Hemoptysis

Question 1

hemopytis

Answer 1

bleeding into the tracheobronchila tree that is subsequently coughed up by the patient.

Question 2

source of bleeding

Answer 2

Source of bleeding may be in the airway, parenchyma, or
vasculature

Question 3

outline a scheme for hemoptysis aproach

Answer 3

Question 4

two sources you sholud exclude to dx hemopytiss

Answer 4

nasopharync or upper GI bleed.

Question 5

5 causes of airway disease that can cause hemopytiss

Answer 5

1. bronchitis
2. bronchiectasis
3. bronchogenic lung cancer
4. other endobronchila tumors
5. fistulas between the airway and a blood vessel

Question 6

causes of parenchymal disease that cuases hemoptysis (PMMD)

Answer 6

1. pneumonia
2. mycobacteiral/TB
3. mycetoma
4. drugs (cocaine)

Question 7

vascular causes of hemoptysis

Answer 7

1. pulmonary emobolism
2. icnrease pulmonary venous pressure
3. vasculitis
4. capillaritis: Goodpasture’s (anti-GBM) mediated
5. pulmonary AVM- atriovenous malformation

Question 8

pulmnary AVM

Answer 8

a shunt where the pulmonary artery stem and the pulmonary vein stem do not anasatome at a capillary bed.

Question 9

4 main components to initial rapid evaluation of hemopytsis

Answer 9

1. ABC
2. hisotyr
3. PE
4. Chest Xray

Question 10

what signs on PE might indicate cause of hemopytiss

Answer 10

1. check vitals– might have low BP and tachy if enough blood loss.
2. respiratory distres
3. focal or diffuse findings on respiratory exam
4. telangiectasia
5. skin rashes
6. inflamed joints
7. splinter hemorrahages (which can indicate endocarditis)
8. clubbing
9. heart murmur/mitral stenosis
10. signs of DVT

Question 11

in addition to chest Xray what labs and investigations should you do

Answer 11

1. chest xray
2. labs: cbc, ccreatinine/urea lytes
   - platelets, INR/PTT Type and screen
   - ANA, ANCA, anti-GBM
   - BNP (heart failure indicator)
3. bronchoscopy
4. CT Scan ( including high resolution CUTS)

Question 12

how does bleeding from pulmonary circulation differ from bleeding from bronchial arteries?

Answer 12

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.

Question 13

risk factors for underlying lung cancer causing the hemoptysis presentation (DAMS)

Answer 13

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

Question 15

 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

Answer 15

 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

Question 16

definition of massive hemoptysis

Answer 16

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

Question 17

T/F it’s important to manage massive hemoptysis promptly because the person will die from blood loss

Answer 17

false.patients with massive hemoptysis die from asphyxiation, not exanguination. Still important to manage promptly though.

Question 18

note: DDX for massive hemoptysis is a bit less than small volume hemoptysis

Question 19

splinter hemorrhages might indicate ____ causes of hemptysis

Answer 19

endocarditis.

Question 20

massive hemoptysis management/investigations

Answer 20

1. assess how rapid the bleeding is:
   - airway (double lumen tube if bleeding unilateral)
   - bleeding side down
   - hemodynamics/transfusion (lower priorty than airway)
2. involve a respirologist/thoracic surgeon/intensivist quickly
3. bronchoscopy +/1 cold saline/epipnehprine/fogarty catheter
4. CT

5/ Arteriography

6. resection of the lung or partial resection.

Question 21

why is a bronchoscopy helpful?

Answer 21

1. helps localize segment the bleeding is coming from.
2. might get lucky and cause of hemoptysis can be seen immediately and you can inject epi or address the tamponade with the bronchoscope itselg

Question 22

what focal chest X ray findings would be seen in someone with vasculitis

Answer 22

might see focal chest XRAY cavitation.

Question 23

investigations into pulmonary renal syndromes; what test would you order and waht are the expected findings/

Answer 23

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.

Question 24

Goodpastr’es syndome is a renal capillaritis invovles the formation of antibodies to the:

• which demographic does it affect?

Answer 24

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.

Question 26

management of pulmonary-renal syndromes presenting with hemoptysis

Answer 26

• 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.

Question 27

What ABC management strategies would you do in Massive hemoptysis

Answer 27

• 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

Question 28

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

Answer 28

No pleural effusion because it’s not blunting the costophrenic angle, but there is definite clouding in the bilateral lower lobes.
• Reticular findings

Question 29

4 KEY causes of massive hemoptysis

Answer 29

1. AVM
2. lung abscess/mycetoma
3. maligancy
4. bronchiectasis.