Sunday, July 9, 2017

Hemoptysis - Causes. Workup And Management



Definition and Pathophysiology
• Expectoration of blood or blood-streaked sputum
• Massive hemoptysis: ~>600 mL/24–48 h; gas exchange more important than blood loss
• Massive hemoptysis usually results from tortuous or invaded bronchial arteries

Etiology

1. Infections/Inflammation:

  • Bronchitis - the most common cause of trivial hemoptysis
  • Bronchiectasis 
  • Cystic fibrosis
  • Tuberculosis
  • Aspergilloma
  • Pneumonia
  • Lung abscess
2. Neoplasms:
  • Usually primary lung cancer
  • sometimes metastases
3. Cardiovascular causes:
  • Pulmonary embolism - can cause massive hemoptysis
  • Pulmonary arterial rupture
  • Congestive heart failure
  • Mitral stenosis
  • Trauma
  • Foreign body
  • Broncovascualr fistula
4. Other causes:
  • Vasculitis (Wegener's Good pasture) 
  • Anticoagulant drug therapy
  • Cocaine
  • Rarely lung endometriosis. 

Diagnostic workup
• Localize bleeding site
Rule out GI or ENT source by exam, history; may require endoscopy
Pulmonary source: determine whether unilateral or bilateral, localized or diffuse, parenchymal or airway by CXR or chest CT, bronchoscopy if necessary
• PT, PTT, CBC to rule out coagulopathy
• Sputum culture/stain for bacteria, fungi and AFB; cytology to r/o malignancy
• ANCA, anti-GBM, urinalysis to ✓ for vasculitis or pulmonary-renal syndrome

Treatment
• Mechanism of death is asphyxiation not exsanguination; maintain gas exchange, reverse coagulation and treat underlying condition; cough suppression . may ↑ risk of asphyxiation
• Massive hemoptysis: put bleeding side dependent; selectively intubate nl lung if needed 

- Angiography: diagnostic as well as therapeutic (vascular occlusion balloons or selective embolization  of bronchial artery) 
- Rigid bronchoscopy: allows more interventional options (electrocautery, laser) than flexible bronchoscopy. 
- Surgical resection




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