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An unusual case of haemoptysis. Hardy Firm. Mr X is a 60yr old Caucasian man from Levenshulme. PC: Massive haemoptysis Short of breath Pleuritic chest pain localised to the upper zone of the left hemithorax. Initial concerns?. Cancer TB. HPC Non-productive cough for 1 week

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mr x is a 60yr old caucasian man from levenshulme
Mr X is a 60yr old Caucasian man from Levenshulme

PC:

  • Massive haemoptysis
  • Short of breath
  • Pleuritic chest pain localised to the upper zone of the left hemithorax
initial concerns
Initial concerns?
  • Cancer
  • TB
  • HPC
  • Non-productive cough for 1 week
  • No previous haemoptysis
  • He is regularly SOB on exertion, but his SOB on this occasion is much worse
  • No weight loss
  • No night sweats
differential diagnosis
Differential Diagnosis?
  • Causes of haemoptysis....
slide5
PMH:
  • 2 x TIA
  • Hypertension
  • Peptic ulcer repair plus vagotomy
  • Cholecystectomy
  • Hernia repair
  • COPD - previous admission to hospital in Feb 2011 with cough, SOB, and green sputum
slide8

DIAGNOSIS?

Emphysematous bullous disease

treatment
Treatment:
  • Left upper bullectomy - increased Mr X’s FEV1 by 10%
slide10

SH:

  • Ex-smoker - 35 pack years, stopped in 2010
  • Retired at age of 53 - was a manager of a newspaper company
  • Drinks about 14 units of alcohol/week
  • Lives with his wife - both have no history of travel outside the UK

DH:

  • Symbicort
  • Salbutamol
  • Tiotropium
  • Azithromycin
  • Simvastatin
  • Ramipril
  • Aspirin
  • Lansoprazole
  • No known allergies
on this admission
On this admission

Reminder of PC:

  • Massive haemoptysis
  • Short of breath
  • Pleuritic chest pain localised to the upper zone of the left hemithorax

Examination findings:

  • Tachycardic
  • Tachypnoeic
  • Quiet, dull left upper zone
  • Expiratory wheeze
  • BP: 100/70
  • GCS: 15
  • Temp: 36.2
investigations
Investigations:

Reminder of PC:

  • Massive haemoptysis
  • Short of breath
  • Pleuritic chest pain localised to the upper zone of the left hemithorax

Bloods:

  • Hb:11.3
  • WCC: 14.8
  • Creatinine: 68
  • CRP: 83

ABG’s:

  • pH: 7.66
  • pO2: 10.1
  • pCO2: 3.29
  • BE: -0.7
  • Bicarb: 24.7

02: 100% on 24% oxygen??

slide16

DIAGNOSIS

Left upper lobe bulla containing acute large haematoma plus active haemorrhage

treatment1
Treatment:
  • Embolisation of the arteries involved using PVA (polyvinyl alcohol) particles
  • Multiple blood transfusions
  • Discharged 10 days later
emphysema
Emphysema
  • Emphysema = dilatation + destruction of lung tissue distal to terminal bronchiole
  • Loss of elastic recoil
  • Collapse of small airways on expiration = expiratory wheeze

COPD = emphysema + chronic bronchitis

          • UK: causes 18m lost working days for men/y
pathophysiology
Pathophysiology
  • Infiltration of bronchiole walls with inflammatory cells  predominantly CD8+
  • Scarring and thickening of walls = narrowing
  • Epithelial layer: columnar cells replaced by squamous cells
  • Emphysema causes expiratory flow limitation and air trapping = pursed lip breathing
  • VA/Q mismatch = tachypnoeic
classifications of emphysema
Classifications of Emphysema
  • Centri-acinar
          • Around bronchioles affected, common
  • Pan-acinar
          • Whole lung affected, less common
          • Severe  can become bullous
          • Occurs in alpha- antitrypsin deficiency
  • Irregular
          • Scarring and damage is patchy
symptoms

Signs

Symptoms
  • Often no signs if mild
  • Tachypnoea + prolonged expiration
  • Accessory muscle use
  • Hoover sign = paradoxical lower chest movement
  • Hyperinflation and loss of cardiac + liver dullness
  • Hypercapnia: bounding pulse and flapping tremor
  • Productive cough with white/clear sputum
  • Wheeze
  • Breathlessness
  • Frequent infective exacerbations
  • Worsened by cold weather and pollution
  • Severe breathlessness on exertion
  • Systemic effects
diagnosis
Diagnosis
  • Clinical history and examination
  • Pulmonary function tests
  • Chest X-ray
  • CT
  • Blood gases
  • ECG
  • Alpha- antitrypsin levels and genotype
bullous lung disease

Definition

Bullous Lung Disease

  • Bulla (pl. bullae) – A thinly walled (<1mm thick) air filled space within the lung parenchyma of >1cm diameter.
  • Bleb – Gas containing space between lung parenchyma and visceral pleura or between the pleura.

[1]

bullous lung disease1
Bullous Lung Disease

Aetiology

  • Chronic disease
  • Diffuse emphysema
  • Cystic Fibrosis
  • Sarcoidosis
  • Acquired
  • Cannabis smoking
  • Occupational exposure (carbon, silica)
  • Genetic
  • Marfan’s syndrome
  • Ehler-Danlos syndrome
  • Alpha 1-antitrypsin deficiency
  • Alpha 1- antichymotrypsin deficiency
bullous lung disease2
Bullous lung disease

Pathophysiology

bullous lung disease3
Bullous Lung Disease

Complications

  • Spontaneous pneumothorax
  • Infection
  • Haemorrhage
  • Lung cancer
bullous lung disease aetiology

Emphysematous lung disease: Vanishing lung syndrome, Chronic emphysema.

Fibrotic lung disease: Sarcoidosis and Ankylosing Spondylitis are conditions characterised by fibrosis of the lung tissue which predisposes to bullae development.

Genetic conditions: Birt-Hogg-Dube syndrome, Marfan Syndrome, Ehlers-Danlos Syndrome.

Infective: HIV infection

Bullous Lung Disease Aetiology

bibliography
Bibliography
  • http://www.umm.edu/patiented/articles/emphysema_000195.htm
  • Kumar and Clark, p835-839