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Hemoptysis, Cough, and Pulmonary Lesions

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Hemoptysis, Cough, and Pulmonary Lesions 13 Hemoptysis, Cough, and Pulmonary Lesions John E. Langenfeld Objectives Hemoptysis 1. To know how to assess whether a patient has life- threatening hemoptysis. 2. To list the differential diagnosis of a patient with hemoptysis. 3. To discuss the initial stabilization of a patient pre- senting with hemoptysis. 4. To know the different diagnostic modalities avail- able in the assessment of pulmonary bleeding. 5. To understand the risk and benefits of surgery versus pulmonary embolization in the treatment of hemoptysis. Pulmonary Nodule 1. To discuss the differential diagnosis of nodules presenting in the lung and mediastinum. 2. To describe the common risk factors for lung cancer and the presenting symptoms. 3. To know the algorithm for the evaluation of a patient with a lung nodule. 4. To be able to discuss the prognosis of patients with different stages of lung cancer and how sur- gical and medical therapies affect on survival. 5. To understand which patients do not benefit from a surgical resection. 6. To know how to evaluate a patient’s risk when considering a pulmonary resection. 7. To discuss the surgical management of metastatic tumors to the lung. 233 234 J.E. Langenfeld Cases Case 1 A 57-year-old man presents to the emergency room with the complaint of hemoptysis. What is the initial workup of this patient and how should he be treated? Case 2 A 62-year-old man is referred to you because a routine chest x-ray demonstrated a 1.2-cm asymptomatic nodule in the right upper lobe. How should this patient be evaluated? Hemoptysis Hemoptysis most often is caused by bronchogenic carcinomas and inflammatory diseases of the lung. Hemoptysis also can be caused by interstitial lung disease, pulmonary embolism, cardiac disease, coagulopathy, trauma, and iatrogenic causes. The most commonly associated cardiac disease to cause hemoptysis is mitral stenosis. The Swan-Ganz catheter is the most common iatrogenic cause of massive hemoptysis in the hospital. See Table 13.1 for a thorough listing of causes of hemoptysis. Immediate Evaluation The assessment of stability is the most important determination in the initial evaluation of a patient who presents with hemoptysis. Massive hemoptysis generally is defined as more than 250mL of expectorated blood within 24 hours and is associated with higher mortality rates. Patients rarely exsanguinate from hemoptysis, but rather they asphyx- iate from aspirated blood. Aspiration of even a small amount of blood into the airways can lead to asphyxiation. See Case 13.1. Table 13.1. Causes of hemoptysis. Bronchogenic carcinoma Iatrogenic Inflammatory diseases Swan-Ganz catheter Tuberculosis Bronchoscopy Aspergillosis Pulmonary embolism Cystic fibrosis Arteriovenous fistula (rare) Lung abscess Chest trauma Pneumonia Pulmonary contusion Bronchiectasis Gunshot wound Bronchitis Stab wound Cardiovascular Transected bronchus Mitral stenosis Miscellaneous Congestive heart failure Coagulopathy Congenital heart disease Epistaxis Interstitial lung disease Broncholithiasis Goodpasture’s syndrome Wegener’s granulomatosis 13. Hemoptysis, Cough, and Pulmonary Lesions 235 The initial immediate assessment should determine quickly whether the patient has life-threatening hemoptysis. Patients should be con- sidered to have potentially life-threatening hemoptysis if they have an altered mental status, diminished blood pressure, rapid or slow pulse, or labored breathing; give a history of aspiration or massive hemoptysis; or have a room air O2 saturation below 90%. These patients should be evaluated and treated emergently. Fortunately, most patients do not present with massive hemoptysis or with evidence of aspiration of blood. Most patients can be worked up on a more elective basis, but they should be admitted to the hospital for close observation. Consultants, who typically consist of a pulmonologist and a thoracic surgeon, should be called upon early in the patient’s evaluation. Evaluation of a Stable Patient The initial evaluation of a stable patient with hemoptysis consists of a good history and physical. It is important when taking a history to establish clearly that the bleeding is occurring from the lungs. Bleed- ing from the nose or upper gastrointestinal tract at times can be con- fused with hemoptysis. A good history usually can distinguish whether the blood was coughed up from the lungs or whether it was regurgi- tated or vomited from the gastrointestinal tract. History The following information, obtained from a good history, can help determine the etiology of the hemoptysis, help guide the diagnostic evaluation, and help direct therapy: 1. The amount of bleeding (greater than 250mL/24 hours is massive) 2. Smoking or other risk factors for cancer 3. Fever, chills, productive cough (infectious) 4. Acute onset of shortness of breath prior to hemoptysis (pulmonary embolism) 5. History of previous hemoptysis and pulmonary diseases 6. Cardiac history 7. Medications: Coumadin and platelet inhibitors; patients taking immunosuppressive drugs (e.g., steroids, chemotherapy) are at risk of developing fungal opportunistic infections 8. Alcohol use (patient at risk for aspiration pneumonia) 9. Prior history or exposure to tuberculosis 10. Travel history: (coccidioidomycosis in the Southwest, tuberculosis, common in many countries, histoplasmosis in Mississippi, Missouri, Ohio River Valley) 11. Trauma history Physical Examination Vital Signs Heart rate, blood pressure, temperature, and respiratory rate should be determined immediately. The oxygen saturation also should be 236 J.E. Langenfeld determined using a pulse oxymeter (90% or below demonstrates severe hypoxia). Head, Eyes, Ears, Nose, Throat Assess the presence of enlarged lymph nodes, which may signify metastatic lung carcinoma. A carotid bruit suggests the presence of car- diovascular disease. Examine the nose for evidence of bleeding. Chest/Lung Assess whether breathing is labored, which may indicate pneumonia, presence of blood in the tracheobronchial tree, or pulmonary embolus. The presence of diminished breath sounds and vocal fremitus sug- gests consolidation of the lung. The presence of rales suggests conges- tive heart failure. Cardiovascular The rhythm, presence of a cardiac murmur or a jugular venous distention, and the point of maximal impact should be determined. Abdomen Examine for the presence of an enlarged liver, which can occur in right- sided heart failure. Extremities/Skin Assess for the presence of a coagulopathy (petechia, bruises). Unilateral leg swelling suggests deep venous thromboses. Bilateral leg edema is more consistent with lymph edema or congestive heart failure. Diagnostic Evaluation (Table 13.2) The history and physical help determine which diagnostic tests are needed and the urgency with which you need to proceed. In general, Table 13.2. Diagnostic evaluation for hemoptysis. Vital signs Arterial blood gas Portable chest radiograph Blood work CBC Electrolytes BUN/creatinine Liver function PT/PTT Type and crossmatch Sputum cultures Pulmonary function test Computed tomography (CT) of the chest Bronchoscopy Flexible Rigid (massive hemoptysis) Echocardiogram IF heart disease is suspected 13. Hemoptysis, Cough, and Pulmonary Lesions 237 Figure 13.1. Chest radiograph of a patient with non–small-cell lung cancer dis- closes right hilar enlargement. all patients should receive a chest x-ray, an electrocardiogram (ECG), arterial blood gases, and blood work consisting of a complete blood count (CBC), electrolytes, blood ureanitrogen (BUN)/creatinine, liver function tests, prothrombin time/partial thromboplastin time (PT/PTT), and a type and crossmatch. Sputum cultures for bacteria and fungus should be obtained on all patients. A chest radiograph is the first diagnostic test that should be done (Fig. 13.1). A chest x-ray may demonstrate the presence of an abscess, lung nodule, consolidation, or atelectasis representing the possible source of bleeding. It also can suggest the presence of heart disease, showing enlargement of the ventricle or atrium and the presence of Kerley B lines. Massive pulmonary hemorrhage may occur from an area that appears normal on routine chest radiograph. Computed tomography (CT) of the chest helps to delineate the cause of hemoptysis (Fig. 13.2). In patients with bronchiogenic carci- noma, a CT scan may demonstrate the presence of a pulmonary mass, determine the extent of local invasion, and assess metastatic spread to the mediastinal lymph nodes, liver, or adrenal glands. A CT scan also can identify a lung abscess, bronchiectasis, lung consolidation, and an arteriovenous malformation. A flexible bronchoscopy frequently is used in the evaluation of a patient with hemoptysis. A flexible bronchoscopy can identify the site of the bleeding, which is critical if surgery is contemplated as a means of controlling the bleeding. A flexible bronchoscope can detect the presence of a tumor obstructing a lobar bronchus. Bronchial washings should be sent for cultures, and a cytology specimen should be exam- ined for the presence of cancer cells. A rigid bronchoscopy most often 238 J.E. Langenfeld * * * Figure 13.2. Accompanying computed tomography (CT) scan confirms the presence of extensive hilar and mediastinal adenopathy. In addition, a focal peripheral lung opacity is present: the primary lung neoplasm. Atelecfic changes also are seen in the right upper lung (**). The tumor invades the main pulmonary artery (*). A right pleural effusion is seen. This is too small to be visible on the posteroanterior (PA) chest radiograph. is used in
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