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A 46-year-old man, a nonsmoker, was examined by his hometown physician because of a 4-year history of recurrent hemoptysis. Six months before the onset of this symptom, a persistent cough had developed, unassociated with a respiratory illness. During the 4-year period, he expectorated 1 to 3 teaspoonsful (5 to 15 mL) of bright red blood on at least seven occasions. The patient denied having dyspnea, wheezing, fever, or chills. The medical history included symptoms of chronic nocturnal gastroesophageal reflux and nephrolithiasis treated several years earlier.
1.
Which two of the following diagnoses are unlikely in this patient?
a.
Carcinoid tumor of bronchus
b.
Small cell carcinoma of lung
c.
Tracheobronchialforeign body
d.
Bronchiectasis
e.
Chronic aspiration pneumonia
Carcinoid tumor of the bronchus is a possibility because it typically manifests with hemoptysis and wheezing in patients of this age-group, and hemoptysis can be substantial.
Small cell carcinoma is unlikely because it almost exclusively occurs in heavy smokers and is more likely to occur in persons older than the current patient. Slow progression during a 4-year period is also unlikely. Retention of a foreign body, although uncommon in this age-group, may remain asymptomatic for many years and then cause hemoptysis because of either erosion of a blood vessel or development of bronchiectasis in the area of foreign body impaction. Similarly, idiopathic chronic bronchiectasis may remain asymptomatic and manifest with hemoptysis. Hemoptysis of the severity described in our patient is not a feature of chronic aspiration pneumonia.
Clinical examination during the third episode of hemoptysis revealed coarse lung sounds with a bronchial quality in the basal areas of the left lung. Intermittent wheezing was heard in the left anterior chest area. The patient had no clubbing. A chest roentgenogram disclosed increased markings in the base of the left lung without volume loss (Fig. 1). Pulmonary function tests showed no abnormalities. Results of routine laboratory tests were normal. During the examination, the patient expectorated 1 teaspoonful (5 mL) of blood.
Fig. 1Posteroanterior roentgenogram of chest, demonstrating increased markings in left basal lung regions behind the heart.
Which one of the following procedures is most likely to be helpful at this point?
a.
Direct laryngoscopy
b.
Computed tomography (CT) of chest
c.
Coagulation studies
d.
Bronchoscopy
e.
Barium esophagogram
Direct laryngoscopy may reveal bleeding in the upper respiratory tract but not in the lower respiratory tract. CT of the chest may be indicated at a later stage in this patient, but it is not the test of choice at this time because the chest roentgenogram has already indicated the left lower lobe of the lung as the likely site of bleeding. Even if abnormalities are detected on coagulation tests, they will not reveal the cause of hemoptysis. Furthermore, a coagulopathy, in the absence of an underlying bronchial or pulmonary pathologic condition, almost never causes this degree of hemoptysis. In contrast to laryngoscopy, bronchoscopy will allow visualization of the entire respiratory tract and is most likely to provide answers about the site and cause of hemoptysis. Barium examination of the esophagus is unlikely to yield the necessary information in a patient with hemoptysis.
The patient underwent a diagnostic flexible bronchoscopy on two separate occasions, both of which revealed active bleeding and appreciable amounts of granulation tissue in the distal part of the left main stem bronchus. Because of the fear of inciting further bleeding, no brushings or biopsy specimens were obtained. Cytology and cultures of bronchoscopic washings were nondiagnostic. The patient returned several days later for further evaluations, at which time he had no hemoptysis.
3.
Which one of the following tests should be scheduled next?
a.
Pulmonary angiography
b.
Bronchial angiography
c.
Magnetic resonance imaging
d.
Videothoracoscopy
e.
High-resolution CT ofchest
Pulmonary and bronchial angiographic studies are likely to demonstrate the site of bleeding during active bleeding. In this patient, who was not currently bleeding, these tests should be postponed until completion of other less invasive diagnostic studies to determine the nature of the process noted on the chest roentgenogram. Magnetic resonance imaging is helpful in assessing the relationship between the airways and the vascular structures, but it is unlikely to help in this patient. Videothoracoscopy is an option if lung biopsy is necessary. to substantiate the pathologic process responsible for the lung abnormality observed on the chest roentgenogram. At this point, the best test for further characterization of the abnormality on the chest roentgenogram is high-resolution CT of the chest.
The high-resolution CT of the chest demonstrated extensive cylindrical bronchiectasis, limited to the lower lobe of the left lung, but no other abnormalities. Because bleeding can be profuse in patients with bronchiectasis, recognizing the vascular source of hemorrhage (pulmonary artery versus bronchial artery or other vascular structures) is important, inasmuch as treatment depends on this information.
4.
Which one of the following vascular structures is responsible for the hemoptysis in patients with bronchiectasis?
a.
Pulmonary artery
b.
Pulmonary vein
c.
Bronchial artery
d.
Bronchial vein
e.
Pulmonary capillaries
Hemorrhage from any of the aforementioned vessels can be brisk and life-threatening. Bleeding from the pulmonary artery and vein is more common in patients with arteriovenous fistulas than in those with bronchiectasis. Pulmonary venous bleeding is rare and may occasionally occur in patients with pulmonary veno-occlusive disease. In almost all patients with bronchiectasis, hemoptysis is caused by rupture of a bronchial artery into the bronchial lumen. Bronchial arteries arise from the systemic circulation (branches of the thoracic aorta) and therefore have higher systemic blood pressure in contrast to that within the pulmonary arteries and veins. Consequently, hemorrhage in bronchiectasis can be brisk and severe. The normal course of the bronchial artery is along the bronchus. High-resolution CT of the chest in patients with bronchiectasis usually demonstrates the ectatic bronchus and an adjoining prominent bronchial artery (“signet-ring sign”). Bleeding from a bronchial vein is rare. Hemorrhage from the pulmonary capillary network can occur in patients with pulmonary edema and various alveolar hemorrhage syndromes. Hemoptysis can also arise from a fistulous communication between airways and pulmonary or bronchial vessels, such as in patients with trauma, thoracic aortic aneurysm, or Behçet's syndrome.
The patient was advised to undergo left lower lobectomy. He was referred to our, institution for the surgical treatment.
On further inquiry, no other information about the cause of the bronchiectasis was forthcoming from the patient. Findings on clinical examination were as described earlier.
5.
Which one ofthe following tests should be consideredto identify the cause ofbronchiectasis in this patient?
a.
Pilocarpine iontophoresis to exclude cystic fibrosis
b.
Serum immunoglobulins
c.
Ultrastructural studies to exclude ciliary dysmotility
d.
Bronchography
e.
Bronchoscopy
Cystic fibrosis, agammaglobulinemia or hypogammaglobulinemia, and ciliary dysmotility are well-known causes of bronchiectasis. These entities generally produce bilateral diffuse bronchiectasis, and all are usually associated with other chronic symptoms.
As described previously, our patient had localized bronchiectasis, and his symptoms began somewhat abruptly 4 years earlier. Currently, bronchiectasis is reliably confirmed by high-resolution CT of the chest. Therefore, bronchography with use of a radiocontrast agent is rarely indicated.
Furthermore, bronchography is unlikely to detect the cause of the bronchiectasis.
Even though the patient had undergone bronchoscopy twice elsewhere, we elected to repeat the procedure because the information obtained from the earlier procedures was inconclusive. With the patient under general anesthesia, flexible bronchoscopic examination revealed a foreign body (aluminum pull tab from a beer can) impacted in and partially obstructing the distal left main stem bronchus. Even though rigid bronchoscopy is the preferred method for removal of foreign bodies, we decided to attempt flexible bronchoscopy but made provisions to proceed immediately with rigid bronchoscopy if necessary. The foreign body was removed with a flexible bronchoscopic biopsy forceps without difficulty and with minimal bleeding.
The patient was dismissed and given empiric antibiotic therapy for 4 weeks. A follow-up telephone interview 5 years later revealed that no hemoptysis or major respiratory symptoms had occurred since removal of the foreign body.
6.
Which one of the following statements about tracheobronchial foreign bodies is not true?
a.
Tracheobronchial foreign bodies are very uncommon in adults
b.
Most adults, but not children, recall the episode of for eign body aspiration
c.
Organic foreign bodies are more likely than inorganic foreign bodies to produce mucosal inflammation and granulation tissue
d.
Foreign bodies made of aluminum are radiolucent
e.
Rigid, rather than flexible, bronchoscopy is preferable
Tracheobronchial foreign bodies are very common in children but very uncommon in adults. All patients-both adults and children—generally have a poor memory of foreign body aspiration. Mucosal inflammation, edema, and formation of granulation tissue are more likely to occur when the aspirated foreign body consists of organic rather than inorganic material.
These findings are caused by the release of chemicals, oils, and other irritants contained in the organic foreign body. Even though aluminum is a metal, it is radiolucent and may not be visible on roentgenographic studies. Rigid bronchoscopy is the procedure of choice for removal of foreign bodies in children and adults.
7.
Which one of the following statements about the clinical features of tracheobronchial foreign bodies in adults is not true ?
a.
A chest roentgenogram is not helpful in the diagnosis
b.
Foreign body aspiration can remain undiagnosed for years
c.
Hemoptysis occurs in 15%
d.
The right 'bronchial tree is the most common site of lodgment
e.
Acute and subacute complications are less frequent in adults than in children
A chest roentgenogram (posteroanterior or lateral) is helpful in the diagnosis of tracheobronchial foreign bodies.
The roentgenographic findings include atelectasis, pneumonia, air-trapping, and mediastinal shift to the opposite side on a postexhalation film. Retention of a foreign body in adults can remain undiagnosed for years and may lead to incorrect diagnoses of asthma, bronchitis, or chronic pneumonia. Hemoptysis has been noted in 15% of patients.
The site of lodgment of the foreign body is dependent on the anatomic variations in the tracheobronchial tree and the body posture of the subject at the time of aspiration. The most frequent site is the right bronchial tree because of its somewhat straight (vertical) orientation.
Acute and subacute complications are more frequent in children than in adults and may include acute dyspnea, laryngeal edema, asphyxia, stridor, cardiac arrest, and pneumothorax.
DISCUSSION
The first step in evaluating hemoptysis is to ascertain that the blood is truly originating from the respiratory tract. Frequently, patients are unable to distinguish true hemoptysis from hematemesis or expectoration of aspirated blood. The expectoration of blood previously aspirated into the respiratory tract from other sources constitutes pseudohemoptysis. Clinically distinguishing the differences between true hemoptysis and pseudohemoptysis is important (Table 1). In patients with massive hemoptysis, the urgent situation may not allow performance of all analyses outlined in Table 1.
Table 1Differences Between Hemoptysis and Pseudohemoptysis
The most common cause of insignificant or streaky hemoptysis is bronchitis. Among the most common causes of severe hemoptysis are acute and chronic infections and pulmonary neoplasms (Table 2). Although cavitary lung lesions, especially those caused by tuberculosis, remain among the most frequent causes of severe or massive hemoptysis worldwide, the role of tuberculosis as a cause of massive hemoptysis in the United States has decreased (accounting for 18% of cases of massive hemoptysis and 10% of moderate hemoptysis).
Once the clinician has established that a patient has true hemoptysis (blood originating from the tracheobronchial tree), chest roentgenography should be performed immediately because an abnormality, if detected, may represent the lesion responsible for the bleeding. Bronchoscopy is the most important diagnostic test for localizing the site of bleeding and for determining the pathologic reason for the hemorrhage. In patients with a single episode of streaky hemoptysis, low clinical suspicion for an airway malignant lesion, and normal chest roentgenographic findings, however, bronchoscopy has a low diagnostic yield.
Localized bronchiectasis may occur as a result of chronic localized stenosis of a segmental or lobar bronchus, right middle lobe syndrome (localized bronchiectasis limited to the right middle lobe), chronic retention of a foreign body, chronic broncholithiasis, rare congenital defects, or chronic recurrent aspiration into the same segment or lobe of the lung,
Chronic benign or slow-growing neoplasms that obstruct the bronchial lumen also can potentially cause localized bronchiectasis.
As previously mentioned, bronchography currently is rarely indicated for diagnosing bronchiectasis because highresolution CT of the chest clearly shows the extent of involvement.
Surgical therapy can be planned on the basis of information obtained from CT. Pulmonary and bronchial angiographic studies are indicated in patients with suspected pulmonary arteriovenous malformation, bronchial arterial bleeding from telangiectasia, and pulmonary mycetoma (fungus ball). Ideally, these studies should be performed during active bleeding.
Tracheobronchial foreign bodies are common in children but rare in adults. Indeed, during a 33-year period, only 60 cases of foreign bodies were documented in adults (older than 16 years of age) at the Mayo Clinic.
The median age of the 42 men and 18 women was 60 years. In that series, the most commonly aspirated foreign bodies were food items and dental prostheses or equipment. Underlying reasons for the aspiration of foreign bodies included neurologic disorders in 11 patients, dental procedures in 10, medical procedures in 9, posttraumatic loss of consciousness in 6, and alcohol or excessive use of sedatives in 5.
As discussed, tracheobronchial foreign bodies can remain undiagnosed for years and may lead to an incorrect diagnosis of asthma, bronchitis, or chronic pneumonia. Abrupt onset of cough should suggest the possible presence of a foreign body. Hemoptysis has been noted in 15% of patients. The most important factor in diagnosing tracheobronchial foreign body aspiration in an adult is a high index of suspicion. Although we successfully extracted the foreign body with a flexible bronchoscope in the current patient, the instrument of choice for such extraction procedures is the rigid bronchoscope. In the series of adult Mayo Clinic patients, flexible bronchoscopy.
however, in selected cases and with experienced bronchoscopists, the flexible instrument has been successfully used to extract foreign bodies in children.
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