219 - Haemoptysis 2 (Pulmonary circulation)

Question 1

what is haemoptysis and what can it be confused with?

Answer 1

coughing up of blood/bloody sputum from respiratory tract below the larynx (blood is bright red & acidic)
confused with haematemesis (blood from GIT usually coffee ground colour & acidic) & epistaxis (ENT source)

Question 2

haemoptysis always warrants invesitgation, what tests should a GP organise?

Answer 2

CVR (mandatory), bloods (FBC, clotting screens & MC&S), ABGs, sputum (MC&S, AFB (acid fast bacilli) & cytology)

Question 3

what can cause small and massive haemoptysis?

Answer 3

• bronchitis in smokers, pneumonia (lobular usuallt streptococcus pneumonia), tuberculosis, bronchiectasis, lung cancer, heart failure, PE, anticoagulation
• massive haemoptysis (>100ml emergency) - bronchiectasis, lung CA, TB, aspergilloma, vascular abnormalities, vasculitis

Question 4

what can cause cavities and are prone to opportunistic infections?

Answer 4

TB, sarcoidosis, aspergilloma

Question 5

what is bronchiectasis?

Answer 5

abnormal & permanent dilation of the proximal bronchioles due to inflammation leading to the destruction of elastic/muscular components of walls. Occurs after damage by resp infections/cystic fibrosis & bronchioles dilate with damaged cilia & mucous stasis. infections occur as a result and further damage - cycle

Question 6

what are the signs and symptoms of bronchiectasis?

Answer 6

• persistent productive cough with symptoms of chronic bronchial sepsis (foul smelling, purulent sputum)
• dyspnoea, polyphonic wheeze, finger clubbing, coarse mid inspiratory crackles, haemoptysis

Question 7

what are the inherited and acquired causes of bronchiectasis?

Answer 7

• inherited - cystic fibrosis, immotile cilia syndromes (kartagener’s)
• acquired - childhood pneumonia (pertusis, measles, TB), chronic bronchial obstruction, chronic aspiration, allergic bronchopulmonary Aspergillosis (ABPA), IG deficiency, HIV, RA, UC

Question 8

what is aspergillosis?

Answer 8

mould (fungal) infection seen in asthmatics & Cystic fribrosis with fungus ball in cavity. S&S - flitting pulmonary consolidations, blood & sputum eosinophilia & ↑IgE and apergillus precipitins. Tests - skin prick test

Question 9

what investigations can be done for suspected bronchiectasis?

Answer 9

• sputum - MC&S, bloods

* imaging - CT/MRI - cygnet ring - large lilated bronchiloles next to arterioles

Question 10

what treatment should be given for bronchiectasis?

Answer 10

abx to treat infection

• physiotherapy
• bronchodilatiors

Question 11

what is the difference between a non massive and massive PE?

Answer 11

• non-massive - px haemodynamically stable, small distal infarction causes pleuritic pain, SOB, fever, haemoptysis
• massive - px haemodynamically unstable, PE at bifurcation of PAs with ↑RR, ↓O2, systolic BP<90 or 40mm drop, ↑JVP, AF

Question 12

what is a paradoxical emboli?

Answer 12

caused by atrial septal defect causing systemic manifestation

Question 13

what is virchow’s triad?

Answer 13

a presdisposition to thrombosis caused by:

• venous stasis
• injury to vessel wall
• ↑blood coagulability

Question 14

what are the risk factors for a PE?

Answer 14

• prothrombotic states - post surgery, pregnancy, malignancy
• immobility - fracture, paralysis, bed rest
• previous VTE

Question 15

how might a px with a PE present?

Answer 15

• often asymptomatic

* chest signs - pleuritic pain, dyspnoea, haemoptysis (in s sign (calf pain on dorsiflexion)

Question 16

how might you assess the risk of a PE in a px?

Answer 16

Wells score - high >6 mod 2-6

Question 17

what investigation can be carried out on a px with a suspected PE?

Answer 17

• bloods - D-Dimer (breakdown of cross linked fibrin ↑in thromboembolism) - only excludes those with low prob as can also be due to trauma, post surgery, liver/renal disease, pregnancy, ca, heart disease. ABG low CO2 & ↑pH (hyperventilation. FBC & clotting screen
• ECG - S1Q3T(inv)3, RIght ventricular strain (ST depress & T wave in rt side (V1-V,II, III, aVF)), New right bundle branch block
• CT Pulmonary angiogram 1st line
• bedside echo - show RV overloaded

Question 18

what treatment would you give for a PE?

Answer 18

• O2 therapy
• resuscitation + fluids
• anticoagulant therapy - Low molecular weight heparin - stop when INR 2.5 then warfarin
• Thrombolysis in haemodynamic instability. warfarin for 3m if clear cause, 6m if no clear cause

Question 19

what other causes are there for a PE?

Answer 19

fat embolism (long bone fracture), tumour emblism, septic embolism (iv drug users - usually strphylococci)

Question 20

what causes a cavitating mass?

Answer 20

• carcinoma (Squamous cell)
• lung abscess
• rheumatoid nodule
• embolus (septic)
• vasculitis with granulomatosis - chronic ENT symptoms, systemic symptoms, renal failure, +ve cANCA, high ESR
• bronchogenic cyst
• hydratic cyst

Question 21

what can cause pulmonary arterial hyperternsion?

Answer 21

collagen vascular disease, pulmonary shunts, portal hypertension, drugs/toxins, HIV. mean PAP>25mmHg…needs R+LHC to confirm

Question 22

what can cause pulmonary venous hyperternsion?

Answer 22

L sides atrial or ventricular heart disease / valvular disease

Question 23

what can cause pulmonary hyperternsion with hypoxia?

Answer 23

COPD, instititial lung disease, OSA

Question 24

what can cause pulmonary hyperternsion due to chronic thromboembolic disease?

Answer 24

thromboembolic obstruction pf proximal/distal PA, tumor, foreign material