COMO ABORDAR UM CASO DE HEMOPTISE

APPROACH IN CASE OF HEMOPTYSIS
Neeraj Jain, Vibha Mangal, Vibhu KabatraDepartment of Pediatrics, HIMS Jolly Grant, Rishikesh, India
Address for correspondence : Neeraj Jain , 77 SBM Complex, Rishikesh- 249201 India..E-mail: neerajjain@vsnl.net
Definition:
Hemoptysis is defined as the spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage. (1) The lungs receive blood from the pulmonary and bronchial arterial systems. (2) The low-pressure pulmonary system tends to produce small-volume hemoptysis whereas bleeding from the bronchial system which is at systemic pressure tends to be profuse. (2).
Types of hemoptysis:
Frank hemoptysis: it is expectoration of blood only.
Spurious hemoptysis: hemoptysis is present secondary to upper respiratory tract infection above level of larynx.
Pseudo-hemoptysis: It is due to pigment prodigiosin produced by gram negative organism such as serratia marcescens.
Endemic hemoptysis: present in infection with paragonimus westermani.
After confirming the presence of blood, an initial task is differentiating between hemoptysis, pseudohemoptysis (i.e. the spitting of blood that does not come from the lungs or bronchial tubes) and hematemesis (i.e. the vomiting of blood).
Table 1: Differentiating Features of Hemoptysis and Hematemesis (2-4):

Hemoptysis
Hematemesis
History
Absence of nausea and vomiting
Presence of nausea and vomiting
Lung disease
Gastric or hepatic disease
Asphyxia possible
Asphyxia unusual
Sputum examination
Frothy
Rarely frothy
Liquid or clotted appearance
Coffee ground appearance
Bright red or pink
Brown to black
Laboratory
Alkaline pH
Acidic pH
Mixed with macrophages and neutrophils
Mixed with food particles
Causes of hemoptysis (5):
Infection - Tracheobronchitis - Pneumonia
Bacterial (Staphylococcus aureus, Pseudomonas aeruginosa)
Tuberculosis
Fungal organisms (e.g. Aspergillosis)
Influenza
Parasitic (e.g. echinococcosis)
Tracheostomy related
Bronchiectasis
Cystic fibrosis
Ciliary dyskinesia
Immunodeficiency
Foreign body
Congenital heart disease (mainly with pulmonary vascular obstructive diseases)
Pulmonary AV malformations
Trauma
Alveolar hemorrhage syndromes
Connective tissue disease/vasculitis (e.g. Goodpasture syndrome, Wegeners granuloma)
Primary pulmonary hemosiderosis (e.g. Idiopathic Heiner syndrome)
Pulmonary thromboembolism
Tumour
Bronchial adenoma
Metastatic
Diagnosis:
Patient HistoryHistoric clues are useful for differentiating hemoptysis from hematemesis. Patient history also can help identify the anatomic site of bleeding, differentiate between hemoptysis and pseudohemoptysis and narrow the differential diagnosis. Factors such as age, nutrition status, and comorbid conditions can assist in the diagnosis and management of hemoptysis.
Table 2: Diagnostic Clues in Hemoptysis:
Physical History
Suggested diagnosis
Anticoagulant use
Medication effect, coagulation disorder
Association with menses
Catamenial hemoptysis
Dyspnea on exertion, fatigue, nocturnal dyspnea, frothy pink sputum
Congestive heart failure, left ventricular orthopnea, paroxysmal dysfunction, mitral valve stenosis
Fever, productive cough
Upper respiratory infection, acute sinusitis, acute bronchitis, pneumonia, lung abscess
History of chronic lung disease
Bronchiectasis, lung abscess
Recurrent lower respiratory track infection, cough with copious purulent sputum
HIV, immunosuppression, Neoplasia, tuberculosis, Kaposi's sarcoma
Nausea, vomiting, malena
Gastritis, gastric or peptic ulcer, chronic use of nonsteroidal anti-inflammatory drugs, esophageal varices
Pleuritic chest pain, calf tenderness
Pulmonary embolism or infarction
Travel history
Tuberculosis, parasites (e.g., paragonimiasis, schistosomiasis, amebiasis, leptospirosis), biologic agents (e.g. plague, tularemia, T2 mycotoxin)
Once true hemoptysis is suspected, the investigation should focus on the respiratory system. Blood from the lower bronchial tree typically induces cough, whereas a history of epistaxis or expectorating without cough would be consistent with an upper respiratory source but does not exclude a lower tract site.Bleeding is difficult to quantify clinically. Patients may find it difficult to discern whether they are throwing up, coughing or spitting out bloody material. The amount of blood loss usually is overestimated by patients and physicians but an attempt to determine the volume and rate of blood loss should be made. Methods of determination include observing as the patient coughs and the use of a graduated container. Blood-streaked sputum deserves the same diagnostic consideration as blood alone. It is helpful to determine whether there have been previous episodes of hemoptysis and what diagnostic assessments have been done. Low-risk patients with normal chest radiographs can be treated on an outpatient basis with close monitoring and appropriate oral antibiotics, if medication is clinically indicated. Bronchial adenomas, although malignant, are slow growing and may present with occasional bleeding over many years. A history of chronic, purulent sputum production and frequent pneumonias, including tuberculosis may represent bronchiectasis. Association of hemoptysis with menses (i.e., catamenial hemoptysis) may represent intrathoracic endometriosis. (6) A travel history may be helpful. Tuberculosis is endemic in many parts of the world, and parasitic etiologies should be considered. (7,8). In regions where drinking from springs is common, there are case reports of hemoptysis caused by leeches attaching to the upper respiratory tract mucosa. (9) Also, biologic weapons such as plague may cause hemoptysis. (3,10).Physical Examination Historic clues often will narrow the differential diagnosis and help focus the physical examination (2,3,5). Examining the expectoration may help localize the source of bleeding.(2,3,4) The physician should record vital signs including pulse oximetry levels to document fever, tachycardia, tachypnea, weight changes, and hypoxia. Constitutional signs such as cachexia and level of patient distress also should be noted. The skin and mucous membranes should be inspected for cyanosis, pallor, ecchymoses, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa. The examination for lymph node enlargement should include the neck, supraclavicular region, and axillae. The cardiovascular examination includes an evaluation for jugular venous distention, abnormal heart sounds, and edema. The physician should check the chest and lungs for signs of consolidation, wheezing, rales, and trauma. The abdominal examination should focus on signs of hepatic congestion or masses, with an inspection of the extremities for signs of edema, cyanosis, or clubbing. (2, 11).
Table 3: Clinical Clues to Diagnosis:
Clinical clues
Suggested diagnosis
Cachexia, clubbing, voice hoarseness
primary lung cancers
hyperpigmentation
Cushing's syndrome, Horner's syndrome
Clubbing
bronchiectasis, lung abscess, severe chronic lung disease
Dullness to percussion, fever, unilateral rales
Pneumonia
Facial tenderness, fever
Acute upper respiratory infection
Acute mucopurulent nasal discharge, postnasal drainage
Sinusitis
Gingival thickening
Wegener's granulomatosis
Gingivitis, saddle nose
Nasal septum perforation
Heart murmur, pectus excavatum
Mitral valve stenosis
Lymph node enlargement, cachexia, violaceous tumors on skin
Kaposi's sarcoma
Orofacial and mucous membrane, telangiectasia, epistaxis
Osler-Weber-Rendu disease
Tachycardia, tachypnea, hypoxia, jugulovenous distention, S3 gallop, decreased lung sounds, bilateral rales, dullness to percussion in lower lung fields
Congestive heart failure caused by left ventricular dysfunction or severe mitral valve stenosis
Tachypnea, tachycardia, dyspnea, fixed split S2, pleural friction rub, unilateral leg pain and edema
Pulmonary thromboembolic disease
Tympani to percussion over lung apices, cachexia
Tuberculosis
Diagnostic Evaluation:
After a careful history and examination, a chest radiograph should be obtained. If a diagnosis remains unclear, further imaging with chest computed tomography (CT) or direct visualization with bronchoscopy often is indicated.
Table 4: Diagnostic Clues in Hemoptysis by Chest Radiograph (2,3):
Chest radiograph finding
Diagnosis
Cardiomegaly, increased pulmonary vascular distribution
Chronic heart failure, mitral valve stenosis
Cavitary lesions
Lung abscess, tuberculosis
Diffuse alveolar infiltrates
Chronic heart failure, pulmonary edema, aspiration, toxic injury
Hilar adenopathy or mass
infectious process, sarcoid
Lobar or segmental infiltrates
Pneumonia, thromboembolism, obstructing carcinoma
Mass lesion, nodules, granulomas
Wegener's granulomatosis, septic embolism, vasculitides
Normal or no change from baseline
upper respiratory infection, sinusitis, pulmonary embolism
Patchy alveolar infiltrates (multiple bleeding sites)
Bleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture's syndrome
Diagnosing Non-massive Hemoptysis:
Fiberoptic bronchoscopy is mainly for diagnostic purpose as it permits tissue biopsy, bronchial lavage, or brushings for pathologic diagnosis. Fiberoptic bronchoscopy also can provide direct therapy in cases of continued bleeding. Rigid bronchoscopy is the preferred tool for cases of massive bleeding because of its greater suctioning and airway maintenance capabilities. High-resolution CT has become increasingly useful in the initial evaluation of hemoptysis and is preferred if parenchymal disease is suspected. Its complementary use with bronchoscopy gives a greater positive yield of pathology. (12-14) Its role in hemoptysis continues to evolve, and further studies are needed to evaluate its effect on patient management and outcome. Patients with recurrent or unexplained hemoptysis may need additional laboratory evaluation to establish a diagnosis (3,5).
Table 5: Diagnostic Clues in Hemoptysis: Laboratory Tests:
Test
Diagnostic findings
White blood cell count and differential
Elevated cell count and differential shifts may be present in upper and lower respiratory tract infections
Hemoglobin, hematocrit
Decreased in anemia
Platelet count
Decreased in thrombocytopenia
Prothrombin time, International Normalized Ratio, partial thromboplastin time
Increased in anticoagulant use, disorders of coagulation
Arterial blood gases
Hypoxia, hypercarbia
d-dimer
Elevated in pulmonary embolism
Sputum Gram stain, culture
Pneumonia, lung abscess
Acid-fast bacillus smear and culture
Tuberculosis, mycobacterial infections
Purified protein derivative skin test
Positive increases risk for tuberculosis
Human immunodeficiency virus test
Positive increases risk for tuberculosis, Kaposi's sarcoma
Erythrocyte sedimentation rate
Elevated in infection, autoimmune disorders (e.g., Wegener's syndrome, systemic lupus erythematosus, sarcoid, Goodpasture's syndrome)
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Advance Access on 1st May 2009
Last updated on 1st July 2009. Vol 6 Issue 7 Art # 36
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Jain N, Mangal V, Kabatra V. Approach in a case of Hemoptysis.Pediatric Oncall [serial online] 2009 [cited 2009 July 1];Vol 6 Art # 36.. Available from:
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