Primary_Care_Medicine_----_(Chapter_42_Evaluation_of_Hemoptysis).pdf

Chapter 42 EVALUATION OF HEMOPTYSIS Hemoptysis is the coughing up of either blood-tinged or grossly bloody sputum. Because of its well-known associations with cancer and tuberculosis, hemoptysis is an alarming symptom for both patient and physician. In the office, the primary physician is usually co...

Chapter 42 EVALUATION OF HEMOPTYSIS Hemoptysis is the coughing up of either blood-tinged or grossly bloody sputum. Because of its well-known associations with cancer and tuberculosis, hemoptysis is an alarming symptom for both patient and physician. In the office, the primary physician is usually confronted with a patient who has noted sputum streaked with blood. Most patients prove to have inconsequential lesions, but a thorough evaluation is necessary because the seriousness of the underlying cause does not correlate with the amount of blood coughed up. PATHOPHYSIOLOGY PRESENTATION (1–13) AND CLINICAL Copyright © 2020. Wolters Kluwer Health. All rights reserved. Inflammation of the tracheobronchial mucosa accounts for many cases of hemoptysis. Minor mucosal erosions can result from upper respiratory infections and bronchitis; blood-streaked sputum is often noted, especially if coughing has been vigorous and prolonged. Patients with bronchiectasis are more subject to recurrent episodes of grossly bloody sputum because necrosis of the bronchial mucosa can be quite severe. Up to 50% of patients with bronchiectasis experience hemoptysis. In the developing world, tuberculosis (TB) is the most common cause. In the United States, hemoptysis occurring with TB is usually caused by mucosal ulceration, although potentially fatal bleeding can occur when a blood vessel adjacent to a cavitary lesion ruptures. About 10% to 15% of patients with TB report some form of hemoptysis; most of these episodes are minor and involve sputum tinged with small amounts of blood. Endobronchial inflammatory injury from granuloma formation is the mechanism of hemoptysis associated with sarcoidosis; small amounts of blood-streaked sputum are occasionally noted. Mucosal injury can also be a consequence of bronchogenic carcinoma. Disruption of endobronchial tissue may be minor and cause little more than minimal hemoptysis from time to time; hemorrhage is rare. Between 35% and 55% of patients with proven bronchogenic carcinoma report at least one episode of hemoptysis during the course of their illness; it is the presenting symptom in about 10% of cases. The amount of bleeding can vary considerably and need not be impressive. For example, in one study, malignancy was the cause in 25% of patients with minimal hemoptysis. However, most patients have a positive smoking history and abnormal chest radiographic findings. Carcinoma metastatic to the lung rarely results in hemoptysis. Bronchial adenomas are quite vascular, and they are commonly central and endobronchial in location; as a consequence, they frequently bleed, and recurrent episodes of hemoptysis are reported in about half of cases. Injury to the pulmonary vasculature is an important source of hemoptysis. Lung abscess Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. may result in damage to adjacent vessels and frequently presents with bloody and purulent sputum. Necrotizing pneumonias, especially those from aspiration of polymicrobial anaerobic mouth organisms as well as those from monomicrobial infection caused by Klebsiella, Staphylococcus aureus, and Legionella, can cause substantial vascular disruption; 25% to 50% of patients cough up tenacious, bloody sputum referred to as “currant jelly.” Aspergillomas are also capable of causing vascular injury; hemoptysis is the most common symptom of the condition. The patient with an aspergilloma is typically a compromised host with prior cavitary disease from TB, bronchiectasis, or the like. Pulmonary infarction secondary to embolization is characterized by the sudden onset of pleuritic pain in conjunction with hemoptysis; embolization without infarction does not cause hemoptysis. Pulmonary contusion resulting from blunt chest trauma may present with hemoptysis following a nonpenetrating blow to the thorax. Marked elevations in pulmonary capillary pressure can cause vascular injury and extravasation of red cells. The pink, frothy sputum of pulmonary edema is a manifestation of this process. More grossly bloody sputum sometimes occurs in severe mitral stenosis when a dilated pulmonary–bronchial venous connection ruptures after long-standing pulmonary venous hypertension. Vasculitic injury is responsible for the hemoptysis found in granulomatosis with polyangiitis (formerly called Wegener granulomatosis), Goodpasture syndrome (anti-GBM disease), and microscopic polyangiitis. Hematuria often accompanies both conditions. Hereditary vascular malformations are subject to recurrent bleeding. Arteriovenous malformations may be accompanied by an audible bruit on auscultation of the lung. In hereditary hemorrhagic telangiectasia, a family history of bleeding problems is often present, or prior episodes of bleeding from multiple sites have been noted; telangiectasia may be visible in the buccal cavity and on the skin. Bleeding into the interstitium characterizes idiopathic pulmonary hemosiderosis. This rare disease, uncommon in adults, is manifested by diffuse interstitial infiltrates, anemia, and hemoptysis. Hemoptysis may be the first sign of a bleeding disorder or excessive anticoagulant therapy; however, an underlying bronchopulmonary lesion is usually also present. Copyright © 2020. Wolters Kluwer Health. All rights reserved. DIFFERENTIAL DIAGNOSIS (3,4,7,12) Acute and chronic bronchitis are the most common causes, followed by bronchogenic carcinoma, TB, pneumonia, and bronchiectasis. Most prevalence figures are obtained from chest clinics and inpatient units serving preselected populations of patients with either abnormal chest radiographic findings or unexplained hemoptysis; therefore, they cannot be readily extrapolated to the primary care setting. In everyday office practice, the nasal mucosa and oropharynx are more often the source of blood-tinged sputum than is the lower respiratory tract. The high incidence of pulmonary infections associated with HIV, the more widespread use of fiberoptic bronchoscopy, and increases in cigarette smoking and lung cancer in women also must be kept in mind when data from published clinical series that are more than 10 years old are being interpreted. In a fiberoptic bronchoscopy study performed in a general hospital setting that included both inpatients and outpatients, bronchitis Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. accounted for 37% of cases, bronchogenic carcinoma for 19%, TB for 7%, and bronchiectasis for only 1%. The briskness of bleeding did not help in discriminating among causes. In primary care settings, the diagnosis of lung cancer following a first presentation with hemoptysis is much lower: 7.5% in men and 4.3% in women in a large study of alarm symptoms in the United Kingdom. This study included patients with abnormal chest x-rays at the time of presentation. In a review of studies comprising a total of nearly 1,000 patients with hemoptysis and normal chest radiographic findings, lung cancer was eventually diagnosed in 5.4%. Most cancers that cause hemoptysis are endobronchial, but about 15% are parenchymal. The more common and important causes of hemoptysis are listed in Table 421. Copyright © 2020. Wolters Kluwer Health. All rights reserved. Table 42-1 Important Causes of Hemoptysis Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. Copyright © 2020. Wolters Kluwer Health. All rights reserved. Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. WORKUP (1–5,7–9,11,12,14–21) As noted earlier, most cases of blood-tinged sputum encountered in the primary care setting, especially during the winter, originate in the upper respiratory tract. Such cases do not require further investigation. To avoid unnecessary workup for a pulmonary cause, the history and physical examination should first focus on the nasal and oropharyngeal mucosa. Only in the absence of an upper respiratory source of bleeding need further workup proceed in the manner detailed in the following paragraphs. History Evaluation of the patient with a suspected lower respiratory tract source of hemoptysis should begin with consideration of the epidemiology of the serious underlying causes. Concern about pulmonary neoplasm should be highest in the older man with a long history of heavy smoking or asbestos exposure. The elderly patient with evidence of old disease on chest x-ray films should be presumed to have reactivated TB infection. The adolescent with hemoptysis may have a new infection resulting from recent TB exposure. The compromised host with previous cavitary disease is at risk for an aspergilloma. TB is also a major concern among patients with HIV infection. The patient’s description of the sputum associated with hemoptysis can be of some diagnostic help. Pink sputum is suggestive of pulmonary edema fluid; putrid sputum is indicative of a lung abscess; material resembling currant jelly points to a necrotizing pneumonia; copious amounts of purulent sputum mixed with blood are consistent with bronchiectasis. The commonly described blood-streaked sputum is nonspecific. Copyright © 2020. Wolters Kluwer Health. All rights reserved. The patient should be asked about previous episodes of bleeding, any family history of hemoptysis, hematuria, concurrent pleuritic chest pain, known heart murmur or history of rheumatic fever, lymph node enlargement, blunt chest trauma, symptoms of heart failure (see Chapter 32), and use of anticoagulant drugs. Determining the amount of blood produced is not particularly helpful for diagnostic purposes. As noted earlier, it is important to be certain that the patient has no history of a coexisting nasopharyngeal problem or a source of gastrointestinal bleeding that may be mistaken for true hemoptysis. Physical Examination Physical examination is directed at detecting nonpulmonary sources of bleeding in addition to evidence of chest and systemic disease. The vital signs should be checked for fever and tachypnea, the skin for ecchymoses and telangiectasia, and the nails for clubbing. Clubbing is associated with neoplasm, bronchiectasis, lung abscess, and other severe pulmonary disorders (see Chapter 45). Nodes are examined for enlargement, which is suggestive of sarcoidosis, TB, and malignancy (see Chapters 12 and 51). The neck is noted for jugular venous distention, consistent with heart failure and severe mitral disease. Examination of the chest should include a search for bruits, signs of consolidation, wheezes, crackles, and chest Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. wall contusion. The history and physical findings can be used to determine the pace at which workup should proceed, in addition to the selection and sequence of laboratory tests. Patients with minimal hemoptysis may be evaluated on an outpatient basis as long as they are given explicit advice to return immediately if severe bleeding ensues. The patient with a suspected bleeding diathesis should not be sent home. Laboratory Studies Chest X-Ray Chest radiography is essential to assessment. As noted earlier, the majority of patients with hemoptysis resulting from bronchogenic carcinoma have abnormal chest radiographic findings. In addition to uncovering a mass lesion, chest films may reveal an abscess, infiltrate, interstitial change (see Chapter 51), hilar adenopathy, signs of congestive failure (see Chapter 32), or evidence of significant mitral stenosis (see Chapter 33). Less common radiologic findings include peribronchial cuffing, indicative of bronchiectasis, and a crescentic radiolucency surrounding a coin lesion, characteristic of an aspergilloma. However, in most instances, the appearance of the chest film is normal, and consideration of further study is warranted. Sputum Stains Copyright © 2020. Wolters Kluwer Health. All rights reserved. A sputum Gram stain is essential if the sputum appears grossly purulent or the patient is febrile. An acid-fast stain for tubercle bacilli is also essential, not only for diagnosis but also for a rough assessment of infectivity (see Chapter 49). The sensitivity of the acid-fast smear depends on the diligence with which the search for pathogenic organisms is made. In one series, only 20% of culture-positive samples were identified in advance by acid-fast smear. It should be noted that despite the very high specificity of a positive smear, its predictive value may be as low as 50% when the sputum specimens of low-risk patients are examined. A tuberculin skin test should be performed if the patient’s purified protein derivative reactivity status is not known. However, approximately 7% of all adults (25% of adults >50 years) will have positive reactions (see Chapters 38 and 49). Sputum Cytologies Sputum cytologies should be obtained in all patients without a clear diagnosis. It used to be thought that the sensitivity of a single sputum cytology examination was about 70% in the detection of squamous cell lesions and that three consecutive cytologic examinations increased the sensitivity to 90%. However, data from the large screening trials suggest a lower sensitivity, at least for early cancers. The specificity of sputum cytology is greater than 99% when the specimen is reviewed by an experienced cytopathologist. Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. Fiberoptic Bronchoscopy Fiberoptic bronchoscopy can be extremely helpful for diagnosis when used thoughtfully. Its most common indication is to exclude the possibility of tumor. However, the test should not be viewed as a routine part of the evaluation for hemoptysis because the yield is extremely low in situations in which the risk for malignancy is very low (e.g., a nonsmoker 50 years, male gender, history of smoking), even if the chest radiographic findings are nonlocalizing. Patients with a high-risk profile, “positive” or “suspect” cytology, or a radiologic abnormality are appropriate candidates for bronchoscopy. Subjecting low-risk patients to bronchoscopic examination is wasteful and unlikely to affect management or outcome. Moreover, the cost and morbidity associated with bronchoscopy are not trivial. Serious complications are rare with fiberoptic bronchoscopy, but they do occur. In a review of 48,000 procedures, less than 100 life-threatening cardiovascular or respiratory complications were reported, most often in older persons with chronic obstructive pulmonary disease and coronary disease. Hypoxia occurs commonly following bronchoscopy. Bronchoscopy is mandatory in all patients with massive hemoptysis who are being seriously considered for surgery, to localize the site of bleeding. Chest Computed Tomography Chest computed tomography (CT) may better define a suspect lesion seen on chest x-ray films and may be indicated for some patients with normal chest radiographic findings to increase the sensitivity for parenchymal lesions. CT also identifies endobronchial tumors with a sensitivity of approximately 80%. However, the specificity of CT-visualized endobronchial lesions for cancer is somewhat limited (~65%). Copyright © 2020. Wolters Kluwer Health. All rights reserved. Bleeding Studies The parameters of bleeding, such as the prothrombin time, partial thromboplastin time, platelet count, and bleeding time, should be considered if more than one site of bleeding is noted. Cryptogenic Hemoptysis Cryptogenic hemoptysis is hemoptysis occurring in patients with normal or nonlocalizing chest radiographic findings and nondiagnostic findings on fiberoptic bronchoscopy. What to do in such a situation can be perplexing. The prognosis appears to be favorable, with greater than 90% of these patients experiencing resolution of their hemoptysis by 6 months and no cases of cancer, active TB, or other serious pathology emerging after the initial evaluation. A careful history and physical examination, in combination with chest radiography and the Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. proper use of bronchoscopy, appear to exclude cancer, active TB, and other must-not-miss diseases effectively, so repeated bronchoscopy, pulmonary angiography, CT, and bronchography are of little use in these patients. In one study, bronchial inflammation (bronchitis) was the most common cause, followed by the sequelae of old tuberculous disease. SYMPTOMATIC MANAGEMENT (3,15) The best treatment is etiologic, especially for readily treatable causes such as TB and necrotizing pneumonias where prompt initiation of properly targeted antibiotic therapy is essential (see Chapters 49 and 52). However, in some instances, symptomatic measures are required. The most obvious is correcting a bleeding diathesis, especially one due to excessive oral anticoagulation (see Chapter 83). Minor hemoptysis needs no symptomatic management other than cough suppression when due to the airway trauma of persistent forceful coughing from an upper respiratory infection (see Chapter 41). More substantial bleeding requires urgent hospitalization and consideration for such procedures as bronchoscopy and angiography. INDICATIONS FOR REFERRAL ADMISSION (1,3–5,7,14,15,19) AND Patients with hemoptysis who are believed to be at increased risk for an underlying malignancy (abnormal chest radiographic findings, male sex, >50 years, smoking history) are candidates for bronchoscopy. As noted, patients with brisk bleeding require urgent hospitalization. A.G.M./A.H.G. Copyright © 2020. Wolters Kluwer Health. All rights reserved. ANNOTATED BIBLIOGRAPHY Adelman M, Haponik EF, Bleecker ER, et al. Cryptogenic hemoptysis: clinical features, bronchoscopic findings, and natural history in 67 patients. Ann Intern Med 1985;102:829. (Prognosis was excellent, and no cancer, tuberculosis, or other serious causes were missed by a careful history and physical examination combined with chest radiography and bronchoscopy.) Barker AF. Medical progress: bronchietasis. N Engl J Med 2002;346:1383. (Excellent review.) Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am Fam Physician 2005;72:1253. (Lucid review highlighting diagnostic cues and offering an algorithm for efficient approach to diagnosis.) Casey JD, Englert JA, Katz JT, et al. An unexpected expectoration. N Engl J Med 2018;378:853. (A thoughtful case-based discussion and review of hemoptysis in a patient who turns out to have legionella as the cause.) Collard HR, Gruber MP. Anatomy of a diagnosis. N Engl J Med 2003;349:987. (Clinical care demonstrates a logical approach to diagnosis, in this case leading to the urgent repair of aortobronchial fistula.) Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin. Chest 2001;120:1592. (After workup, 19% of patients had hemoptysis of unknown origin; with observation for 6.6 years after initial presentation, lung cancer developed in 6%.) Hirshburg B, Biran I, Glazer M, et al. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997;112:440. (Retrospective analysis of 208 patients; bronchietasis, cancer, bronchitis, and pneumonia each accounted for Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42. Copyright © 2020. Wolters Kluwer Health. All rights reserved. approximately 20% of cases.) Johnston H, Reisz G. Changing spectrum of hemoptysis. Arch Intern Med 1989;149:1666. (A study of bronchoscopy in both inpatients and outpatients in the general hospital setting; emphasizes that bronchiectasis is waning as a cause of hemoptysis; bronchitis is first, followed by cancer and tuberculosis.) Jones R, Latinovic R, Charlton J, et al. Alarm symptoms in early diagnosis of cancer in primary care: cohort study using General Practice Research Database. BMJ 2007;334:1040. (After 4,812 new episodes of hemoptysis, 220 diagnoses of respiratory tract cancer were made in men and 81 in women, for positive predictive values of 7.5% and 4.3%, respectively.) Leatherman J, Davies SF, Hoidal JR. Alveolar hemorrhage syndromes: diffuse microvascular lung hemorrhage in immune and idiopathic disorders. Medicine (Baltimore) 1984;63:343. (Comprehensive review.) Nelson JE, Forman M. Hemoptysis in HIV-infected patients. Chest 1996;110:737. (Most cases are attributable to infection, usually bacterial.) Santiago S, Tobias J, Williams AJ. A reappraisal of the causes of hemoptysis. Arch Intern Med 1991;151:2449. (Bronchogenic carcinoma, bronchitis, and idiopathic disease were the leading causes.) Weber F. Catamenial hemoptysis. Ann Thorac Surg 2001;72:1750. (Describes this rare result of thoracic endometriosis.) Colice GL. Detecting lung cancers as a cause of hemoptysis in patients with a normal chest radiograph. Chest 1997;111:877. (Review of the literature and decision analysis concluding that bronchoscopy, with or without initial sputum cytology, is the most efficient diagnostic strategy.) Johnson JL. Manifestations of hemoptysis. How to manage minor, moderate, and massive bleeding. Postgrad Med 2002;112:101. (Reviews differential diagnosis and treatment.) Garvey CJ, Hanlon R. Computed tomography in clinical practice. BMJ 2002;324:1077. (Describes advantages and disadvantages of conventional, spiral, and multislice computed tomography scanning and contrasts them with magnetic resonance imaging.) McGuinness G, Beacher JR, Harkin TJ, et al. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest 1994;105:1155. (Fifty-seven patients underwent both studies; computed tomography had a sensitivity of 84% and a specificity of 68%.) Millar AB, Boothroyd AE, Edwards D, et al. The role of computed tomography in the investigation of unexplained hemoptysis. Respir Med 1992;86:39. (An unusually large proportion of parenchymal cancers was reported in this study.) O’Neil K, Lazarus AA. Hemoptysis: indications for bronchoscopy. Arch Intern Med 1991;151:171. (Review of 119 cases; bronchogenic cancer was found in 2.5%.) Set PAK, Flower CDR, Smith IE, et al. Hemoptysis: comparative study of the role of CT and fiberoptic bronchoscopy. Radiology 1993;189:677. (Computed tomography had a low false-positive rate for endobronchial lesions.) Surratt PM, Smiddy JF, Gruber B. Deaths and complications associated with fiberoptic bronchoscopy. Chest 1976;69:747. (In nearly 50,000 procedures, 52 severe respiratory complications and 27 severe cardiovascular complications were found.) Goroll, Allan. Primary Care Medicine, Wolters Kluwer Health, 2020. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bgu-ebooks/detail.action?docID=6743419. Created from bgu-ebooks on 2024-02-20 09:04:42.