Case study

81 years old male, P/W haemoptysis

PPHx: Sudden onset haemoptysis for 2/7 Seaspoonful frank blood mixed with phlem 4-5 times the day before, The day admission,3-4 times frank blood only First episode Nil pleuritic pain/SOB/recent chest

infection/precious TB/pets, birds/recent travel

Otherwise previously well Independent to ADLs 1 year ago able to walk 1km, now 100-200m limited, pt blames arthritic hip pain, but not SOB

PHx: IHD – PTCA 2003 R CVA 27 years ago – Nil deficiency ? CRF ( Cr 118/ eGFR 51 in 2008) HT High Chol

Social Hx: From Ltaly Migrated 1960 Builder/labour job Heavy smoker 70 pack year

Medication: Aspirin Atacand Plavix Lipitor

Physical Examinatioin Afebrile T 36.5 HR 75 RR15 SatO2 96% RA BP 117/44 Chest: Treachea midline AE decreased, Fixed monophonic wheez L & R mid zone Others NAD

Blood result: FBC: HB 140 / WCC 8 EUC: Urea 7.2 / Cr 12.1 / eGFR 53 LFT: Normal Coag: INR 0.9 Resp Culture: neg

CXR

Spirometry: FEV1 1.59 (57%) FVC 2.69 (71%) FER?? 0.59

Showed obstruction

Impression: Haemoptysis for investigation B/G Heavy smoker & undignosed COPD DDX: -- ? Malignancy -- ? Infection

Management: Admit resp. ENT review: excluded ENT issue Chest and neck CT: 3X2.2 central RLL mass,

possible liver mass Haemoptysis solved the third day of

admission, discharged, bronchoscopy as outpatient

Bronchoscopy: A polypoid appearing rounded tumour

visualised in the medial based segment of the RLL approx 1cm from the foramen

Culture Bronchial lavage: neg Rt lower lobe medial segment tumour biopsy. Histology showed differentiated invasive squamous

carcinoma. Bronchial Washing (RLL) - Atypical squamous cells.

Pt follow up with ARAC clinic

PHx: IHD – recently inferior STEMI 1 PCI to RCA VF arrest –required 1X DC shock –VT Previous PCI 6 years ago HTN High chol TIA 2006 Left ilio femoral endarterectomy 2009 Carotid endarterectomy 2007

Social Hx: Ex-smoker: 40 pack years Quit smoke 1/12 ago EtoH occasional

Medication: Aspirin Prasugel Atenolol Atorvastatin Fosinopril Thyroxine

Physical examination: Afebrile T 36.5 P 60 BP 115/65 RR 20 SatO2 97% RA Coughing frankl blood Chest: Right side dullness Right midzone creps

Blood test: HB 129 PLT 450 INR normal

CXR: Complete collapse of RUL No definite hilar mass

CXR

Impression: Frank haemoptysis secondary to RUL mass

Pt is reviewed by Dr. Johnson. Bleeding is from the mass, unlikely from

pulmonary vessel as CTPA neg Bronchoscopy at this stage will not be of any

benefit The definite Tx option is for Cardiac thoracic

involvement with possible RUL lobectomy As per cardiac thoracic:

Watch till haemoptysis settles Then for definite therapy in the next few days

Management plan: Need HDU admission Fluids resuscitation Stop aspirin & plevix Sputum cytology NBM If pt cont. massive haemoptysis, require

urgent intervention O/Night – bronchoscopy by cardiac thoracic +/- RUL lobectom

Management plan ( cont’s) If pt stable O/N, then

Bronchoscopy, Bx OT Sputum cytology PET scan for staging

Discussed with cardiology: not for platelets unless active bleeding

Management plan (cont’s)Further discussed with Dr. Desai & Dr.

French (cardiac thoracic), suggest: No surgical intervention at this stage If severe haemoptysis recur,

Protection of airway by double lumen tube Pt need to have bronchoscopy Embolization

Progress: Pt had Bronchoscopy next day, showed:

RUL bronchus mass Histology result: Poorly differentiated

invasive squamous carcinoma PET showed: only right hilar and upper

lobe uptake, nil mets

Progress (cont’s): Pt is stable, haemoptysis is settled,

Discharge home Follow up with Dr. Johnson and DR. French (CTS)

Further admission later for stent thrombosis and NSTEMI

Had chemotherapy Now on Radiotherapy – with curative intent

62 years male, P/W Haemoptysis for 1/7 PPHx:

Sudden onset of haemoptysis First episode Up to 1 L of bright blood with small blood clots Nil SOB / TB / pleuritic pain / recent chest

infection / CP