STUDY - Technical - New Dacian's Medicine
Cough
and Hemoptysis (2)
Translation Draft
Hemoptysis is defined as the expectoration of blood from the respiratory tract, ranging from bloody striations in the sputum to the coughing elimination of a large amount of blood (100 ml in 24 hours). Massive hemoptysis can be a life-threatening problem. Large amounts of blood can fill the airways and alveolar spaces, seriously disturbing gas exchanges and at the same time being a potential cause of suffocation. Waiting for even a small amount of blood is an alarming symptom, which is why sometimes we can't rely on the patient's quantitative assessment. Hemoptysis may be a sign of a potentially serious disease such as bronchial carcinoma.
Let's go to a few presentations on etiology! Since, most commonly, blood originating in the nasopharynx or gastrointestinal tract can be confused with that from the lower respiratory tract, it is important to check first whether the source of bleeding does not originate from here (nasopharynx or digestive tract).
Indications of gastrointestinal origin are the dark red color and the acidic pH of the blood, in contrast to the typical light red appearance and alkaline pH of true hemoptysis. The bronchial arteries, which belong to the high-pressure systemic circulation, originate either in the aorta or in the intercostal arteries and are the source of bleeding from bronchitis and bronchiectasis, as well as in the case of endobronsic tumors.
An etiological classification of hemoptysis can be done depending on the place of origin of the lung. The airways most commonly bleed, i.e. the tracheobronsic shaft, which may be affected by inflammation (acute or chronic bronchitis, bronchectasis) or neoplasm (bronchial carcinoma, metastatic endobronsic carcinoma or bronchial carcinoid tumor).
Blood from the pulmonary parenchyma may originate either in a localized source, such as an infection (pneumonia, pulmonary abscess, tuberculosis), or in a diffuse process affecting all parenchyma (coagulopathy or autoimmune process, such as Goodpasture syndrome).
Disorders primarily affecting pulmonary vascularization include pulmonary embolic disease and those conditions associated with high capillary and venous pulmonary pressures, such as mitral stenosis or left ventricular insufficiency. Although the relative frequency of different etiologies of hemoptysis varies from one study group to another, more recent studies indicate that bronchitis and bronchial carcinoma are the most common causes.
Despite the decrease in the frequency of tuberculosis and bronchiectasis in recent study groups compared to the older ones, these two diseases still represent the most common causes of massive hemoptysis in some groups. Even after thorough investigations, a quantifiable proportion of patients (up to 30% in some groups) does not have a clear etiology of hemoptysis.
These patients are said to have idiopathic or cryptogenic hemoptysis and probably responsible for this bleeding is parechimatous or airway suffering at the early stage.
From the point of view of differential diagnosis is noted: 1. sources other than the lower respiratory tract (bleeding from the upper airways - nasopharynx - and gastrointestinal bleeding), 2. tracheobronsic source (neoplasm - bronchial carcinoma, endobronsic metastatic tumors, bronchial carcinoid -, bronchitis - acute or chronic -, bronchectasis, broncholithiasis, airway trauma, foreign body), 3. parenchymatous pulmonary source (pulmonary abscess, pneumonia, tuberculosis, mycetom - "fungal ball" -, Goodpasture syndrome, idiopathic pulmonary hemosiderosis, Wegener granulomatosis, lupus pneumonitis, pulmonary contusion), 4. primary vascular disease (arteriovenous malformations, pulmonary embolism, increased pulmonary venous pressure - especially mitral stenosis -) and 5. causes (pulmonary endometriosis, systemic coagulopathy or the use of anticoagulants).
From the point of view of the patient's approach, anamnesis is very valuable. Hemoptysis described as bloody streaks in purulent or mucopurulent sputum frequently suggests bronchitis. Chronic removal of sputum with a recent change in quantity or appearance indicates an acute chronic bronchitis. Fever or chills accompanying the removal of purulent sputum with blood striations suggest pneumonia, while a putrid smell of sputum indicates a possible pulmonary abscess.
When the removal of sputum was chronic and large quantitative, the diagnosis of bronchectasis should be taken into account, although the lack of chronic expectoration does not necessarily exclude it (it is about so-called dry bronchitis). Hemoptysis following the acute installation of pleuritic chest pain and dyspnea is suggestive for pulmonary embolism.
Past or coexisting conditions, such as renal distress (found in Goodpasture syndrome or Wegener granulomatosis), lupus erythematosus (with associated pulmonary haemorrhage due to lupus pneumonitis) or a previous neoplastic process (recurrent lung cancer or endobronchial metastases of a nonpulmonary primary tumor) should be sought. In a patient with AIDS, endobronsic or pulmonary parenchymatos sarcoma should be considered.
The existence of risk factors for bronchial carcinoma, in particular smoking and asbestos exposure, should also be investigated. Patients should be questioned about previous bleeding, ongoing anticoagulant treatment or the use of medicines that may induce thrombocytopenia.
Physical examination can also provide useful clues for diagnosis. For example, pulmonary auscultation may highlight pulmonary friction (in pulmonary embolism), localized or diffuse rals (parenchymatous bleeding or background parenchymatos process associated with bleeding), obstruction of the airways (chronic bronchitis) or ronhus, whether or not accompanied by wheezing and rals (in bronchitis).
Pulmonary arterial hypertension, mitral stenosis or heart failure may be discovered when examining the cardiovascular system. Kaposi sarcoma, arteriovenous malformations in Osler-Rendu-Weber disease or lesions suggestive of systemic lupus erythematosus can be discovered upon examination of the skin.
Diagnostic evaluation of hemoptysis begins with chest X-ray which may reveal the presence of tumor lesions, signs suggestive of bronchectasis (representing either a focal or diffuse bleeding or a focal area of pneumonia).
Additional initial diagnostic assessment includes both haemogram, clotting times, and assessment of renal function with urine analysis and measurement of urea and creatinine levels in the blood. When sputum is present, Gram and acid-alcohol-resistant bacilli (as well as corresponding cultures) are indicated.
Fibrooptic bronchoscopy is especially useful for locating the source of bleeding and for visualizing endobronchial lesions. When bleeding is massive, rigid bronchoscopy is often preferred to fibrooptic ones due to better airway control and higher suction capacity. In patients with suspected bronchitis, HRCT is now the diagnostic process of elective, which replaced bronchography.
Let's get to the treatment. The rate of bleeding and its effect on gas exchanges require urgency in treatment. When bleeding is limited to a few bloody streaks in the sputum or small amounts of pure blood, the exchange of gases is usually preserved, making a diagnosis a priority.
When hemoptysis is massive, first of all we need to maintain the proper gas exchange, prevent blood flow in the unaffected areas of the lung and avoid asphyxia. Bleeding can be slowed by bed rest and partial cough suppression. If the origin of bleeding is known and is limited to a single lung, it must be in a declative position so that blood is not sucked into the unaffected lung.
In heavy bleeding, endotracheal intubation and mechanical ventilation may be required to control the airways and keep gas exchanges within normal limits. In patients at risk of flooding the unaffected lung despite correct positioning, isolation of the right and left main bronchi from each other can be achieved with the help of special two-channel endotracheal tubes.
Another option is to insert a balloon catheter by direct bronchoscopic visualization and inflating it to obstruct the bronchi leading to the source of bleeding. This technique not only prevents the suction of blood in unaffected areas, but can also ensure that the source of bleeding is buffered and thus stopping it.
Other techniques available for controlling significant bleeding are laser phototherapy, therapeutic embolization and surgical resection of the affected lung area. In the case of bleeding from an endobronsic tumor, the neodymium laser may frequently perform at least one temporary hemostasis by clotting at the site of bleeding. Therapeutic embolization involves an arteriographic procedure whereby the vessel proximal to the bleeding site is canted and a Gelfoam-type material is injected to obstruct the bleeding vessel.
Surgical resection is a therapeutic option either in the emergency treatment of a life-threatening hemoptysis that has not responded to other measures, or in the elective but definitive resolution of a localized disease, the cause of repeated bleeding.
And just like that, I've also completed this group of posts... From tomorrow we'll talk about "heart" and more of her breaths.
Hemoptysis is defined as the expectoration of blood from the respiratory tract, ranging from bloody striations in the sputum to the coughing elimination of a large amount of blood (100 ml in 24 hours). Massive hemoptysis can be a life-threatening problem. Large amounts of blood can fill the airways and alveolar spaces, seriously disturbing gas exchanges and at the same time being a potential cause of suffocation. Waiting for even a small amount of blood is an alarming symptom, which is why sometimes we can't rely on the patient's quantitative assessment. Hemoptysis may be a sign of a potentially serious disease such as bronchial carcinoma.
Let's go to a few presentations on etiology! Since, most commonly, blood originating in the nasopharynx or gastrointestinal tract can be confused with that from the lower respiratory tract, it is important to check first whether the source of bleeding does not originate from here (nasopharynx or digestive tract).
Indications of gastrointestinal origin are the dark red color and the acidic pH of the blood, in contrast to the typical light red appearance and alkaline pH of true hemoptysis. The bronchial arteries, which belong to the high-pressure systemic circulation, originate either in the aorta or in the intercostal arteries and are the source of bleeding from bronchitis and bronchiectasis, as well as in the case of endobronsic tumors.
An etiological classification of hemoptysis can be done depending on the place of origin of the lung. The airways most commonly bleed, i.e. the tracheobronsic shaft, which may be affected by inflammation (acute or chronic bronchitis, bronchectasis) or neoplasm (bronchial carcinoma, metastatic endobronsic carcinoma or bronchial carcinoid tumor).
Blood from the pulmonary parenchyma may originate either in a localized source, such as an infection (pneumonia, pulmonary abscess, tuberculosis), or in a diffuse process affecting all parenchyma (coagulopathy or autoimmune process, such as Goodpasture syndrome).
Disorders primarily affecting pulmonary vascularization include pulmonary embolic disease and those conditions associated with high capillary and venous pulmonary pressures, such as mitral stenosis or left ventricular insufficiency. Although the relative frequency of different etiologies of hemoptysis varies from one study group to another, more recent studies indicate that bronchitis and bronchial carcinoma are the most common causes.
Despite the decrease in the frequency of tuberculosis and bronchiectasis in recent study groups compared to the older ones, these two diseases still represent the most common causes of massive hemoptysis in some groups. Even after thorough investigations, a quantifiable proportion of patients (up to 30% in some groups) does not have a clear etiology of hemoptysis.
These patients are said to have idiopathic or cryptogenic hemoptysis and probably responsible for this bleeding is parechimatous or airway suffering at the early stage.
From the point of view of differential diagnosis is noted: 1. sources other than the lower respiratory tract (bleeding from the upper airways - nasopharynx - and gastrointestinal bleeding), 2. tracheobronsic source (neoplasm - bronchial carcinoma, endobronsic metastatic tumors, bronchial carcinoid -, bronchitis - acute or chronic -, bronchectasis, broncholithiasis, airway trauma, foreign body), 3. parenchymatous pulmonary source (pulmonary abscess, pneumonia, tuberculosis, mycetom - "fungal ball" -, Goodpasture syndrome, idiopathic pulmonary hemosiderosis, Wegener granulomatosis, lupus pneumonitis, pulmonary contusion), 4. primary vascular disease (arteriovenous malformations, pulmonary embolism, increased pulmonary venous pressure - especially mitral stenosis -) and 5. causes (pulmonary endometriosis, systemic coagulopathy or the use of anticoagulants).
From the point of view of the patient's approach, anamnesis is very valuable. Hemoptysis described as bloody streaks in purulent or mucopurulent sputum frequently suggests bronchitis. Chronic removal of sputum with a recent change in quantity or appearance indicates an acute chronic bronchitis. Fever or chills accompanying the removal of purulent sputum with blood striations suggest pneumonia, while a putrid smell of sputum indicates a possible pulmonary abscess.
When the removal of sputum was chronic and large quantitative, the diagnosis of bronchectasis should be taken into account, although the lack of chronic expectoration does not necessarily exclude it (it is about so-called dry bronchitis). Hemoptysis following the acute installation of pleuritic chest pain and dyspnea is suggestive for pulmonary embolism.
Past or coexisting conditions, such as renal distress (found in Goodpasture syndrome or Wegener granulomatosis), lupus erythematosus (with associated pulmonary haemorrhage due to lupus pneumonitis) or a previous neoplastic process (recurrent lung cancer or endobronchial metastases of a nonpulmonary primary tumor) should be sought. In a patient with AIDS, endobronsic or pulmonary parenchymatos sarcoma should be considered.
The existence of risk factors for bronchial carcinoma, in particular smoking and asbestos exposure, should also be investigated. Patients should be questioned about previous bleeding, ongoing anticoagulant treatment or the use of medicines that may induce thrombocytopenia.
Physical examination can also provide useful clues for diagnosis. For example, pulmonary auscultation may highlight pulmonary friction (in pulmonary embolism), localized or diffuse rals (parenchymatous bleeding or background parenchymatos process associated with bleeding), obstruction of the airways (chronic bronchitis) or ronhus, whether or not accompanied by wheezing and rals (in bronchitis).
Pulmonary arterial hypertension, mitral stenosis or heart failure may be discovered when examining the cardiovascular system. Kaposi sarcoma, arteriovenous malformations in Osler-Rendu-Weber disease or lesions suggestive of systemic lupus erythematosus can be discovered upon examination of the skin.
Diagnostic evaluation of hemoptysis begins with chest X-ray which may reveal the presence of tumor lesions, signs suggestive of bronchectasis (representing either a focal or diffuse bleeding or a focal area of pneumonia).
Additional initial diagnostic assessment includes both haemogram, clotting times, and assessment of renal function with urine analysis and measurement of urea and creatinine levels in the blood. When sputum is present, Gram and acid-alcohol-resistant bacilli (as well as corresponding cultures) are indicated.
Fibrooptic bronchoscopy is especially useful for locating the source of bleeding and for visualizing endobronchial lesions. When bleeding is massive, rigid bronchoscopy is often preferred to fibrooptic ones due to better airway control and higher suction capacity. In patients with suspected bronchitis, HRCT is now the diagnostic process of elective, which replaced bronchography.
Let's get to the treatment. The rate of bleeding and its effect on gas exchanges require urgency in treatment. When bleeding is limited to a few bloody streaks in the sputum or small amounts of pure blood, the exchange of gases is usually preserved, making a diagnosis a priority.
When hemoptysis is massive, first of all we need to maintain the proper gas exchange, prevent blood flow in the unaffected areas of the lung and avoid asphyxia. Bleeding can be slowed by bed rest and partial cough suppression. If the origin of bleeding is known and is limited to a single lung, it must be in a declative position so that blood is not sucked into the unaffected lung.
In heavy bleeding, endotracheal intubation and mechanical ventilation may be required to control the airways and keep gas exchanges within normal limits. In patients at risk of flooding the unaffected lung despite correct positioning, isolation of the right and left main bronchi from each other can be achieved with the help of special two-channel endotracheal tubes.
Another option is to insert a balloon catheter by direct bronchoscopic visualization and inflating it to obstruct the bronchi leading to the source of bleeding. This technique not only prevents the suction of blood in unaffected areas, but can also ensure that the source of bleeding is buffered and thus stopping it.
Other techniques available for controlling significant bleeding are laser phototherapy, therapeutic embolization and surgical resection of the affected lung area. In the case of bleeding from an endobronsic tumor, the neodymium laser may frequently perform at least one temporary hemostasis by clotting at the site of bleeding. Therapeutic embolization involves an arteriographic procedure whereby the vessel proximal to the bleeding site is canted and a Gelfoam-type material is injected to obstruct the bleeding vessel.
Surgical resection is a therapeutic option either in the emergency treatment of a life-threatening hemoptysis that has not responded to other measures, or in the elective but definitive resolution of a localized disease, the cause of repeated bleeding.
And just like that, I've also completed this group of posts... From tomorrow we'll talk about "heart" and more of her breaths.
Have a good day!
Dorin, Merticaru