50. Haemoptysis

Question 1

Haemoptysis.

a) Define
b) Should be distinguished from what 2 things?

Answer 1

a) Coughing up of blood originating from the respiratory tract

b) - Haematemesis (darker, mixed with food, concurrent GI disease/symptoms, N+V, more acidic)
- Pseudohaemoptysis: blood originating from outside the respiratory tract that stimulates a cough reflex when aspirated (eg. secondary to aspirated blood from epistaxis, oropharyngeal bleeding or haematemesis)

Question 2

Differentials.

a) Respiratory
b) Vascular
c) Other

Answer 2

a) - Malignancy: bronchogenic, lung metastates, Kaposi’s sarcoma, carcinoid tumour
- Infective: bronchitis, pneumonia, TB, lung abscess
- Inflammatory: bronchiectasis
- Other: airway trauma, foreign body, lung contusion, crack lung

b) - PE
- Pulmonary venous HTN
- Vasculitis: GPA, Churg-Strauss
- Goodpasture’s syndrome
- AV malformation

c) - Idiopathic (10%)
- Iatrogenic (eg, chest drain malposition, secondary to pulmonary artery catheter manipulation).
- Pulmonary endometriosis.
- Coagulopathy - eg, leukaemia, anticoagulant or thrombolytic agents.
- Factitious haemoptysis

Question 3

Haemoptysis: history.

a) HPC
b) Ass Sx
c) PMHx

Answer 3

a) - Site: distinguish haemoptysis from haematemesis or pseudohaemoptysis
- Onset: sudden or gradual
- Character - volume, consistency, pink + frothy (?CCF)
- Timing - duration, frequency, progressive (?malignancy)
-

b) - Fever, SOB - ?pneumonia, bronchitis
- Weight loss, anorexia, night sweats fatigue, SOB - ?malignancy, ?TB
- Cough - very productive? (?bronchiectasis)
- Fevers, night sweats and weight loss - consider TB and other infections or malignancy.
- Orthopnoea, paroxysmal nocturnal dyspnoea, leg swelling - ?CCF
- Acute SOB, pleuritic chest pain - ?PE
- Haematuria - ?vasculitis, Goodpasture’s
- Bleeding elsewhere - ?coagulopathy, vasculitis

c)

Question 4

Haemoptysis: examination

a) Initial assessment
b) Signs of malignancy
c) Possible peripheral signs o/e
d) Resp exam

Answer 4

a) A-E:
- ?Severe blood loss - vital signs - do they need blood/ fluids?
-

b) - Cachexia
- Supraclavicular lymphadenopathy, hoarse voice, Cushing’s syndrome, Horner’s syndrome
- Interosseus muscle wasting
- Monophonic focal wheeze

c) - Vasculitis lesions - ulcers, telangiectasia, nail bed infarcts, etc.
d) - Wheeze/crackles in area of bleeding

Question 5

Haemoptysis: investigations

Answer 5

Bedside

• Sputum culture
• Urinalysis (?haematuria)
• ECG

Bloods

• FBC, CRP, U+Es, clotting, ?cultures
• ESR + vasculitis screen (ANA, ANCA, complement, IgG, etc.)
• Arterial blood gases

Imaging
- CXR +/- CT scan.

Special tests

• Bronchoscopy
• Acid fast bacilli

Question 6

Haemoptysis: investigations (2)

- Who should be referred for CT chest + bronchoscopy?

Answer 6

• Recurrent haemoptysis/ duration > 2 weeks
• Aged > 40 + smoker/ex-smoker
• Volume > 30 mls/day
• Suspected bronchiectasis

Question 7

Major haemoptysis.

a) Define
b) Proportion of patients
c) Management
d) Prognosis

Answer 7

a) Approx >200 mls /24h
b) 5%

c) - A-E as per bleeding from anywhere
- Identify bleeding site (?imaging or bronchoscopy)
- Stop bleeding - embolisation, endobronchial tamponade or topical thrombin, surgical resection)
- Possibly palliative - benzos, dark towels, etc.

d) Generally very poor, especially if malignancy-related