219 - Haemoptysis 2 (Pulmonary circulation) Flashcards
what is haemoptysis and what can it be confused with?
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)
haemoptysis always warrants invesitgation, what tests should a GP organise?
CVR (mandatory), bloods (FBC, clotting screens & MC&S), ABGs, sputum (MC&S, AFB (acid fast bacilli) & cytology)
what can cause small and massive haemoptysis?
- 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
what can cause cavities and are prone to opportunistic infections?
TB, sarcoidosis, aspergilloma
what is bronchiectasis?
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
what are the signs and symptoms of bronchiectasis?
- persistent productive cough with symptoms of chronic bronchial sepsis (foul smelling, purulent sputum)
- dyspnoea, polyphonic wheeze, finger clubbing, coarse mid inspiratory crackles, haemoptysis
what are the inherited and acquired causes of bronchiectasis?
- 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
what is aspergillosis?
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
what investigations can be done for suspected bronchiectasis?
- sputum - MC&S, bloods
* imaging - CT/MRI - cygnet ring - large lilated bronchiloles next to arterioles
what treatment should be given for bronchiectasis?
abx to treat infection
- physiotherapy
- bronchodilatiors
what is the difference between a non massive and massive PE?
- 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
what is a paradoxical emboli?
caused by atrial septal defect causing systemic manifestation
what is virchow’s triad?
a presdisposition to thrombosis caused by:
- venous stasis
- injury to vessel wall
- ↑blood coagulability
what are the risk factors for a PE?
- prothrombotic states - post surgery, pregnancy, malignancy
- immobility - fracture, paralysis, bed rest
- previous VTE
how might a px with a PE present?
- often asymptomatic
* chest signs - pleuritic pain, dyspnoea, haemoptysis (in s sign (calf pain on dorsiflexion)
how might you assess the risk of a PE in a px?
Wells score - high >6 mod 2-6
what investigation can be carried out on a px with a suspected PE?
- 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
what treatment would you give for a PE?
- 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
what other causes are there for a PE?
fat embolism (long bone fracture), tumour emblism, septic embolism (iv drug users - usually strphylococci)
what causes a cavitating mass?
- 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
what can cause pulmonary arterial hyperternsion?
collagen vascular disease, pulmonary shunts, portal hypertension, drugs/toxins, HIV. mean PAP>25mmHg…needs R+LHC to confirm
what can cause pulmonary venous hyperternsion?
L sides atrial or ventricular heart disease / valvular disease
what can cause pulmonary hyperternsion with hypoxia?
COPD, instititial lung disease, OSA
what can cause pulmonary hyperternsion due to chronic thromboembolic disease?
thromboembolic obstruction pf proximal/distal PA, tumor, foreign material
