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LETTER TO THE EDITOR |
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Year : 2016 | Volume
: 9
| Issue : 2 | Page : 280-282 |
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Trepopnea due to blood clot: An uncommon presentation
Girish Sindhwani, Rakhee Khanduri, Varuna Jethani, Sanjeev Kumar
Department of Pulmonary Medicine, Swami Ram Himalayan University, Dehradun, Uttarakhand, India
Date of Web Publication | 1-Mar-2016 |
Correspondence Address: Girish Sindhwani Department of Pulmonary Medicine, Swami Ram Himalayan University, Dehradun, Uttarakhand India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.167964
How to cite this article: Sindhwani G, Khanduri R, Jethani V, Kumar S. Trepopnea due to blood clot: An uncommon presentation. Med J DY Patil Univ 2016;9:280-2 |
Sir,
We present an interesting case of trepopnea due to a large blood clot occluding right main bronchus. A 68-years-old lady presented to emergency department with complaints of an episode of hemoptysis and breathlessness. Hemoptysis of around 200 ml had occurred a few hours before she presented to hospital. Breathlessness started after bout of hemoptysis and was of grade-IV of modified Medical Research Council Scale. Dyspnea was more pronounced in the right lateral decubitus position. There was no preceding history of respiratory complains and past history of cardiac or respiratory disease was not given by the patient. She was not on medications like antiplatelets or anticoagulants. On examination, she was having tachypnea and hypoxia without oxygen supplementation (SpO 2 = 92% and 70% in left and right decubitus positions, respectively). Breath sounds were reduced in intensity on right lung fields. Rest of systemic examination was normal. Her routine blood counts and coagulogram were normal. Her echocardiography was normal. Computed tomography pulmonary angiogram was done which was normal and bronchiectatic changes along with collapse were found in right middle lobe [Figure 1]. Management with oxygen supplementation, hemostatics and cough suppressants along with intravenous fluids was started. Hypoxia improved with oxygen supplementation but differential oxygen saturation in the lateral decubitus positions (lesser in right lateral position) persisted. Bronchoscopy was performed with the patient in semi-supine position. It revealed a large blood clot lying in the right main bronchus almost completely occluding it [Figure 2]. The bronchoscope could not be negotiated further down this bronchus. Removal of the clot was not attempted as it could precipitate recurrence of bleeding. By next day, her condition worsened for which she had to be intubated endotracheally and transferred to intensive care unit for mechanical ventilation. Her right lung had collapsed by this time [Figure 3]. Bronchoscopy was repeated under general anesthesia. The blood clot stuck in right main bronchus was removed with the help of snare and forceps. The clot came out in the shape of a bronchial cast. Further down the main bronchus, blood clots were present in all the segmental bronchi of right bronchial tree. All the clots were removed. Bronchoalveolar lavage was obtained from middle lobe. The patient got stabilized and could be weaned off artificial ventilation by next day. The chest X-ray done after the procedure was normal [Figure 4].
Trepopnea is a term used to define breathlessness in either lateral decubitus position. Trepopnea in left lateral position is seen in patients with congestive heart failure, wherein the mechanism depicted is increased sympathetic input and increased pulmonary venous pressure in the decubitus position. [1] However in patients with pulmonary conditions, dyspnea occurs with the affected lung in the dependent decubitus position. Various other conditions like lung cancer, cardiac tumors, diaphragmatic paralysis, right to left interatrial shunts, etc. [2],[3],[4],[5] have been reported to cause trepopnea. | Figure 1: Chest computed tomography showing collapse and bronchiectasis of the right middle lobe
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| Figure 2: Bronchoscopic image showing blood clot occluding the right main bronchus
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| Figure 4: Chest skiagram showing normalization of the right lung after the procedure
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The present case is interesting because the similar presentation of trepopnea due to a blood clot obstructing a main bronchus has not been reported. The case exhibited right main bronchus obstruction by a large blood clot. The patient had bleeding from a bronchiectatic right middle lobe, and the blood got clotted before it could be coughed out and caused obstruction of all the segments of the right lung. The resulting ventilation perfusion mismatch caused trepopnea; the patient became breathless and hypoxemic in the right lateral decubitus position. Initially, we thought that dyspnea with hemoptysis was probably due to pulmonary embolism, but a normal pulmonary angiogram ruled it out. The cause of unexplained trepopnea was then found out on bronchoscopy. The blood clot was then removed bronchoscopically.
References | | |
1. | Leung RS, Bowman ME, Parker JD, Newton GE, Bradley TD. Avoidance of the left lateral decubitus position during sleep in patients with heart failure: Relationship to cardiac size and function. J Am Coll Cardiol 2003;41:227-30. |
2. | Tufekcioglu O, Yildiz A, Kacmaz F, Sokmen Y, Ozeke O, Celenk MK, et al. Trepopnea in a patient with cardiac tumor. Echocardiography 2006;23:165-7. |
3. | Alfaifi S, Lapinsky SE. Trepopnea due to interatrial shunt following lung resection. Chest 1998;113:1726-7. |
4. | Tsunezuka Y, Sato H, Tsukioka T, Shimizu H. Trepopnea due to recurrent lung cancer. Respiration 2000;67:98-100. |
5. | Acosta J, Khan F, Chitkara R. Trepopnea resulting from large aneurysm of sinus of Valsalva and descending aorta. Heart Lung 1982;11:342-4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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