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Snapshot
  • A 58-year-old man presents to an urgent care clinical after coughing up blood and experiencing shortness of breath. The patient reports that he has been coughing recently and decided to cut back on his cigarette use. He notes a 25-lb unintentional weight loss over the course of 6 months, along with night sweats and generalized malaise. On physical exam, the patient has blood in his sputum and no notable source of bleeding in his oropharynx. A chest radiograph is performed, which demonstrates a bronchial mass. (Lung cancer)
Introduction
  • Definition
    • expectoration of blood from the lower respiratory tract
      • hemoptysis is said to be massive when there is ≥ 500 mL of blood over 24 hours or ≥ 100 mL/hour 
  • Etiology
    • airway diseases
      • bronchitis
      • bronchogenic carcinoma
      • bronchiectasis
    • pulmonary parenchymal diseases
      • tuberculosis
      • abscess
    • rheumatic diseases
      • amyloid
      • anti-glomerular basement membrane disease (Goodpasture disease) 
        • treat with steroids, plasmapheresis, and cyclophosphamide for acute flares 
      • granulomatosis with polyangiitis (Wegener disease) and other vasculitides
      • systemic lupus erythematosus
    • pulmonary vascular diseases
      • pulmonary embolism 
      • pulmonary arteriovenous malformation
      • heart failure
    • coagulation disorders
      • disseminated intravascular coagulation
      • anticoagulant and antiplatelet medications
    • iatrogenic
      • bronchoscopy
    • other
      • cocaine use
      • catamenial hemoptysis due to thoracic endometriosis
  • Pathoanatomy
    • blood comes from 2 sources
      • pulmonary arteries
      • bronchial arteries (most common source of massive hemoptysis)
Presentation
  • Symptoms
    • hemoptysis
  • Physical exam
    • blood can range from a streak of blood to gross blood
Imaging
  • Chest radiograph
    • indication
      • initial imaging study in the evaluation of hemoptysis
  • CT of the chest
    • indication
      • considered in patients with an abnormal chest radiograph, risk factors for malignancy, or recurrent hemoptysis
        • risk factors for malignancy include
          • > 40 years of age
          • substantial smoking history
  • Bronchoscopy
    • indication
      • confirms hemoptysis and localizes the bleeding
Studies
  • Diagnostic approach
    • based on an extensive history and physical and chest imaging
      • it is important to differentiate hemoptysis from hematemesis or from the upper respiratory and gastrointestinal tract
    • laboratory testing is dependent on clinical suspicion
      • e.g., a patient comes from a tuberculosis-endemic region presenting with hemoptysis should get sputum acid-fast bacilli testing
Differential
  • Hematemesis
    • differentiating factors
      • source of bleeding is noted on endoscopy
Treatment
  • Conservative
    • patient positioning
      • indication
        • in cases of severe hemoptysis
        • position patient on the side of the involved lung and intubate the normal lung if necessary
          • e.g., if the source of the bleed is from the right lung, position the patient on the right side
  • Procedural
    • therapeutic bronchoscopy
      • indication
        • recommended in life-threatening cases
    • bronchovascular artery embolization
      • indication
        • first-line for massive, recurrent, or malignant hemoptysis
    • emergency thoracotomy 
      • indicated for massive hemoptysis that does not respond to initial measures (such as bronchoscopy)
Complications
  • Asphyxiation
  • Exsanguination

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Questions (4)
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(M2.PL.16.4691) A 27-year-old male presents to clinic complaining of coughing up small amounts of blood daily for the past week. He denies smoking, sick contacts, or recent travel. Chest radiographs demonstrates interstitial pneumonia with patchy alveolar infiltrates suggestive of multiple bleeding sites. Urinalysis is positive for blood and protein. A positive result is returned for anti-glomerular basement membrane antibody (anti-GBM Ab). What is the most likely diagnosis?

QID: 107625
1

Systemic lupus erythematous (SLE)

0%

(0/16)

2

Granulomatosis with polyangiitis (Wegner's)

12%

(2/16)

3

Microscopic polyangiitis

0%

(0/16)

4

Churg-Strauss syndrome

0%

(0/16)

5

Goodpasture disease

88%

(14/16)

M 6 D

Select Answer to see Preferred Response

(M2.RH.14.50) A 47-year-old man presents with hemoptysis, diffuse muscle pain, and shortness of breath. He has had these symptoms before but did not seek treatment. His past medical history is not known as he is not typically followed by a doctor and is homeless. His temperature is 99.0°F (37.2°C), blood pressure is 154/94 mmHg, pulse is 89/min, respirations are 22/min, and oxygen saturation is 90% on room air. Physical examination is notable for crackles noted in the bases of the lungs bilaterally. Labs values are ordered as seen below.

Serum:
Na+: 140 mEq/L
Cl-: 103 mEq/L
K+: 5.8 mEq/L
HCO3-: 21 mEq/L
BUN: 33 mg/dL
Glucose: 129 mg/dL
Creatinine: 2.6 mg/dL

Urine:
Color: Amber
Protein: Positive
Blood: Positive

Which of the following is the most appropriate treatment for this patient?

QID: 105867
1

Methylprednisolone

28%

(13/46)

2

Methylprednisolone and cyclophosphamide

37%

(17/46)

3

Methylprednislone, IVIG, and cyclophosphamide

11%

(5/46)

4

Methylprednisolone, plasmapheresis, and cyclophosphamide

15%

(7/46)

5

Plasmapheresis and cyclophosphamide

2%

(1/46)

M 7 E

Select Answer to see Preferred Response

(M2.PL.14.31) A 60-year-old man presents to the emergency department with pleuritic chest pain. He recently returned from a vacation in Germany and noticed he felt short of breath and had chest pain the following morning. The patient is generally healthy but did have surgery on his ankle 3 weeks ago and has been less ambulatory. His temperature is 99.0°F (37.2°C), blood pressure is 137/88 mm Hg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 96% on room air. Physical exam is notable for a warm and swollen lower extremity. The physician has high clinical suspicion for pleuritis given a recent cough the patient experienced. Which of the following findings would warrant further workup with a CT angiogram?

QID: 103521
1

Bilateral wheezing

0%

(0/16)

2

Decreased breath sounds over area of the lung

44%

(7/16)

3

Hemoptysis

56%

(9/16)

4

Increased breath sounds over area of the lung

0%

(0/16)

5

Green sputum

0%

(0/16)

M 7 E

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Evidence (3)
EXPERT COMMENTS (6)
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