cannot wait]. Need to get more information on the presenting history: Questions in the 1- History - How long is the problem [to know is it acute or chronic]? Is its first or recurrent attack! This to determine whether this is an acute or chronic disease. 1 - How frequent is the blood in the sputum? Amount and whether is fresh blood or blood stained sputum? This is to determine the seriousness of the problem and to categorize the hemoptysis. To know the severity of blood,u ask the patient to estimate the amount of blood by as asking how many cups[small\big cups or bottles] also ask about the nature of the blood,is it pure blood or mixed with sputum.sometimes the sputum has foul smell -To categorize the hemoptysis: -massive hemoptysis:more than 600/24hr coughing up the blood -mild hemoptysis -exnaguented hemoptysis:more than 1000/24hr coughing up he blood - The features of chest pain; site, character, duration, radiation, relieving or aggravating factors, etc. This is to determine whether the pain is a pleuritic chest pain, which is associated with pulmonary embolism or infarction[also central compressive chest pain, it may indicate a tumor invading the bronchial tree and causing bleeding]. - Any associated history of chronic lung disease, recurrent lower respiratory tract infection, cough with copious purulent sputum. Purpose: to suggest a diagnosis of bronchiectasis or lung abscess[it indicates chronic infection e.g. bronchiectasis.also acute pneumonia can cause hemoptysis sometimes!] - Any associated dyspnea on exertion, fatigue or orthopnea. To suggest diagnosis of congestive heart failure, left ventricular dysfunction. - History of paroxysmal nocturnal dyspnea, frothy pink sputum. To suggest mitral 2 valve stenosis [also u might ask the patient if he has a prosthetic valve cz it leads to infective endocarditis which cuse hemoptysis directly or indirectly by causing septic emboli]. - History of weight loss, loss of appetite. To suggest lung cancer, tuberculosis. - History of tobacco use. To suggest lung cancer or chronic bronchitis. - History of travel history or similar problem in a family. To suggest tuberculosis. - History of colon or renal cancer. To suggest endobronchial metastatic disease of lungs which lead to hemoptysis - History of fever, productive cough. To suggest acute bronchitis, pneumonia, lung abscess.which leade to hemoptysis - History of anticoagulant medication. This to suggest coagulation disorder which leads to hemoptysis. The additional information will be: This patient states that he has been feeling unwell for the last 3 months with mild fever, no appetite with a weight loss of a few kilograms along with a loss of energy and occasional night sweats. The blood in his sputum worries him. The patient he received one week antibiotics course from a polyclinic. He states that he has less sputum. However, the frequency of hemoptysis and the amount of blood has increased and he complains of increased dyspnea. He has no history of previous similar attacks. He had a severe chest infection as a child that required hospitalization but denied any other illness in the past. He is a smoker (2 packs per day) since the age of 20. He is not on any medications and has no allergies. He has 2 siblings who are well. His parents are deceased, his mother at age 72 and his father at age of 69. He states that they had been well and died of old age. He lives with his spouse and two children, age 11 and 14. For the last 12 years he has worked 3 in his own grocery store and prior to that worked for 10 years at an oil refinery. He does not drink alcohol. Why he pt has dyspnea? Smokingchronic obstructive irway disease Lung cancer Blood filling the lungcoagulation which obstructs the bronchial tree so the pt will suffocate[atalecisis] So most of the pts will die cz all the bronchi are occluded which leads to shock from hypoxia not from hypovolemia. At this point differential diagnosis of his problem: Neoplasm Bronchitis T.B. Bronchiectasis 2. Results of physical examination: He appears anxious and he has no cyanosis or jaundice. HR is 100/min and regular, Bp is 140/85, temperature 37.5º C, and RR is 30/min[tachypenic] with an oxygen saturation of 93% in room air. The trachea is in midline with normal JVP. Chest examination reveals poor chest expansion with normal breath sounds over the right side of the chest, but bronchial type of breath sounds and inspiratory crackles in the left interscapular area. Heart sounds are normal, and no murmurs are heard. The abdomen is soft and non-tender with normal bowel sounds. No masses are felt 4 and liver and spleen are non palpable. No clubbing or peripheral edema is present. The mental status exam is normal. What else we shouldCheck for: Skin rashes--------- vasculitis Splinter hemorrhage----------- endocarditis Lower limb edema----------------- DVT Murmurs ------------------------- pulmonary hypertension, MS 3. Lab. Tests Hb: 10 g/L[anemia] Leucocytes count 13x10 9/L Neutrophils 86% Platelet count INR 1.2 PTT 31 sec Random glucose 6.0 mmol/ L Urea 5.9 mmol/ L 450x10 9/L Creatinine 83 mmol/ L C-reactive protein 112 mg/ L Chest x-ray shows consolidation of left upper lobe. -white area in the upper part of the left lung -deviation of the trachea to the left side[the same side of the lesion] which indicate a collapse or attalectesive.if it is deviated to the opposite side, 5 it indicates the presence of anything that pushing like: fluid and air The ECG shows a sinus tachycardia. The patient was admitted to hospital. Immediate management was established. - At this point differential diagnosis: Neoplasm T.B. Pneumonia Bronchiectasis - Identify unfamiliar terms: Hemoptysis: coughing up blood. Massive hemoptysis: coughing up blood > 500 ml/24 h 6 Dyspnea: breathlessness Crackles: added pulmonary sounds comes from the lung interstitial or alveolar level as in consolidation. - Discussion of management at this time. Admit the patient Resuscitation O2 supplement Intravenous antibiotics (community acquired pneumonia) U give steroid only for vasculitis in certain diseases - Investigations maybe discussed: including Arterial blood gases: pH: 7.4 Paco2: 4.6 PaO2: Hco: 21, SaO2 93% on room air Sputum collection x 3 days Sputum cytology Result: squamous epithelial cells with no bronchial epithelial cells and negative culture. No AFB[acid fast bacilli] was seen and culture results for TB. are pending. CT scan chest was ordered. The next morning the patient had a coughing episode productive of 250 ml of fresh blood [so this is urgent cz a lot of blood is coughed and we have to do bronchoscopy to suck all the clots blood out and to know the source of the blood and we can treat at the same time]. He was transferred to the ICU for stabilization 7 and emergency bronchoscopy[it is therapeutic diagnostic] was ordered. His Hb was dropped to 8.5 g/L. In the ICU his bleeding settled after a total estimated blood loss of 500ml. He responded well to resuscitation and a decision was made to proceed with a bronchoscopy. Bronchoscopy revealed a fresh blood coming from left upper lobe, no masses were seen. Bronchial washing and brushing were taken for bacteriological examination and cytology. Stains showed few AFB and culture results are pending. How we manage this pt: -u clean the airways by bronchoscopy and if u see a lesion in a blood vessel u can catorize or laser them by bronchoscopy -wait for few seconds -if the pt continues to bleed massively 1) we block the left lung by insertion a tube that has a blocker and ventilate the right lung by the ventilator 2)resection of the left lung if the bleeding is life threatening when there is diffuse bleeding the lung has dual blood supply 1)pulmonary artery: it has low pressure so when there is a lesion in it ,it can be stopped by bronchoscopy 2)bronchial artery: it has high pressure so when there is a lesion in it, there will be diffuse bleeding and can not be stopped by bronchoscopy 3) catheterization of the bleeding vessel - Discussion of management of non-massive hemoptysis. - Discussion of management of massive hemoptysis. Principles of management: Resuscitation and prevent asphyxia. Identify the source of bleeding Cessation of bleeding Treat the underlying cause 8 1- medical 2- invasive procedures : embolization 3- Surgery Causes of hemoptysis: 1. Tracheobronchial source Neoplasm Bronchitis Bronchiectasis Airway trauma 2. Pulmonary parenchymal source Lung abscess Pneumonia Tuberculosis Mycetoma Goodpasture’s syndromecommon cause and treated by steroid Wegener’s syndromecommon cause and treated by steroid Lung contusion 3. Primary vascular source AV malformation Pulmonary embolism Mitral stenosis 4. Systemic coagulopathy or use of anticoagulants or thrombolytic agents 9