79-Year-Old Man With Massive Hemoptysis

A 79-year-old man with medical comorbidities notable for a 20-pack-year smoking history, squamous cell carcinoma (SCC), chronic kidney disease stage III, and hypothyroidism presented with hemoptysis. Home medications included aspirin, 81 mg daily, omeprazole, 10 mg twice daily, simvastatin, 20 mg daily, and albuterol nebulizers as needed for dyspnea. He estimated the volume of blood to be about a cup (approximately 200 mL) and described it as bright red with clots and associated with chest tightness. The patient initially presented to an Iowa hospital where his vital signs were notable for a temperature of 37 °C, systolic blood pressure in the 80s, and oxygen saturation of 85%, which improved with supplemental oxygen via 4-L nasal cannula. On general examination, he was alert and well appearing. Pulmonary examination was notable for a cough productive of 10 to 20 mL of blood every few minutes, bilateral rhonchi, and diminished breath sounds at the right lung base. Cardiopulmonary examination revealed tachycardia without murmur or peripheral edema. Skin, abdominal, neurologic, and musculoskeletal examinations yielded unremarkable findings. Immediate chest radiography revealed mild patchy opacification in the lung bases, much greater on the right than on the left. 1.Which one of the following is the most important first step in stabilizing this patient? a.Nasopharyngeal suctioning b.Intubation and mechanical ventilation c.Volume resuscitation d.Immediate computed tomography (CT) of the chest e.Place the patient in the right lateral decubitus position CORRECT ANSWERS: 1. e. 2. d. 3. c. 4. a. 5. e.