hemoptysis_case presentation and discussion

8/14/2019 Hemoptysis_case presentation and discussion

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An Interactive: Case PresentationHemoptysis

Night Float teamDanish Ejaz Bhatti

Khouroush Hudsony

Lalit Kalra


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Brain Storming

Differential Diagnosis Tracheo-bronchial source

Pulmonary Parenchymal source

Primary Vascular Source Source other than lower respiratory tract

Rare Causes


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Presenting Complaint

A 76 year old lady presented to ER with an

episode of massive hemoptysis.

(massive >2ooml in a day)


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Brain Storming

Is it hemoptysis or hematemesis ?

How to differentiate!!!


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Past Medical History

Diabetes Mellitus Type II

Since 1984

Used Insulin for 10 years later on started on pills

Not taking medications for about 1 year Home Blood sugar is around 120

Hypertension

Since 5 years

Takes lisinopril


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History of Present Illness

Loosing weight

Started around a year back

More noticeable since 4-5 months (skin going loose)

48 lbs in 2-3 months (was 165 lbs few months back and now

117 lbs when last weighed)

Pain in Right Shoulder

Started 4-5 months back

Is relieved by keeping her arm up under her head as pillow

Was consulting at Howard university and was told it is probably

arthritits

Had some imaging done but unaware of the results


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Blood in sputum

Had a cough since 4-5 months

Noticed few streaks of blood initially (first time around 4

months back)

Scant blood, infrequently, last time was one month back

This morning had hemoptysis, around one cup-full in amount,

came with cough, with no chest pain, fresh and clotted blood

No asphyxiation, no nausea/vomitting

Spitting up blood frequently in small amount since then. Other complaints

Has been constipated for around one month

Some complaints of swelling of lips a few times especially in the

morning


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Review of Systems Pertinent Negative

No history of fever, rigors, chills

No complaints of being dizzy on standing up

No complaints of hoarseness of voice (my voice has always

been a bit heavy)

No complaints of epi-gastric pain, water brash or acid brash inmouth

She is post menopausal since age of 33yrs

No history of anticoagulant use.

No complaints of PND, chest pain, heart disease No history of chronic lung disease, copious purulent sputum

No history of travel

Never been tested for HIV, no risk factors of HIV

Never had a TB skin test


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Operations:

Hysterectomyat the age of 33 yrs for fibroids

Para-umbilical hernia repair around 1979

Preventive Health:

Immunization: had them last year, not sure about this year

Mammography: 5 years ago Colonoscopy: 5 years ago

Home medications:

Lipitor20 mg PO Q Day

Lisinopril 20 mg PO Q Day

Naproxen 375 mg PO Q Day


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Family History:

Mother alive, have some heart problems

Father alive, has DM

Brother alive, has arthritis

Social History:

Lives by herself and can take care of herself

Alcohol: drinks once a week and last use was 4 days ago

Smoking: Current smoker, >20 pack-years smoking


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Brain Storming

Diagnostic Clues in History !!!


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Physical Examination Vital Signs

Pulse: 122/min B.P: 128/92 R.R: 22/min Temp: 97.3 O2 Sat:

98% on RA

General

AAO x 3, emaciated looking with loose skin, puffy looking face

HEENT

PERRLA, EOMI, Nasal septum normal, Normal Gingiva

Neck

Supple, JVP not elevated but distended superficial veins, Nolymphadenopathy in neck

Lungs

Decreased excursion with slight dullness to percussion in right

upper chest

Bronchial breathing in Right upper lobe with occasional crept


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Physical Examination

Breast:

No palpable nodules, No axillary lymphadenopathy

Heart:

S1 + S2 , some irregular beats occasionally, No rales, murmur

or gallop

Abdomen:

Mid-line scar, soft, NT, No visceromegaly, BS +ive

Extremities:

No clubbing, No peripheral edema, Pulses palpable,

Neurologic:

Power 5/5 in all limbs, Sensations intact. CN II-XII intact

Rectal:

Guaiac -ive normal s hincter tone no stool al able in rectal


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Brain Storming

Diagnostic Clues on Physical Examination !!!


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Brain Storming

Next Best Step in Management !!!


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Admission Studies

Hematology:

WBC: 6.1

HGB: 10.4

HCT: 31.5

PLAT: 415

MCV: 79

MCH: 26

RDW: 15.6 MPV: 8.0

GRAN AUTO: 60.6

LYMPHOS AUTO: 21.2

MONO AUTO: 10.2

PT: 13.3

INR: 1.1

PTT: 27


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Admission Studies

Chemistry:

Ca+: 9.6

Na+: 141

K+: 4.2

CL-: 107

HCO3: 26

BUN: 19

Cr: 1.2 Glu: 84

A.G: 8

LFT's:

Alb: 3.8

Tot. Pr: 7.2

Bili D: 0.04

Bili T: 0.2

AST: 14

ALT: 6

Alk Phos: 119


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Admission Studies

Cardiac Enzymes:

CK/MB 3.2

CPK: 63

Trop T:


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Brain Storming

Diagnostic Clues in Laboratory Tests !!!


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Admission EKG

Sinus Rhythm with premature atrial complexes

T wave abnormality, consider lateral ischemia


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Brain Storming

Diagnostic Clues in Chest Xray!!!


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Chest X Ray

A large homogenous right hilar mass with atelectasis of theanterior segment of the right upper lobe.

Hilar mass measured more than 4 cm in size with

consolidation of the right upper lobe.


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Chest CT Scan with contrast

Large mass in the right lung apex extending to the right

hilum, 11 cm in craniocaudal dimension, 6.5 x 5 cm inaxial dimension consistent with the large malignancy.

Superior vena cava is compressed but not obstructed.

Moderate elevation of right diaphragm may be due to right

phrenic nerve compression by the mass.

Bilateral old rib fractures.


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Treatment Goals in Hemoptysis Management

1.Aspiration Prevention

2.Bleeding Cessation

3.Treating Underlying Cause


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Non Massive Hemoptysis

The most common presentation is mild hemoptysis in

Acute Bronchitis.In low risk patients (


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Massive Hemoptysis

Mortality less than 9% with blood loss less than1000ml/24 hours but rises to 59% if more blood loss,with causes other than Lung CA.

Mortality for Cancer associated bleeding is 59% butrises to 80% with blood loss more than1000ml/24hours.

Necrotizing pneumonitis, lung abcess, bronchiectasishas less than 1% mortality and can be managedconservatively.

i f i i


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Interventions for Massive Hemoptysis

Bronchoscopy rigid vs flexible Double lumen endo-bronchial intubation

Endo-bronchial tamponade

Bronchial artery embolization Surgery (lobectomy vs pneumectomy)

B h


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Bronchoscopy

Rigid Bronchoscopy Better airway patency

Greater suctioning

Needs to be done in OR with general anesthesia

Only visualize major airways Flexible Bronchoscopy

Can be used in ER

Visualize upto 5th or 6th bronchial division

Instillation of Epinephrine

After bleeding localization

1:20,000 solution into bronchial tree

Variable success depending on bleeding severity

D bl l E d b hi l I t b ti


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Double lumen Endo-bronchial Intubation

Allows proper ventilation ofnon bleeding lung whilesuctioning bleeding lung (astemporary measure)

Flexible bronchoscopy can

still be performed via lumen Main disadvantage is tube

misplacement (upto 50 %)

Flexible bronchoscopy canbe performed to look fortube placement

Alternative is to place singlelumen endo-bronchial tubedeep down into right or leftmain stem bronchus

E d b hi l t d


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Endo-bronchial tamponade

To occlude bleedingbronchus by using a ballooncatheter.

Foleys catheter (14 Fr) aretoo big and will not protect

normal segments frombleeding segments.

Fogarthy Catheter (4 Fr) is abetter option, however hasa proximal balloon that

needs to be removed. Freitage Catheter, similar to

Fogarthy but withoutproximal balloon.

Bronchial arter emboli ation


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Bronchial artery embolization

Should only beperformed in ICU

Selectiveangiographic study ofbronchial arteries

Polyvinyl alcoholfoam, absorbablegelatin, pledgets ofGianturco steel coils


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Abstract


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Abstract

Six patients with hemoptysis were treated by

endobronchial sealing, with n-butyl cyanoacrylate, of thebleeding segment or subsegment. There was animmediate arrest of bleeding without any recurrence for a

mean follow-up period of 127 ( 67.17) days.Endobronchial sealing appears to be an effective method

of managing hemoptysis.

Discussion


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Discussion

Hemoptysis poses serious problems, especially when theconservative treatment fails.

Cold saline lavage with 50-mL aliquots of iced saline at 4C(total of 500 mL) showed good results when instilled througha rigid bronchoscope in 23 patients; recurrence of

hemoptysis was observed in two cases. Wedging of the bleeding segmentwith the flexible

bronchoscope tip is effective in controlling bleeding aftertransbronchial lung biopsy. Local administration ofadrenaline solution (1:20,000), thrombin , and fibrinogen-

thrombin have been attempted in a small number of cases. The ND-Yag laserused bronchoscopically can effectively

stop bleeding from endobronchial pathology and can alsoallow more definite therapy at the same sitting.

Balloon tamponading of the bleeding bronchial segment

is also helpful, with variable success rates.

Discussion


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Discussion

Bronchial artery embolization effectively stops bleedingfrom a bronchial arterial source, although failures andcomplications occur. There is also occasional difficulty

cannulating the vessel,

vessel perforation, intimal tears, and

inadvertent ectopic embolism

Surgeryis currently recommended when

Bronchial artery embolization not available or technicallyimpossible or unsuccessful;

when the bleeding is so massive that any delay inarranging the embolization is very risky;

when the underlying cause is unlikely to be controlled byembolization, as in a case of suspected rupture of

pulmonary artery or a mycetoma with profuse collateral

Discussion


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Discussion

We have adopted sealing of the bleeding segment orsubsegment with n-butyl cyanoacrylate.

It is a biocompatible adhesive that solidifies quickly onexposure to humidity with antibacterial effects.

Cyanoacrylate glues are already in use. They have beenused to prevent postoperative air leak from the bronchialstamp after lung resectional surgery.

The cyanoacrylate glues have prothrombotic propertiessuch as increased platelet aggregation and possibleenhancement of local thromboxane production.

Although cyanoacrylates are significantly safe, they arevolatile and chemically active materials reported to causeeczema, rhinitis, and asthma in occupational exposure.Occupational contact dermatitis has also been reported.

Conclusion


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Conclusion

In using cyanoacrylate for endobronchial sealing forhemoptysis, we have not found any significant side

effects. Moreover, the glue is expectorated graduallyover the next few days. In conclusion, it appears thatendobronchial sealing with n-butyl cyanoacrylate glue

is a simple, less invasive, and safe procedure to

control hemoptysis.

hemoptysis_case presentation and discussion

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