pulmonary disorders
Hemoptysis
Evaluation of Hemoptysis
History of present illnessshould cover the duration and temporal patterns (eg, abrupt onset, cyclical recurrence), provoking factors (eg, allergen exposure, cold, exertion, supine position), and approximate volume of hemoptysis (eg, streaking, teaspoon, cup). Patients may need specific prompting to differentiate between true hemoptysis, pseudohemoptysis (ie, bleeding originating in the nasopharynx that is subsequently coughed up), and hematemesis. A sensation of postnasal drip or any bleeding from the nares without coughing is suggestive of pseudohemoptysis. Concomitant nausea and vomiting with black, brown, or coffee-ground–colored blood is characteristic of hematemesis. Frothy sputum, bright red blood, and (if massive) a sensation of choking are characteristic of true hemoptysis. should seek symptoms suggesting possible causes, including fever and sputum production ( Overview of Pneumonia ); night sweats, weight loss, and fatigue ( Patients should be asked about risk factors for causes. These risk factors include Human Immunodeficiency Virus (HIV) Infection , use of immunosuppressants (TB, fungal infection); exposure to TB; long smoking history (cancer); and recent immobilization or surgery, known cancer, prior or family history of clotting, pregnancy, use of should cover known conditions that can cause hemoptysis, including chronic lung disease (eg, Chronic Obstructive Pulmonary Disease (COPD) [chronic obstructive pulmonary disease], A history of frequent nosebleeds, easy bruising, or liver disease suggests possible coagulopathy. The medication profile should be reviewed for use of anticoagulants and antiplatelet drugs. Vital signs are reviewed for fever, tachycardia, tachypnea, and low oxygen saturation. Constitutional signs (eg, cachexia) and level of patient distress (eg, accessory muscle use, pursed lip breathing, agitation, decreased level of consciousness) should also be noted. A full lung examination is done, particularly including adequacy of air entry and exit, symmetry of breath sounds, and presence of crackles, rhonchi, Stridor , and Neck veins should be inspected for distention, and the legs and presacral area should be palpated for pitting edema (suggesting heart failure). Heart sounds should be auscultated with notation of any extra heart sounds or murmur that might support a diagnosis of heart failure and elevated pulmonary pressure. The abdominal examination should focus on signs of hepatic congestion or masses, which could suggest either cancer or hematemesis from potential esophageal varices. The skin and mucous membranes should be examined for ecchymoses, petechiae, telangiectasia, gingivitis, or evidence of bleeding from the oral or nasal mucosa. If the patient can reproduce hemoptysis during examination, the color and amount of blood should be noted. The following findings are of particular concern: Massive hemoptysis Back pain Presence of a pulmonary artery catheter or tracheostomy Malaise, weight loss, or fatigue Extensive smoking history Dyspnea at rest during examination or absent or decreased breath sounds The history and physical examination often suggest a diagnosis and guide further testing (see table). Despite the many possibilities, some generalities can be made. A previously healthy person with a normal examination and no risk factors (eg, for TB, pulmonary embolism) who presents with acute-onset cough and fever most likely has hemoptysis due to an acute respiratory illness; chronic disorders are much lower on the list of possibilities. However, if risk factors are present, those specific disorders must be strongly suspected. Clinical prediction can help estimate the risk of Pulmonary Embolism (PE) . A normal oxygen saturation does not exclude pulmonary embolism. Patients whose hemoptysis is due to a lung disorder (eg, COPD, cystic fibrosis, bronchiectasis) or heart disease (eg, heart failure) typically have a clear history of those disorders. Hemoptysis is not an initial manifestation. Patients with known immunocompromise should be suspected of having TB or a fungal infection. Patients with symptoms or signs of chronic illness but no known disorders should be suspected of having cancer or TB, although hemoptysis can be the initial manifestation of lung cancer in a patient who is otherwise asymptomatic. Several specific findings are of note: Known renal failure or hematuria suggests a pulmonary-renal syndrome (eg, Goodpasture Syndrome , Patients with granulomatosis with polyangiitis may have nasal mucosal lesions. Visible telangiectasias suggest arteriovenous malformations. Patients with hemoptysis due to a bleeding disorder usually have cutaneous findings (petechiae, purpura, or both) or a history of anticoagulant or antiplatelet drug use. Recurrent hemoptysis coinciding with menses strongly suggests pulmonary Endometriosis . Patients with massive hemoptysis require treatment and stabilization, usually in an intensive care unit, before testing. Patients with minor hemoptysis can undergo outpatient testing. Imagingis always done, typically chest x-ray, although sometimes (eg, with known bronchiectasis) CT is the initial test. Patients with normal results, a consistent history, and nonmassive hemoptysis can undergo empiric treatment for bronchitis. Patients with abnormal results and patients without a supporting history should undergo CT and bronchoscopy. CT may reveal pulmonary lesions that are not apparent on the chest x-ray and can help locate lesions in anticipation of bronchoscopy and biopsy. CT angiography or, less commonly, ventilation/perfusion scanning with or without pulmonary arteriography can confirm the diagnosis of pulmonary embolism. CT and pulmonary angiography can also detect pulmonary arteriovenous fistulas. Fiberoptic inspectionof the pharynx, larynx, and airways may be indicated along with esophagogastric endoscopy when the etiology is obscure to distinguish hemoptysis from hematemesis and from nasopharyngeal or oropharyngeal bleeding. . Serologies for Diagnosis , The cause of hemoptysis remains unknown in 30 to 40% of patients, but the prognosis for patients with cryptogenic hemoptysis is generally favorable, usually with resolution of bleeding within 6 months of evaluation. 