Chapter 034. Cough and Hemoptysis (Part 5) ppt

Chapter 034. Cough and Hemoptysis (Part 5) Approach to the Patient: Hemoptysis The history is extremely valuable. Hemoptysis that is described as blood- streaking of mucopurulent or purulent sputum often suggests bronchitis. Chronic production of sputum with a recent change in quantity or appearance favors an acute exacerbation of chronic bronchitis. Fever or chills accompanying blood- streaked purulent sputum suggests pneumonia, whereas a putrid smell to the sputum raises the possibility of lung abscess. When sputum production has been chronic and copious, the diagnosis of bronchiectasis should be considered. Hemoptysis following the acute onset of pleuritic chest pain and dyspnea is suggestive of pulmonary embolism. A history of previous or coexisting disorders should be sought, such as renal disease (seen with Goodpasture's syndrome or Wegener's granulomatosis), lupus erythematosus (with associated pulmonary hemorrhage from lupus pneumonitis), or a previous malignancy (either recurrent lung cancer or endobronchial metastasis from a nonpulmonary primary tumor) or treatment for malignancy (with recent chemotherapy or a bone marrow transplant). In a patient with AIDS, endobronchial or pulmonary parenchymal Kaposi's sarcoma should be considered. Risk factors for bronchogenic carcinoma, particularly smoking and asbestos exposure, should be sought. Patients should be questioned about previous bleeding disorders, treatment with anticoagulants, or use of drugs that can be associated with thrombocytopenia. The physical examination may also provide helpful clues to the diagnosis. For example, examination of the lungs may demonstrate a pleural friction rub (pulmonary embolism), localized or diffuse crackles (parenchymal bleeding or an underlying parenchymal process associated with bleeding), evidence of airflow obstruction (chronic bronchitis), or prominent rhonchi, with or without wheezing or crackles (bronchiectasis). Cardiac examination may demonstrate findings of pulmonary arterial hypertension, mitral stenosis, or heart failure. Skin and mucosal examination may reveal Kaposi's sarcoma, arteriovenous malformations of Osler-Rendu-Weber disease, or lesions suggestive of systemic lupus erythematosus. Diagnostic evaluation of hemoptysis starts with a chest radiograph (often followed by a CT scan) to look for a mass lesion, findings suggestive of bronchiectasis (Chap. 252), or focal or diffuse parenchymal disease (representing either focal or diffuse bleeding or a focal area of pneumonitis). Additional initial screening evaluation often includes a complete blood count, a coagulation profile, and assessment for renal disease with a urinalysis and measurement of blood urea nitrogen and creatinine levels. When sputum is present, examination by Gram and acid-fast stains (along with the corresponding cultures) is indicated. Fiberoptic bronchoscopy is particularly useful for localizing the site of bleeding and for visualization of endobronchial lesions. When bleeding is massive, rigid bronchoscopy is often preferable to fiberoptic bronchoscopy because of better airway control and greater suction capability. In patients with suspected bronchiectasis, HRCT is the diagnostic procedure of choice. A diagnostic algorithm for evaluation of nonmassive hemoptysis is presented in Fig. 34-2. Figure 34-2 An algorithm for the evaluation of nonmassive hemoptysis. ENT, ear, nose, and throat; GI, gastrointestinal; CT, computed tomography. Hemoptysis: Treatment The rapidity of bleeding and its effect on gas exchange determine the urgency of management. When the bleeding is confined to either blood-streaking of sputum or production of small amounts of pure blood, gas exchange is usually preserved; establishing a diagnosis is the first priority. When hemoptysis is massive, maintaining adequate gas exchange, preventing blood from spilling into unaffected areas of lung, and avoiding asphyxiation are the highest priorities. Keeping the patient at rest and partially suppressing cough may help the bleeding to subside. If the origin of the blood is known and is limited to one lung, the bleeding lung should be placed in the dependent position, so that blood is not aspirated into the unaffected lung. With massive bleeding, the need to control the airway and maintain adequate gas exchange may necessitate endotracheal intubation and mechanical ventilation. In patients in danger of flooding the lung contralateral to the side of hemorrhage despite proper positioning, isolation of the right and left mainstem bronchi from each other can be achieved by selectively intubating the nonbleeding lung (often with bronchoscopic guidance) or by using specially designed double- lumen endotracheal tubes. Another option involves inserting a balloon catheter through a bronchoscope by direct visualization and inflating the balloon to occlude the bronchus leading to the bleeding site. This technique not only prevents aspiration of blood into unaffected areas but also may promote tamponade of the bleeding site and cessation of bleeding. Other available techniques for control of significant bleeding include laser phototherapy, electrocautery, bronchial artery embolization, and surgical resection of the involved area of lung. With bleeding from an endobronchial tumor, argon plasma coagulation or the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser can often achieve at least temporary hemostasis by coagulating the bleeding site. Electrocautery, which uses an electric current for thermal destruction of tissue, can be used similarly for management of bleeding from an endobronchial tumor. Bronchial artery embolization involves an arteriographic procedure in which a vessel proximal to the bleeding site is cannulated, and a material such as Gelfoam is injected to occlude the bleeding vessel. Surgical resection is a therapeutic option either for the emergent therapy of life-threatening hemoptysis that fails to respond to other measures or for the elective but definitive management of localized disease subject to recurrent bleeding. FURTHER READINGS American College of Chest Physicians: Diagnosis and management of cough: ACCP evidence-based clinical practice guidelines. Chest 129:1S, 2006 Gibson PG et al: Eosinophilic bronchitis: Clinical manifestations and implications for treatment. Thorax 57:178, 2002 [PMID: 11828051] Haque RA et al: Chronic idiopathic cough. A discrete clinical entity? Chest 127:1710, 2005 [PMID: 15888850] Irwin RS, Madison JM: The diagnosis and treatment of cough. N Engl J Med 343:1715, 2000 [PMID: 11106722] ———, ———: The persistently troublesome cough. Am J Respir Crit Care Med 165:1469, 2002 Jean-Baptiste E: Clinical assessment and management of massive hemoptysis. Crit Care Med 28:1642, 2000 [PMID: 10834728] Khalil A et al: Role of MDCT in identification of the bleeding site and the vessels causing hemoptysis. AJR Am J Roentgenol 188:W117, 2007 . Chapter 034. Cough and Hemoptysis (Part 5) Approach to the Patient: Hemoptysis The history is extremely valuable. Hemoptysis that is described as blood- streaking. coagulation profile, and assessment for renal disease with a urinalysis and measurement of blood urea nitrogen and creatinine levels. When sputum is present, examination by Gram and acid-fast stains. hemoptysis is presented in Fig. 34-2. Figure 34-2 An algorithm for the evaluation of nonmassive hemoptysis. ENT, ear, nose, and throat; GI, gastrointestinal; CT, computed tomography. Hemoptysis: