[CPX] 객혈 hemopytpsis

 

Hemoptysis

 

Definition

The expectoration of blood… …ranging from sputum to gross blood.

 

D/Dx (organ of origin?)

Hematemesis (GI origin)     

Pseudohemoptysis

- Technically defined as expectorated blood that does not arise from the lungs or bronchial tubes.

- Nasopharynx (e.g. posterior epistaxis) / Oropharynx (above the level of the larynx)

- About 10% of cases initially thought to be true hemoptysis are actually pseudohemoptysis.

- Ask about recent sinusitis, epistaxis, rhinorrhea, pharyngitis, and/or aspiration.

 

Hemoptysis	Hematemesis
Bright red blood (+) sputum present Frothy or clotted appearance pH > 7 Associated with asphyxiation (-) nausea/vomiting	Dark red/brown blood (+) gastric contents present Coffee-ground appearance pH < 7 Asphyxiation much less common (+) nausea/vomiting

 

Risk factors

male, > 40 years old, and a smoking history.

 

Classification

The amount of bleeding does matter, particularly depending on the precise etiology

(1) Mild : 10 ~ 20mL per 24hr

(2) Moderate : 20 ~ 100mL per 24hrs

(3) Massive :  100 ~ 600mL per 24hrs

 

Causes

- Mild to moderate : Acute/Chronic bronchitis, Bronchogenic carcinoma
- Massive : Pul. TB, bronchiectasis, lung abscess, lung malignancy

- 그 외 : COPD, pneumonia (Klebsiella), lung fluke (paragonimiasis), Fungal ball (Aspergilloma)

Wegener granulomatosis, Goodpasture syndrome, Behcet ds

Pul. HTN, Pul. embolism, AV malformation

Medication (ASA, NSAIDs, Anticoagulant)

 

Histroy

- OVNDCFAM Hx FHx SHx

- Can’t Miss Questions

* A : Any hematuria (Goodpasture syndrome)

* Hx : Any prior lung, renal, heart (valvular) disease, DVT, PE

* SHx : cigarette smoking, Chemical/Asbestos exposure, Travel history (TB, parasitic, fungal exposure)

 

PE

Hyperpigmentation → Bronchogenic cancer, SCLC

Finger clubbing → primary lung malig', bronchiectasis, chronic lung abscess

Cutaneous ecchymosis → hematologic ds, anticoagulant use

Unilateral Leg swelling → DVT, PE

Arthralgias, synovitis, nasal septal perforation → Wegener granlomatosis

diastolic rumble, opening snap, loud s1, s2 → MS 

Aphthous ulcers → Behcet ds

 

Approach

1. 출혈부위를 파악하고 출혈의 양에 따라 분류

* massive hemoptysis인 경우에는 즉각적인 조취를 취할 것!

- 산소, IV line 잡기, 기침이 심한 경우에는 codein 줄 것

- 출혈이 계속되면 내경8 이상의 튜브로 intubation

- 출혈 부위 쪽 폐를 밑으로 한 측와위를 취함 (출혈이 반대쪽 폐로 흡입되는 것을 막음)

2. Hx, PE를 통해 출혈의 원인 질환 impression을 잡기

3. Lab과 함께 아래 flow에 따라서 assessment 하면 됨

 

 

 

CPX

 

 

 

(References)

1. http://ir.uiowa.edu/cgi/viewcontent.cgi?article=1030&context=fmrc

2. http://radiopaedia.org/articles/granulomatosis-with-polyangiitis

3. http://www.dirjournal.org/sayilar/69/buyuk/299-309.pdf

4. 서울아산병원 내과매뉴얼

5. Epocrates app.