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 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? HemoptysisHematemesis 1Cough+- 2SputumFrothy Bright red-pink Liquid or clotted Rarely frothy Brown to Black Coffee ground 3Respiratory symptoms+- 4Gastric or Hepatic disease-+ 5Vomitting &Nausea-+ 6Melena-+ 7Lab ParametersAlkaline; 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 GRADEAMOUNT/24HRS Mild ＜ 50ml Moderate50-200ml Severe ＞ 200ml

Sources

E tiology 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 abscess, 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): thrombocytopenia, leukemia, hemophilia Inflammatory or immune disorders: Goodpasture’s syndrome, lupus pneumonitis, and Wegener’s granulomatosis AID: epidemic hemorrhagic fever, leptospirosis Latrogenic, percutaneous or transbronchial lung 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

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 examination B) Investigations : 1. Chest X-ray 2. Sputum examination 3. Chest CT 4. Bronchoscopy 5. Bronchography 6. Cardiac investigations : ECG & echocardiography 7. 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 hemoptysis The patient smoked one pack of cigarettes per day for the past 45 years. He did not use alcohol or other recreational drugs

Physical Exam The patient appeared uncomfortable and in distress Vital signs were notable for a blood pressure of 101/60 mmHg, a heart rate of 113 beats per minute, a respiratory rate of breaths per minute The head and neck exam was notable for the presence of blood in the oropharynx and clear nares The cardiac exam demonstrated tachycardia, a normal S1 and S2, and no murmur, gallop or rub The lungs were notable for the presence of low-pitched rhonchi, right greater than left The 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/mm 3 with a slight left shift present( ) Hematocrit 12% （ 40-50% ） Platelet count was 378,000/mm 3 ( ) BUN 49 mg/dl(9-19.9), serum creatinine was 1.1 mg/dl( ) 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 and the presence of hyaline casts

Chest Radiograph

CT Pulmonary Angiogram Soft Tissue Window Coronal Reconstruction A pulmonary artery aneurysm

Pulmonary Angiogram