Review Question - QID 105819

With this patient's presentation and smoking history it is most likely that his episodes of hemoptysis are a result of the development of chronic bronchitis. In smokers, chronic bronchitis is the most common cause of hemoptysis.

This patient as described, is presenting as a "blue bloater," a common phenotype of the heavy smoker and the development of chronic bronchitis (defined as having a productive cough for more than 3 months within a two year period). These patients are exposed to near constant airway irritation resulting in the production of large amounts of sputum and the narrowing of the small airways. This can result in episodes of hemoptysis. These patients compensate by increasing the diameter of the chest (barrel chest) in an effort to change their own respiratory physiology due to the obstructive pulmonary disease that they have developed. Cardiac, pulmonary, coagulopathic, vasculitides, and infectious causes all can cause hemoptysis in these patients, however in this clinical vignette they are less likely.

Bidwell and Pachner review the diagnosis and management of a patient presenting with hemoptysis. They place the importance of a focused history and physical exam as the optimal method to determine the correct diagnosis in each patient. The goals of management in both the acute and chronic setting are cessation of bleeding, prevention of aspiration, and addressing the underlying cause of the bleeding episode.

Tsoumakidou et al. followed 184 consecutive patients in a prospective fashion who initially presented to the emergency room with hemoptysis. Their conclusion was that non-smokers are most likely to present due to bronchiectasis secondary to previous tuberculosis infection. Smokers presenting with hemoptysis must be evaluated for lung cancer.

Illustration A: This is a chest x-ray of a patient with chronic bronchitis. Note the over expanded appearance of the lungs.

Incorrect Answers:
Answer 1: This patient's disease and onset of symptoms is most likely a primary pulmonary process, it is unlikely that he has developed pulmonary edema secondary to a cardiac issue.
Answer 2: This patient is afebrile making an infectious process unlikely.
Answer 4: With no other associated symptoms the development of a coagulopathy is unlikely.
Answer 5: With not other associated symptoms such as renal involvement the development of Goodpasture's disease is unlikely.