Case Answers:

Case answers will be presented after review of the HPI.

Answer 1

• Amount of blood being coughed up
• Color of blood being coughed up, presence of clots
• Sensations felt when producing blood
• Antecedent cold or fevers/chills
• Weight loss
• Smoking History (quantify pack years)
• Medications: specifically blood thinners
• Previous history of lung problems/chronic sputum production/chronic cough, hx pulmonary embolism
• History of trauma to chest
• Associated chest pain or dyspnea
• Travel
• Occupation/hobbies
• History of epistaxis/bleeding gums/black stools/bloody stools
• History of hypercoaguble disorders (e.g. SLE)
• ETOH history (varices, ulcers)
• Family history or exposure to TB

Answer 2

• Morning productive cough.
• Patients with chronic cough (secondary to chronic bronchitis or simple smoker’s cough) may occasionally experience hemoptysis in the form of blood streaked sputum, particularly after periods of increased coughing or more intense coughing.
• Has there been a change?
• 54% dissipate within one month of smoking cessation.

Answer 3

• ABCs: airway, breathing, circulation--blood pressure, respiratory rate, oxygen saturation
• Lung exam: focal wheezes or rhonchi, crackles, consolidation…? Pneumonia, endobronchial tumor obstruction
• Cardiac exam: murmur of mitral stenosis
• Extremities: clubbing/cyanosis…….? Lung cancer or bronchiectasis or lung abscess
• Skin: evidence of telangiectasias…………? Pulmonary AVM’s
• HEENT: source of nasopharyngeal bleeding…….? Sinus source
• Abdomen: epigastric discomfort, stool for occult blood….? GI source

Answer 4

• Bronchitis
• Bronchogenic carcinoma
• Bronchiectasis
• Tuberculosis

Answer 5
Necessary Virtually Always:

• Chest radiograph, PA and lateral
• CBC with platelets
• coagulation profile
• Sputum examination for bacterial culture, AFB smear and culture, cytology
• PPD

Frequently, but Not Always, Indicated:

• Arterial blood gas…..if respiratory distress or borderline pulse oximetry
• Type and cross for red blood cells……if massive or planned surgery
• Consider V/Q scan or Helical CT…….if high suspicion for PE

Answer 6
Non-diagnostic at this time. Consistent with underlying emphysema and perhaps superimposed infection (including pneumonia, TB or focal bronchiectasis), but conceivably the infiltrate is secondary to tumor or pulmonary embolism.

Answer 7
CXR findings suggestive of emphysema would include hyperinflation, an increased A-P diameter, an increased retrusternal airspace, flattened diaphragms, blebs, and decreased vascular markings in the periphery.

Answer 8

• Pneumonia
• Bronchogenic carcinoma
• Tuberculosis
• Less likely includes focal bronchiectasis and/or pulmonary embolism

Answer 9

• Consider admission to the hospital for observation.Whether to hospitalize a given patient depends upon a number of factors including the quantity of hemoptysis, associated comorbidities, and the patient’s home support
• Treat with antibiotics for bronchitis vs. Pneumonia
• Consider a CT scan to further characterize, as well as isolate the location of, the CXR lesion
• Bronchoscopy to hopefully rule out cancer and perhaps obtain better samples for ruling out TB

Answer 10

• Massive hemoptysis
• Hemodynamic instability
• Hypoxemia

Answer 11
Lots of alveolar macrophages (compared to squamous epithelial cells) suggest the sputum was obtained from the lower airways rather than simply being spit.

  Answer 12

• Consider positional changes….by placing the "bad side down", one might reduce further soiling of other lung units. However, placing the "bad side up" may help reduce shunting of blood through the already blood filled alveolar units and thereby improve oxygenation.
• Judicious cough suppression with narcotics.
• Minimize procedures which may induce coughing.
• Correct any potential coagulopathy.
• Equipment for intubation should be readily available if the quantity of hemoptysis is significant.

Answer 13

• Suspicion of tuberculosis
• Negative AFB smears (usually three consecutive am specimens)

Answer 14

• Massive hemoptysis: rigid
• Less than massive hemoptysis: fiberoptic
• However, flexible fiberoptic bronchoscopy may be attempted first, even in massive hemoptysis, if it is readily available with the hope that it may quickly identify the source of bleeding and perhaps allow "tamponade" of the bleeding area by inserting the bronchoscope into the bleeding segment.

Answer 15
Variably defined as greater than (a) 100 cc per 24 hours, (b) 300 cc per 24 hours, or © life-threatening hemoptysis regardless of its quantity.

Answer 16
The lungs have a dual blood supply, both from pulmonary arteries and bronchial arteries. Most hemoptysis originates from bronchial sources.

Answer 17
The patient must be evaluated for the extent of disease (typically with a CT scan to look for lymphadenopathy, other unsuspected lesions, and adrenal involvement) as well as for pulmonary function (to assess ability to undergo potential curative surgery).

Answer 18
In general, patients must have a predicted post-operative FEV1 of greater than 800 cc. Given the FEV1 of 1.2 liters, one might predict a post-operative FEV1 of 0.6 liters if a pneumonectomy were performed vs approximately 960 cc if one lobe (or 20 % of total lung) were removed. Occasionally, quantitative perfusion scanning is performed to better quantitate the functional capacity of the area of lung which are planned on being removed to more precisely predict the post-operative pulmonary reserve.

Answer 19
Occasionally, embolectomy of the bleeding vessels can be performed by radiology.