Actually had a sick patient the other day. 40-ish female coughing blood every minute or so, about a teaspoon each time, breathing in the 40s, sats in the 70s. The picture of respiratory distress: retracting, scalene muscles pulling the whole rib cage up, abdomen tensing with each expiration, retracting--the whole body working to move air.

They always teach to go through the ABCs; the patient could say her name, and had an obvious B problem. No tracheal deviation, breath sounds equal but 'wet'. Good periperhal pulses and her pressure was 147/86.

History? Gosh darn if she didn't have a history of asthma, COPD as well, tuberculosis (the MAI kind, not the typical TB), pseudomonal pneumonia, and aspergillosis, a fungal infection that can grow in old TB cavities. Well, at least it wasn't unprovoked hemoptysis.

She did well, actually. A non-rebreather got her sats up, duonebs times 2 and then a continuous neb decreased her work of breathing. Her CXR showed new opacity where an old cavitary lesion in the upper lobe had been. Who knows. Those cavities can erode into the bronchial arteries without warning; massive bleeding can occur and we transfuse, specialists embolize.

Her follow up is revealing. Her lung history started with an exposure to tricholoroethylene, which, oddly enough, doesn't mention anything about lung injury, but this poor lady needed a VATS procedure--laparoscopic resection of part of her lung. Wonder what it did to her kidneys. Come to think of it, that was the main reason we couldn't get a CT scan. She underwent embolization because she wasn't a surgical candidate, and recovered well.

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