Hemoptysis Flashcards
hemopytis
bleeding into the tracheobronchila tree that is subsequently coughed up by the patient.
source of bleeding
Source of bleeding may be in the airway, parenchyma, or
vasculature
outline a scheme for hemoptysis aproach
two sources you sholud exclude to dx hemopytiss
nasopharync or upper GI bleed.
5 causes of airway disease that can cause hemopytiss
- bronchitis
- bronchiectasis
- bronchogenic lung cancer
- other endobronchila tumors
- fistulas between the airway and a blood vessel
causes of parenchymal disease that cuases hemoptysis (PMMD)
- pneumonia
- mycobacteiral/TB
- mycetoma
- drugs (cocaine)
vascular causes of hemoptysis
- pulmonary emobolism
- icnrease pulmonary venous pressure
- vasculitis
- capillaritis: Goodpasture’s (anti-GBM) mediated
- pulmonary AVM- atriovenous malformation
pulmnary AVM
a shunt where the pulmonary artery stem and the pulmonary vein stem do not anasatome at a capillary bed.
4 main components to initial rapid evaluation of hemopytsis
- ABC
- hisotyr
- PE
- Chest Xray
what signs on PE might indicate cause of hemopytiss
- check vitals– might have low BP and tachy if enough blood loss.
- respiratory distres
- focal or diffuse findings on respiratory exam
- telangiectasia
- skin rashes
- inflamed joints
- splinter hemorrahages (which can indicate endocarditis)
- clubbing
- heart murmur/mitral stenosis
- signs of DVT
in addition to chest Xray what labs and investigations should you do
- chest xray
- labs: cbc, ccreatinine/urea lytes
- platelets, INR/PTT Type and screen
- ANA, ANCA, anti-GBM
- BNP (heart failure indicator) - bronchoscopy
- CT Scan ( including high resolution CUTS)
how does bleeding from pulmonary circulation differ from bleeding from bronchial arteries?
pulmonary circtulation; slower trickling bleeding because of low pressure despite entire cardiac output being affected
bronchial artery bleeding; high pressure, would see clumps of blood. since it’s so high pressure, it’s easy for a small nick in the bronchial artery to cause BA bleeding.
risk factors for underlying lung cancer causing the hemoptysis presentation (DAMS)
Age>50
Male
smoking history >40 pack years
duration of hemoptysis >1 week
**NOte: not all patients with a lung cancer and hemoptusis will have an abnormal CXR
Not all patients with a lung cancer and hemoptysis will have an abnormal CXR
5% of the time patients with risk factors will have a normal
CXR but an ___ ___ on bronchoscopy
Not all patients with a lung cancer and hemoptysis will have
an abnormal CXR
5% of the time patients with risk factors will have a normal
CXR but an endobronchial lesion on bronchoscopy
definition of massive hemoptysis
100-600 ml. compare to coin size.
- remember: anatomical dead space is only 150 cc. it does not take much bleeding to fill airways with blood
- patients with massive hemoptysis die from asphyxiation, not exanguination
T/F it’s important to manage massive hemoptysis promptly because the person will die from blood loss
false.patients with massive hemoptysis die from asphyxiation, not exanguination. Still important to manage promptly though.
note: DDX for massive hemoptysis is a bit less than small volume hemoptysis
splinter hemorrhages might indicate ____ causes of hemptysis
endocarditis.
massive hemoptysis management/investigations
- assess how rapid the bleeding is:
- airway (double lumen tube if bleeding unilateral)
- bleeding side down
- hemodynamics/transfusion (lower priorty than airway) - involve a respirologist/thoracic surgeon/intensivist quickly
- bronchoscopy +/1 cold saline/epipnehprine/fogarty catheter
- CT
5/ Arteriography
- resection of the lung or partial resection.
why is a bronchoscopy helpful?
- helps localize segment the bleeding is coming from.
- might get lucky and cause of hemoptysis can be seen immediately and you can inject epi or address the tamponade with the bronchoscope itselg
what focal chest X ray findings would be seen in someone with vasculitis
might see focal chest XRAY cavitation.
investigations into pulmonary renal syndromes; what test would you order and waht are the expected findings/
chest x ray: would see diffuse interstitial/reticular findings. Airspace filling due to hemorrhage
CBC: might see anemia because of blood loss
Urinalysis: blood and red cell casts
creatinine
renal biopsy.
Goodpastr’es syndome is a renal capillaritis invovles the formation of antibodies to the:
- which demographic does it affect?
basement membranes that attack the glomerulus.
- triggered by infection/classically influenza, smoking and hydrocarbon inhalation
- check antibodies to anti-GBM
- affects younger patients 20-30 yearts.
management of pulmonary-renal syndromes presenting with hemoptysis
- it’s often life threatening: pulmonary hemorrhage, renal failure
- need high dose steroids
- cyclophsphamide or rituximab
- plasmapheresis for:
- goodpasture’s/anti-GBM disease
- ANCA vasculitis with severe progressive renal disease of severe pulmonary hemorrhage.
What ABC management strategies would you do in Massive hemoptysis
- airway (double lumen tube if bleeding unilateral)
- bleeding side down
- hemodynamics/transfusion (lower priorty than airway)
Involve a respirologist/thoracic surgeon/intensivist quickly
Bronchoscopy (+/- cold saline/epinephrine/Fogarty catheter)
CT
Arteriography (bronchial– would be massive because it’s higher pressure more commonly that pulmonary)
Resection
27 year old male with
fatigue
weight loss
night sweats
hematuria
recent hemoptysis
1 tablespoon several times per day x 3 days
- interpret and give DDX
No pleural effusion because it’s not blunting the costophrenic angle, but there is definite clouding in the bilateral lower lobes.
• Reticular findings
4 KEY causes of massive hemoptysis
- AVM
- lung abscess/mycetoma
- maligancy
- bronchiectasis.
