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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.