Hemoptysis Liu Zhenhua. In the emergency room A 67-year-old man who was recently diagnosed with pulmonary tuberculosis and treated with four- drug antituberculous.

Hemoptysis

Liu Zhenhua

In the emergency room A 67-year-old man who was recently diagnosed wit

h pulmonary tuberculosis and treated with four-drug antituberculous for the last month presented to the emergency department with hemoptysis

The patient stated he had small amounts of blood-streaked sputum for the past 2 weeks, but noted that immediately prior to coming to the emergency department he had coughed up approximately “a cup” of bright red blood. While still in the emergency department, he had a witnessed episode of large volume hemoptysis, estimated to be greater than 250 cc of fresh blood

What will you do next? History: age, characteristics, concomitant

symptoms, past medical and surgical history, personal history, medications, etc

Physical Examination Lab Imaging and diagnostic options

Hemoptysis Expectoration of blood originating from below

the vocal cords. It may occur in the form of blood-streaked or blood-tinged sputum or frank hemoptysis

Bleeding originating from above the vocal cords is known as false or spurious hemoptysis

Is it hemoptysis or not?Hemoptysis Hematemesis

1 Cough + -

2 Sputum Frothy

Bright red-pink

Liquid or clotted

Rarely frothy

Brown to Black

Coffee ground

3 Respiratory symptoms + -

4 Gastric or Hepatic disease

- +

5 Vomitting &Nausea - +

6 Melena - +

7 Lab Parameters Alkaline; Mixed with macrophages and neutrophils

Acidic; Mixed with food particles

Characteristics

Blood tinged sputum Blood streaked sputum Red currant jelly sputum Rusty sputum Frank hemoptysis

Color and characteristic

Cardinal red sputum: tuberculosis (TB), lung abscess, bronchiectasis and clotting defects

Rusty sputum: pneumonia, parasitic Wine sputum: mitral stenosis, Pulmonary

infarction Frothy and blood-tinged sputum: left heart

failure

Amount

GRADE AMOUNT/24HRS

Mild ＜ 50ml

Moderate 50-200ml

Severe ＞ 200ml

Sources

Etiology

Respiratory causes

Cardiovascular causes

Systemic causes

Cryptogenic

Respiratory causes

Tracheobronchial:

- Bronchiectasis

- Acute & chronic bronchitis

- Bronchogenic carcinoma

- Bronchial adenoma

- Inhaled foreign body

Respiratory causes

Pulmonary - Pulmonary infections : pulmonary tuberculosis, lung absc

ess, pneumonia- Aspergilloma- Massive pulmonary embolism & pulmonary infarction- Trauma- Pulmonary hemosiderosis- Pulmonary A-V malformation

Cardiovascular causes

Elevated pulmonary capillary pressure

Mitral stenosis

Significant left ventricular failure

Congenital heart disease

Severe pulmonary hypertension

Systemic causes Hematologic (Coagulopathy): thrombocytopeni

a, leukemia, hemophilia Inflammatory or immune disorders: Goodpastur

e’s syndrome, lupus pneumonitis, and Wegener’s granulomatosis

AID: epidemic hemorrhagic fever, leptospirosis Latrogenic, percutaneous or transbronchial lun

g biopsy, over-anticoagulation by drugs Catamenial hemoptysis

Cryptogenic

Depending upon the study, up to 30% of patients with hemoptysis have no cause identified even after careful evaluation

In a series of 67 patients with crytogenic hemoptysis, the prognosis was generally good, and most patients had resolution of bleeding within six months of evaluation

Adelman, M, et al. Intern Med 1985;102:829

Causes

Causes

Concomitant symptoms Fever Chest pain Cough Purulent sputum Bleeding Jaundice

Differential Diagnosis

I. Exclusion of false hemoptysis

Examination of upper respiratory tract usually reveals the cause of false hemoptysis

II. Differentiation between hemoptysis & hematemesis

III. Detection of the cause of hemoptysis A) Full clinical evaluation including history taking & physical examinationB) Investigations :1. Chest X-ray2. Sputum examination3. Chest CT4. Bronchoscopy5. Bronchography6. Cardiac investigations : ECG & echocardiography7. Investigations for hemorrhagic blood diseases

The patient’s past medical history was unremarkable with the exception of longstanding tobacco abuse. Other than his recent antituberculous therapy he took no regular medications. He did not regularly use aspirin or other NSAIDs. He had no history of rash, kidney disease, hematuria, or known autoimmune disease. Prior to the episodes described above, he had no history of pneumonia or hemoptysisThe patient smoked one pack of cigarettes per day for the past 45 years. He did not use alcohol or other recreational drugs

Physical ExamThe patient appeared uncomfortable and in distressVital signs were notable for a blood pressure of 101/60 mmHg, a heart rate of 113 beats per minute, a respiratory rate of 25-32 breaths per minute The head and neck exam was notable for the presence of blood in the oropharynx and clear naresThe cardiac exam demonstrated tachycardia, a normal S1 and S2, and no murmur, gallop or rubThe lungs were notable for the presence of low-pitched rhonchi, right greater than leftThe abdomen was benign without organomegally The patient’s extremities were slightly cool, without cyanosis, clubbing or edema. The skin was clear without a rash

Lab White blood cell count 11,000/mm3 with a slight left

shift present(4000-10000) Hematocrit 12% （ 40-50%） Platelet count was 378,000/mm3 (100-300) BUN 49 mg/dl(9-19.9), serum creatinine was 1.1 mg/

dl(0.6-1.2) Total bilirubin 1.4mg/dl （＜ 1.0） AST 50 IU/L, ALT 29 IU/L (40) The patient’s electrolytes and serum glucose were

within normal limits An INR and PTT were within normal limits A urinalysis showed an elevated specific gravity an

d the presence of hyaline casts

Chest Radiograph

CT Pulmonary Angiogram

Soft Tissue Window Coronal Reconstruction

A pulmonary artery aneurysm

Pulmonary Angiogram