Hemoptysis 3 (1).....................pptx

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1. APPROACH TO HEMOPTYSIS HISTORY AND CLINICAL EXAMINATION. 6/27/2017 1 Nikhil Panjiyar Roll:13,IIIrd year Aug 2014 th batch

2. hemoptysis H emoptysis is the expectoration of blood or bloody sputum from the lungs or tracheobronchial tree . Expectoration of 200 ml of blood in a single episode suggests severe bleeding expectoration of 400 ml in 3 hours or more than 600 ml in 16 hours signals a life-threatening crisis . Hemoptysis can range from blood-tinged sputum to life-threatening large volumes of bright red blood. 6/27/2017 2

3. CAUSES Usually results from chronic bronchitis, lung cancer, or bronchiectasis. It may also result from inflammat o ry, infectious, cardiovascular , or coagulation disorders and, rarely, from a ruptured aortic aneurysm. 6/27/2017 3 The most common causes of massive hemoptysis are lung cancer, bronchiectasis, active tuberculosis, and cavitary pulmonary disease from necrotic infections or tuberculosis . In up to 15% of patients , the cause is unknown.

4. History and physical examination. 6/27/2017 4

5. Hemoptysis is first differentiated from other common source of bleeding including upper respiratory tract and g astrointestinal tract. 6/27/2017 5

6. History and physical examination Begins with an assessment of vitals signs and oxygen saturation. Specific focus on respiratory and cardiac examinations are important . 6/27/2017 6

7. Inspection Inspect nares,mouth and pharynx for the source of bleeding.(specific attention is given as they are the potential source of bleeding.) Inspect the configuration of chest and look for abnormal movement during breathing, use of accessory muscles, and retractions . Observe respiratory rate , depth, and rhythm . Finally, examine skin for lesions. 6/27/2017 7

8. palpation P alpate the patient's chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations. Also look for masses and lymph nodes. 6/27/2017 8

9. percussion 6/27/2017 9

10. auscultation 6/27/2017 10

11. investigations Sputum smear and culture. Standard chest radiograph (plain x-ray). Computed tomography. Bronchoscopy. Complete blood count. Coagulation studies. Pulmonary arteriography. Lung biopsy. Renal function and urinanalysis . 6/27/2017 11

12. Differential diagnosis Aortic aneurysm (ruptured): Lead to sudden death Bronchial adenoma : Causes recurrent hemoptysis along with chronic cough and local wheezing. Bronchiectasis : Vary from blood-tinged sputum to blood.Typically present with chronic cough producing copious amount of foul smelling sputum. may also exhibit coarse crackles, clubbing (a late sign ),fever , weight loss, fatigue, weakness, malaise, and dyspnea on exertion. 6/27/2017 12

13. Bronchitis (chronic): Typically present with a productive cough that lasts at least 3 months including dyspnea, prolonged expirations , wheezing, scattered rhonchi, accessory muscle use, barrel chest , tachypnea, and clubbing. Coagulation D isorders : Thrombocytopenia and Disseminated intravascular coagulation can cause hemoptysis, multisystem hemorrhage and purpuric lesions . Laryngeal cancer: H oarness is usually the initial sign and other finding related are dysphagia, dyspnea, stridor, cervical lymphadenopathy , and neck pain. 6/27/2017 13

14. Lung abscess : P roduces blood-streaked sputum resulting from bronchial ulceration, necrosis, and granulation tissue . Common associated findings include a cough producing large amounts of purulent, foul-smelling sputum ; fever with chills; diaphoresis; anorexia; weight loss; headache; weakness; dyspnea ; pleuritic or dull chest pain; and clubbing . Auscultation reveals tubular or cavernous breath sounds and crackles. Percussion reveals dullness on the affected side. 6/27/2017 14

15. Lung cancer :Related findings include a productive cough, dyspnea, fever, anorexia, weight loss, wheezing, and chest pain. Plague: Pneumonic form of this acute bacterial infection, caused by Yersinia pestis , can produce hemoptysis, a productive cough, chest pain, tachypnea, dyspnea, increasing respiratory distress, and cardiopulmonary insufficiency. Pulmonary hypertension (primary): Hemoptysis, exertional dyspnea, and fatigue generally develop late in this disorder.Other findings include arrhythmias , syncope, cough, and hoarseness. 6/27/2017 15

16. Pneumonia: K lebsilla pneumonia- dark brown or red(currant jelly) sputum, begins abruptly with chills, fever, dyspnea, a productive cough, and severe pleuritic chest pain associated with cyanosis,prostration,tachycardia,decreased breath sounds & crackles. Pneumococcal pneumonia-pinkish or mucoid rusty sputum, It begins with sudden shaking chills; a rapidly rising temperature; and, in over 80% of patients, tachycardia and tachypnea with severe stabbing chest pain. Pulmonary arteriovenous fistula : Occurs in young adults with red ruby patches in face,tongue,skin,mucous membrane and lips. 6/27/2017 16

17. Pulmonary tuberculosis : C hronic productive cough, fine crackles after coughing, dyspnea, dullness on percussion, increased tactile fremitus and,possibly , amphoric breath sounds. The patient may also develop night sweats, malaise,fatigue , fever, anorexia , weight loss, and pleuritic chest pain . Tracheal trauma : Torn tracheal mucosa may cause hemoptysis, hoarseness,dysphagia , neck pain, airway occlusion, and respiratory distress . Silicosis : This chronic disorder causes a productive cough with mucopurulent sputum that later becomes blood streaked. 6/27/2017 17

18. Other causes Pulmonary embolism with infarction Pulmonary edema Systemic lupus erythomatosus Wegener’s granulomatosis 6/27/2017 18

19. Pediatric pointers M ay stem from Goodpasture's syndrome, cystic fibrosis, or (rarely ) idiopathic primary pulmonary hemosiderosis . N o cause can be found for pulmonary hemorrhage occurring within the first 2 weeks of life 6/27/2017 19

20. Geriatric pointers Anticoagulants may be the reason for bleeding. 6/27/2017 20

21. TRUE HEMOPTYSIS SPURIOUS(FALSE)HEMOPTYSIS Below vocal cords. Above vocal cords. Persist as blood tinged sputum. Doesn’t persist. May be mixed with sputum. Not mixed with sputum. History of cardiopulmonary disease. Obvious by ENT examination. CXR may be abnormal. Normal CXR. 6/27/2017 21

22. Factitious hemoptysis If no etiology is discernible after a thorough evaluation,especially when the medical history of the patients behavior is unusual 6/27/2017 22