HEMOPTYSIS by Prof. Arvind Mishra M.D. Department of medicine.
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Transcript of HEMOPTYSIS by Prof. Arvind Mishra M.D. Department of medicine.
What is Hemoptysis
• Expectoration of blood from respiratory tract (from streaking to massive amount)
Massive Hemoptysis
• Expectoration of >100-600ml over a 24hr period
• Acute life threatening condition.• Blood can fill the airways and the alveolar
spaces.• Seriously disturbing gas exchange and may
lead to asphyxia.
Establish Hemoptysis
• Should be differentiated from hemetemesis.• Fresh blood and froth on coughing.• Altered blood ( brown) with food particles in
vomit.• Associated features.• Dilemma
Once established, evaluate etiology
A. Bleeding from tracheobronchial tree• Neoplasms- Bronchogenic CA• Bronchitis – Acute/ Chronic• Bronchiectesis• Airways trauma• Foreign Body
B. Pulmonary Parenchymal Diseases• Tuberculosis• Lung Abscess• Pneumonia• Wegner’s Granulomatosis• Good Pasture’s Syndrome
Approach
HISTORY• Blood streaking with mucopurelent sputum -- Bronchitis • Fever with chills+ Blood with rusty sputum – Pneumonia• Blood + putrid sputum - Lung abscess• Blood + copious sputum - Bronchiectesis• Hemoptysis following acute onset of pleuritic Chest pain with dyspnoea – Pulm.Embolism
H/O coexisting Disorders
• Renal disease-Good Pasture’s Syndrome Wegner’s Granulomatosis• Lupus Eyrthematosus-Lupus Pneumonia• Non pulmonary malignancy-Endobronchial metastasis• AIDS-Kaposi’s Sarcoma• Risk factors for Bronchogenic CA-Smoking Asbestosis
Also ask for• previous bleeding disorders• treatment with anticoagulants• use of drugs leading to thrombocytopenia
PHYSICAL EXAM.
• Pleural friction rub-Pulmonary Embolism• Localised/Diffuse crepts-Parenchymal dis.• Evidence of airflow obstr.-Chr.Bronchitis• Ronchi +Crackles-Bronchiectesis• CVS-Pulm.Hpt., Mitral stenosis, LVF
Diagnostic Evaluation
• Chest radiograph/CT Scan-- mass lesion, bronchiectatic Changes, focal areas of pneumonitis.
• CBC• Coagulation profile• Assessment of renal profile– urine
analysis,Blood urea,S.Creatinine• Sputum– Gm. Staining, C/S
• Fibreoptic bronchoscopy– useful for localising the siteof bleeding and for visualisation of endobronchial lesions.
• Rigid bronchoscopy– preferred when bleeding is massive because this procedure has better airways control and greater suction capability.
Treatment
What determines the urgency of management -Rapidity of bleeding -Effect on gas exchange(A) If streaking or small amount of blood-Diagnosis is priority.(B) If massive—Mx. Is top priority
• Maintaining adequate gas exchange.• Preventing blood spilling into unaffected areas
of the lung. Keep the affected lung in the dependent position to avoid aspiration of blood into the unaffected lung.
• Avoid asphyxiation• Keep patient at rest/provide codeine containing
cough suppressants- may help to stop bleeding.
Management of massive bleeding
• May necessitate - Endobronchial intubation - Mechanical ventilationto control airways and maintain adequate gas exchange.• To avoid blood spilling into contralateral lung (1)Selective intubation of non bleeding lung (2)Use of specially designed double lumen endotracheal tubes.
• Another option- Inserting a ballon catheter through a bronchoscope under direct vision and inflating the ballon to occlude the branches leading to bleeding site.
Other techniques
• Laser Phototherapy• Electrocautery• Bronchial artery embolism• Surgical resection
• Bronchial artery embolisation-it involves an arteriographic procedure in which a vessel proximal to bleeding site is cannulated and a material such as Gelfoam is injected to occlude the bleeding vessel.
• Surgical resection of involved area of the lung—(a) Emergency therapy of life threatening hemoptysis that fails to respond to other measures.
• (b) For the elective but definitive management of localised disease subject to recurrent bleeding.
MCQs
1)Hemoptysis in mitral stenosis occurs due to-a)Left atrial enlargementb)Right ventricular hypertrophyc)Bronchial arterial bleedd)Pulmonary venous congestion
2)A chronic smoker patient presenting with superior vena caval syndrome with hemoptysis.Most likely cause is-a)Intrathoracic tubercular lymphadenitisb)Bronchogenic CAc)Lymphomad)Aortic arch syndrome
3)A patient presenting with high fever ,chest pain and hemoptysis. CXR –Air bronchogram sign present-a)Lobar pneumoniab)Lung abscessc)Bronchiectasisd)Bronchogenic CA