Chapter 034. Cough and Hemoptysis (Part 5)

Approach to the Patient: Hemoptysis The history is extremely valuable. Hemoptysis that is described as bloodstreaking 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 bloodstreaked 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. ...
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Chapter 034. Cough and Hemoptysis (Part 5) 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. Chronicproduction of sputum with a recent change in quantity or appearance favors anacute exacerbation of chronic bronchitis. Fever or chills accompanying blood-streaked purulent sputum suggests pneumonia, whereas a putrid smell to thesputum raises the possibility of lung abscess. When sputum production has beenchronic and copious, the diagnosis of bronchiectasis should be considered.Hemoptysis following the acute onset of pleuritic chest pain and dyspnea issuggestive of pulmonary embolism. A history of previous or coexisting disorders should be sought, such asrenal disease (seen with Goodpastures syndrome or Wegeners granulomatosis),lupus erythematosus (with associated pulmonary hemorrhage from lupuspneumonitis), or a previous malignancy (either recurrent lung cancer orendobronchial metastasis from a nonpulmonary primary tumor) or treatment formalignancy (with recent chemotherapy or a bone marrow transplant). In a patientwith AIDS, endobronchial or pulmonary parenchymal Kaposis sarcoma should beconsidered. Risk factors for bronchogenic carcinoma, particularly smoking andasbestos exposure, should be sought. Patients should be questioned about previousbleeding disorders, treatment with anticoagulants, or use of drugs that can beassociated 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 anunderlying parenchymal process associated with bleeding), evidence of airflowobstruction (chronic bronchitis), or prominent rhonchi, with or without wheezingor crackles (bronchiectasis). Cardiac examination may demonstrate findings ofpulmonary arterial hypertension, mitral stenosis, or heart failure. Skin andmucosal examination may reveal Kaposis sarcoma, arteriovenous malformationsof Osler-Rendu-Weber disease, or lesions suggestive of systemic lupuserythematosus. Diagnostic evaluation of hemoptysis starts with a chest radiograph (oftenfollowed by a CT scan) to look for a mass lesion, findings suggestive ofbronchiectasis (Chap. 252), or focal or diffuse parenchymal disease (representingeither focal or diffuse bleeding or a focal area of pneumonitis). Additional initialscreening evaluation often includes a complete blood count, a coagulation profile,and assessment for renal disease with a urinalysis and measurement of blood ureanitrogen and creatinine levels. When sputum is present, examination by Gram andacid-fast stains (along with the corresponding cultures) is indicated. Fiberoptic bronchoscopy is particularly useful for localizing the site ofbleeding and for visualization of endobronchial lesions. When bleeding ismassive, rigid bronchoscopy is often preferable to fiberoptic bronchoscopybecause of better airway control and greater suction capability. In patients withsuspected bronchiectasis, HRCT is the diagnostic procedure of choice. A diagnostic algorithm for evaluation of nonmassive hemoptysis ispresented 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 theurgency of management. When the bleeding is confined to either blood-streakingof sputum or production of small amounts of pure blood, gas exchange is usuallypreserved; establishing a diagnosis is the first priority. When hemoptysis ismassive, maintaining adequate gas exchange, preventing blood from spilling intounaffected areas of lung, and avoiding asphyxiation are the highest priorities.Keeping the patient at rest and partially suppressing cough may help the bleedingto subside. If the origin of the blood is known and is limited to one lung, thebleeding lung should be placed in the dependent position, so that blood is notaspirated into the unaffected lung. With massive bleeding, the need to control the airway and maintainadequate gas exchange may necessitate endotracheal intubation and mechanicalventilation. In patients in danger of flooding the lung contralateral to the side ofhemorrhage despite proper positioning, isolation of the right and left mainstembronchi from each other can be achieved by selectively intubating the nonbleedinglung (often with bronchoscopic guidance) or by using specially ...