0071643192.pdf

THORACIC AND RESPIRATORY

DISORDERS

SYMPTOMS/EXAM

Historical clues that suggest a cause:

■ A history of TB or sarcoidosis →aspergilloma.
■ Frequent, multiple episodes of pneumonia as a child →bronchiectasis.
■ A diastolic heart murmur →mitral stenosis.
■ A history of epistaxis, telangiectasias, and a bruit in the posterior aspect of
the lungs →hereditary hemorrhagic telangiectasia with a ruptured pul-
monary AVM.
■ Renal insufficiency and hemoptysis →Wegener granulomatosis or Good-
pasture syndrome.
■ Weight loss, tobacco abuse, and cachexia →malignancy.

DIFFERENTIAL

Blood expectorated from the upper respiratory tract and the upper GI tract
can mimic blood coming from the trachea and below.

DIAGNOSIS

■ Obtain a CXR in all patients with hemoptysis.
■ Laboratory studies include CBC with differential, coagulation studies, UA,
BUN, creatinine.
■ Further diagnostic options include high-resolution CT scan with contrast
(stable patients) and bronchoscopy.

TREATMENT

Nonmassive Hemoptysis

■ Treatment is directed at the specific cause (eg, antibiotics for superin-
fected aspergilloma).

Massive hemoptysis:

■ Treatment is directed toward bringing about abrupt cessation of bleeding.
■ Place the patient with bleeding-side down to maximize V/Q ratio.
■ Intubate with a large bore single-lumen endotracheal tube; selectively
intubate the nonbleeding mainstem bronchus, when possible. Double-
lumen endotracheal tubes are notpreferred (difficult to place, small
lumens).
■ Urgent bronchoscopy may help localize the site of bleeding.
■ Angiography of the bronchial arteries (a more common site of bleeding
than the pulmonary arteries) has been shown to identify the bleeding site
in>90% of patients.
■ When angiography is combined with embolization, bleeding can success-
fully be stopped in >90% of cases.
■ Emergency surgery for massive hemoptysis is controversial and usually
reserved for those with failed embolization.

ACUTE UPPER AIRWAY OBSTRUCTION

The upper airway extends from the lips and nares to the first tracheal ring.
When upper airway obstruction is present, patients typically develop dysp-
nea when the obstruction is <8 mm in diameter and stridor when the diam-
eter is <5 mm.