Hemoptysis | Clinical Medicine

foreign what's up Ninja nerds in this video today we're going to be talking about hemoptysis this is a part of our clinical medicine section if you guys like this video it helps you it makes sense please support us and you can do that by hitting that like button commenting down the comment section and please subscribe also really urge you guys please if you gives you an opportunity go down the description box below there's a link to our website really urge you guys to become members we have a lot of cool things there we got notes we get illustrations we're developing question Banks we're developing exam prep courses and if you guys want to we even have some merchandise that you guys can take a look at all right let's start talking about hemoptysis this is a super quick lecture it's designed to help you guys understand how to work it up really so when a patient develop some optuses how would we Define that that's when they're coughing up blood really that's the primary feature that you want to look for when a patient is coughing up blood you definitely want to be thinking about hemoptysis now whenever a patient starts coughing up blood you know the thing that you should start running through your mind is what's the reason for this and the pathophysiological process comes down to three particular things one is there's bronchial alveolar inflammation something is inflaming or affecting the Airways and that's causing a potential erosion through the bronchial wall and then eventually some bronchial arteries to be ulcerated and blood to leak in that's the primary pathophysiology so what are some couple things to think about well one of these things that can cause bronchial alveolar inflammation would be potentially pneumonia so sometimes necrotizing pneumonia can definitely do this I would think that about this more particularly um as a particular pathogens such as tuberculosis tuberculosis is a relatively common cause of patients developing pretty significant hemoptysis so that's one so if a patient has an infection here let's say of their Broncho alveolar area and it just kind of erodes into the smaller bronchial artery area they can start developing blood that kind of starts leaking in to the bronchial Airways and then eventually it'll trigger the irritation of the Airways and cause them to cough that up another scenario could be potentially just bronchitis you know patients who develop bronchitis like acute bronchitis this is another really common etiology as well so bronchitis is a really particular big one another one would be whenever they have dilation of the Airways and lots of inflammation that begins to cause erosion that would be a big one with what's called bronchiectasis this is a very common cause of massive hemoptysis which sometimes people like to Define by volumes or rate at which we produce the amount of blood from the cough but I would think it's more determined based upon the degree of hemodynamic instability or respiratory failure that you should base massive amoptysis but we'll talk about that in the complications either way these are the big things that are going to be precipitating this particular process here where blood will be leaking into the airway via the bronchial arteries being eroded now that is again a big Point here when we talk about hemoptysis there is bronchial arteries that are the primary artery that are getting eroded into or ulcerated into that are causing hemoptysis 90 95 of the time it's those rare scenarios and I mean rare like five percent of cases it could be pulmonary vascular diseases and these pulmonary vascular diseases I think the two big ones that I want you guys to think about here is one is you have a clot you know patients who develop particular clots such as pulmonary embolism so I want you to think about maybe a pulmonary embolism this can cause hemoptysis I'd say It's relatively rare this could be from an infarction of the lung tissue this could be because of elevated pressures proximal to the actual embolus but either way this can definitely cause bleeding to occur all right now another one that I would say is definitely something to consider would be something called vasculitis this is actually a high yield one to remember so there is many different types of vasculidities but I think the two big ones that I want you guys to remember here are called anca vasculitis which you see with what's called granular granulomatosis polyangiitis also known as wegeners and another one is called anti-gbm antibodies which is related to a disease called good pastures disease usually this cause blood in the kidneys and blood in the lungs that's one way that you can think about it but again anti GBM antibodies cause attack of the actual lung tissue and particularly the small pulmonary vessels and so if you cause destruction of these you can cause blood to leak out into the actual Airways and then again cause hemoptysis these are two really big ones but I'd focus on vasculitis and I would also think about again bronchial alveolar inflammation the last one here I would say is a really really common cause and it's pretty obvious I think based upon the name here is Bronco alveolar neoplasia and this is usually due to lung cancer so when patients have lung cancer this is a really big one because they get lots of blood supply for the lung cancer and whenever you get lots of blood supply to the lung cancer there is no doubt about it that that can actually lead to bleeding and so patients who develop hemoptysis I want you to think three pathophysiological processes one inflammation or infection bronchiectasis necrotizing pneumonia with the big one being tuberculosis as well as acute bronchitis bronchiovular neoplasia such as lung cancer and then lastly pulmonary vascular disease with an emphasis vasculitis now that we've talked about hemoptysis and what that actually is and the causes of pathophys let's talk about the complications that can arise all right my friends now we're going to talk about the complications associated with massive hemoptysis So the patient's really coughing up massive amounts of blood and they're really having a really really terrible one usually this could be things like vasculidities or this could be bronchiectasis when there's large amounts of volumes of blood that are being kind of coughed out of the Airways are not effectively coughed out of the Airways that can definitely become a problem so imagine there's just massive volumes that are coming from your bronchioles not all of it's going to be effectively coughed up and so because of that one of the problems here is you can definitely start filling up some of these alveoli and if you start filling up a lot of these alveoli with blood what's the potential complication that's going to arise here you're going to get any good ventilation to these alveoli no and so the downstream effect of having massive hemoptysis is it's going to be literally impossible to clear all of it and so what would happen is you're going to lead to alveolar filling and this is going to be filled with blood and if there's alveolar filling that's going to lead to massive VQ mismatch potentially even a shunt process and we know that VQ mismatching or shunt processes make it very very difficult for gas exchange to occur here and this will be significantly impaired so as perfusion May remain normal through these whenever the blood leaves this particular area where the alveolar Hemorrhage is this is definitely going to lead to a reduction and oxygen and this is referred to as hypoxemia and that could be a potential scary thing that you can have here is massive hemoptysis leading to alveolar filling leading to VQ mismatch leading to hypoxemia now when these patients become hypoxemic they may look pretty terrible there is no doubt about it that they could potentially have an increase respiratory rate and increase work of breathing as a result of this so watch out for that but again I think that this is really one of the big things to take away here is that respiratory failure is a potential sign of massive hemoptysis due to alveolar feeling VQ mismatch and then as an effect hypoxemia all right my friends now that we've covered hemoptysis causes pathophys and complications let's now talk about how to diagnose it how do we approach hemoptysis well the patient's coughing up blood first thing that I would do is I would make sure that you just rule out a simple coagulopathy do they have are they on anticoagulants or anything like that that could be causing this if it's abnormal it could be a coagulopathy the next thing is obtain acid fast bacillus for what this would be particularly for tuberculosis and sputum cultures for necrotizing infections and the next thing I would do is I obtain an anchor and an anti-gbm antibody because this will tell me if this is going to be GPA right especially if it's the sea anchor or if it's EPA and MPA if it's the pankus an anti-gbm for good pasture syndrome okay and lastly I would also consider obtaining a CT pulmonary angiogram this is going to give me a look at the CT of the chest so it'll give me a look at the bronchial tree but it also give me a look at the pulmonary vessels and I'll help to be able to see if there's a pulmonary embolism bronchiectasis or a lung Mass like a lung neoplasia and that's how we could work up the causes but whenever we're talking about treating hemoptysis and diagnosing at the same time it's really important to have this approach in your brain so if a patient has hemoptysis you need to ask yourself the question is it massive enough that it's causing respiratory failure don't base it on the volume paste it upon the risk of respiratory failure do they need to be intubated in other words is there so much sheer volume of blood in the airway that they can't cough and clear the blood from their Airway that's going to cause respiratory failure or are they already experiencing hypoxemic respiratory failure if the answer is no then you can hold off on intubation and the patient is stable enough that if you lay them flat in a CT scanner they're not going to aspirate blood or end up going into respiratory failure so get a chest CT look to see if you can find the focal source of bleeding and where it is if you find that source of bleeding oh it's in one of these bronchial arteries that I located okay I'm going to send them to IR Interventional Radiology they'll sneak a catheter into the area and embolize that bronchial vessel and stop the bleeding if the patient does require intubation because they can't clear the blood that can't cough it they're experiencing hypoxemia there's no way in heck I'm going to send this patient to the CT scanner to lay flat without intubating them they'll aspirate they'll experience a lot of VQ mismatch they'll end up coding over there in the CT scan so I'm going to intubate these patients and then what I'll do is I'll use a bronchoscope to see if I can find where the bleeding is if I can find where the bleeding is in one of those actual bronchi then what I'm going to do is I'll say okay I got an idea of where this is I can then tell IR for right now I'm going to put an endobronchial Blocker in which is going to be from the endotracheal tube and that's going to block that off and then I can go in and embolize that via IR if the patient goes to IR an embolization fails they can't embolize the artery let's say here they go in oh there it is I found the actual vessel embolized it good we're done but if the embolization failed then you have to say is this more of like a central bronchial lesion or a proximal bronchial lesion I might be better to do a rigid bronchoscopy and just go in there and cauterize it or laser that bleed if they fail and they have refractory hemoptysis in other words you've tried everything to stop this dang bleeding and it won't stop then you go to a surgery like a pneumonectomy or a lobectomy all right so that's how we would diagnostically and treatment wise approach hemoptysis I hope this made sense guys I hope that you guys enjoyed it and as always until next time [Music]