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Clinical Presentations > Haemoptysis > Flashcards

Haemoptysis Flashcards

1
Q

What is important to assess when someone presents with haemoptysis

A

– cough, not other sources
(not epistaxis or haematemesis)
– volume of blood
(e.g. flecks, streaks, blobs, teaspoon, cup)
– frequency
– admixed with sputum or blood alone?
– fresh blood (bright red) or old (dark, clots)

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2
Q

What are the 2 sources of the blood in haemoptysis

A

bronchial and pulmonary circulation

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3
Q

Give 3 facts about the bronchial circulation

A
  • Systemic pressure
  • 2% of LV output
  • Runs entire length of bronchial tree
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4
Q

Give 3 facts about the pulmonary circulation

A
  • Low pressure
  • 100% of blood flow
  • Interacts with terminal bronchioles/alveoli
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5
Q

Give 9 areas that cover all the possible differentials for haemoptysis

A

Tumours
Infection
Vascular
Pulmonary
Iatrogenic
Systemic
Drug-induced
Haematological
Miscellaneous

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6
Q

Give the 6 possible mechanisms behind haemoptysis

A
  • Neoplasia
  • Infection
  • Inflammation
  • Impaired clotting
  • Raised pulmonary
    pressure
  • Aberrant anatomy
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7
Q

What are the anatomical areas that could be damaged which would lead to haemoptysis

A
  • Airways
    – proximal/central/distal
  • Lung parenchyma
  • Bronchial vessels
  • Pulmonary vessels
  • Extra-pulmonary
  • Trauma
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8
Q

What defines a large vs massive haemoptysis

Is this bad?

A

– Large haemoptysis 150-400ml / day
– Massive >400ml / day

– Coss Bu et al

Life threatening
– 25% mortality
 ADMISSION & URGENT INVESTIGATION

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9
Q

What kind of disease is the most common source of haemoptysis

A

airway disease

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10
Q

The most common source of haemoptysis is airways disease. What pathologies could this include (5)

A

– Inflammatory diseases - bronchitis or bronchiectasis
– Neoplasms, including primary bronchogenic
carcinoma, endobronchial metastatic carcinoma or
bronchial carcinoid
– In HIV infection, Kaposi’s sarcoma involving the
airways and/or the pulmonary parenchyma
– Foreign body & Airway trauma
– Fistula between a vessel and the tracheobronchial tree

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11
Q

What can cause pulmonary parenchymal disease leading to haemoptysis

A

infection
inflammatory/ immune disorders
coagulopathy
iatrogenic

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12
Q

Which are the key infections that cause pulmonary parenchymal disease leading to haemoptysis

A

tuberculosis, pneumonia,
aspergilloma, and lung abscess

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13
Q

How common is haemoptysis in aspergilloma patients

A

Haemoptysis, which can be life-threatening, occurs in 50 to 85 percent of patients with an aspergilloma

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14
Q

Can TB cause haemoptysis

A

TB can cause massive haemoptysis
– From active cavitary or noncavitary lung disease
– Sudden rupture of a Rasmussen’s aneurysm
(aneurysm of the pulmonary artery that slowly
expands into an adjacent cavity)

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15
Q

Which inflammatory/immune disorders can lead to pulmonary parenchymal disease and haemoptysis

A

– Goodpasture’s syndrome,
idiopathic pulmonary hemosiderosis,
lupus pneumonitis,
Wegener’s granulomatosis

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16
Q

Give 2 iatrogenic causes of haemoptysis

A

– Percutaneous or transbronchial lung biopsy
– Haemoptysis, which is usually minor and transient, occurs in 5-10% of percutaneous lung biopsies

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17
Q

Give 2 miscellaneous causes of parenchymal haemorrhage

A

Cocaine-induced pulmonary haemorrhage
– Haemoptysis has been described in six percent of habitual smokers of free-base cocaine (“crack”) and has been associated with diffuse alveolar haemorrhage

 Catamenial haemoptysis
– haemoptysis that is recurrent & coincident with menses. The cause is intra-thoracic endometriosis, usually involving the pulmonary parenchyma but occasionally affecting airways

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17
Q

Give 2 miscellaneous causes of parenchymal haemorrhage

A

Cocaine-induced pulmonary haemorrhage
– Haemoptysis has been described in six percent of habitual smokers of free-base cocaine (“crack”) and has been associated with diffuse alveolar haemorrhage

 Catamenial haemoptysis
– haemoptysis that is recurrent & coincident with menses. The cause is intra-thoracic endometriosis, usually involving the pulmonary parenchyma but occasionally affecting airways

18
Q

Give 3 key pulmonary vascular disorders that can lead to haemoptysis

A

PE

Pulmonary AV malformation, either with or
without underlying Osler-Weber-Rendu syndrome

 Elevated pulmonary capillary pressure
– mitral stenosis
– significant left ventricular failure
– Congenital heart disease
– severe pulmonary hypertension

19
Q

What is Osler-Weber-Rendu syndrome

A

an autosomal dominant disorder characterized by multiple mucocutaneous telangiectasias. These telangiectasias represent small arterio-venous malformations that frequently tend to bleeds causing the patient a significant amount of distress in their daily lives. Patients typically present with nose bleeds, gastrointestinal (GI) bleeds, and iron deficiency anaemia

20
Q

Is haemoptysis ever cryptogenic

A

up to 30% of patients with haemoptysis can have no cause identified even after careful evaluation

 In a series of 67 patients with cryptogenic haemoptysis, the prognosis was generally good, most resolved within six months of evaluation

21
Q

What are the important features of a history from a haemoptysis patient

A

includes:
age,
smoking history,
duration of haemoptysis,
association with symptoms of acute bronchitis or an acute
exacerbation of chronic bronchitis

22
Q

What are the steps in evaluating haemoptysis in clinic

A

History
Examination
CXR
CT

23
Q

Why may a CT of the chest be helpful when evaluating haemoptysis (3)

A

can help localize the bleeding site & diagnose the cause of haemoptysis

 Evaluates for several diagnoses, such as bronchiectasis, lung abscess & mass lesions, including cancer, mycetomas & AV malformations

 It may also help in the acute setting to guide arteriography or bronchoscopy to the regions of highest yield

24
Q

What is Goodpasture syndrome

A

a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs, glomerulonephritis, and kidney failure.
It is thought to attack the alpha-3 subunit of type IV collagen, which has therefore been referred to as Goodpasture’s antigen

25
Q

What is the most common bacterial cause of CAP

A

strep. pneumoniae

Gram positive diplococcus

26
Q

Which organisms can cause pneumonia with cavitation & haemoptysis?

A

Aspergillus fumigatus

Klebsiella pneumoniae

Mycobacterium tuberculosis

Staphylococcus aureus

27
Q

Describe Community-acquired Klebsiella Pneumonia (Friedlander)

A

 Gram-negative bacilli

 Affects debilitated older patients with alcoholism

 Acute necrotising pneumonia with high mortality

 Affects upper lobes

 Red currant jelly sputum described

28
Q

Give 2 bacterial and 3 fungal causes of lung granuloma

A

Bacteria
– Mycobacterium tuberculosis
– Nontuberculous mycobacteria

Fungi
– Cryptococcus
– Aspergillus
– Histoplasma

29
Q

Which foreign materials can cause lung granuloma

A

– Aspiration
– Suture granuloma
– Beryllium

30
Q

Name 4 immune conditions that can lead to lung granuloma

A

– Sarcoidosis
– Rheumatoid nodule
– Hypersensitivity pneumonitis
– Granulomatosis with polyangiitis

31
Q

Name 4 immune conditions that can lead to lung granuloma

A

– Sarcoidosis
– Rheumatoid nodule
– Hypersensitivity pneumonitis
– Granulomatosis with polyangiitis

32
Q

Why does negative micro-organism stain NOT exclude possibility of infection

A

the organisms, particularly mycobacteria, may be sparse

33
Q

How do types of vasculitis differ

A

Diseases differ according to:
- size of blood vessel involved
- organ(s) involved
- underlying cause

34
Q

What are 5 different causes of vasculitis

A

– Infectious e.g. bacteria and fungi

– Non-infectious
* Immune complex eg systemic lupus erythematosis
* Anti-neutrophil cytoplasmic antibodies (ANCA) eg Granulomatosis with polyangiitis
* Anti-glomerular basement membrane antibodies eg Goodpasture’s disease

35
Q

What is the most common type of lung-affecting vasculitis

What can vasculitis lead to

A

ANCA associated vasculitis (AAV)
* Antibodies to neutrophil granule components result in inflammation of vessel walls

Vasculitis may result in:
– vessel narrowing
– aneurysmal dilatation
– occlusion with ischaemic necrosis
– haemorrhage leading to haemoptysis

36
Q

What is Takayashu arteritis?

A

a form of large vessel granulomatous vasculitis with massive intimal fibrosis and vascular narrowing, most commonly affecting young or middle-aged women of Asian descent, though anyone can be affected.

It mainly affects the aorta (the main blood vessel leaving the heart) and its branches, as well as the pulmonary arteries.

Females are about 8–9 times more likely to be affected than males

37
Q

Give the symptoms of diffuse alveolar haemorrhage

What will CXR and CT show

A

 Haemoptysis
 Diffuse alveolar infiltrates
 Drop in haematocrit level
 Symptoms: cough, haemoptysis, dyspnoea, anaemia

 CXR shows shadowing from ground glass to
consolidation
 CT non-specific, most have ground glass,
may have ill-defined centri-lobular nodules
or consolidation

38
Q

How is TB transmitted

A

 Person to person spread
 Inhalation of respiratory droplets
 Prolonged close contact
 Increased risk of transmission
* Highly infectious host
* Highly susceptible contact

39
Q

Give 6 risk factors for TB infection

A

 Previous exposure (endemic TB in country of origin; BCG)

 Extremes of age

 Nutritional status

 Medical conditions (diabetes, damaged lungs (e.g. silicosis))

 Immunosuppression (steroids, HIV)

 Social factors (homeless; drug and alcohol misuse; imprisonment)

40
Q

How frequent is extra-pulmonary infection in TB

A

 More than half of cases have extra-pulmonary infection

41
Q

Why is the treatment of TB so prolonged

Why may treatment fail

A

 Extremely slow growing
 Waxy outer cell wall
 Intracellular organism

 Drug resistance
 Non-adherence

42
Q

What defines multidrug-resistant TB?

How is it treated?

What is the infection control for MDR-TB?

A

TB resistant to 2 or more first-line antituberculosis drugs
 rifampicin + isoniazid ± others

 MDR-TB treatment:
 4+ drug, 8-month intensive
phase
 20 month recommended

 MDR-TB infection control:
 Isolation in single rooms with negative
pressure ventilation
 Respiratory protection with particulate
masks

Clinical Presentations (2 decks)

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