Haemoptysis Flashcards
What might haemoptysis be confused with by the patient? i.e. how will you tell if it really is haemoptysis?
Need to differentiate from:
Haematemesis: brown-red blood that is vomited from GI tract
Epistaxis (nosebleed): particularly posteriorly
Bleeding gums: combined with a cough
Ask pt where they think it’s coming from. Hx of nosebleeds, nausea, vomiting, gastric disease, alcoholism (CAGE)?
Why should you worry particularly about haemoptysis?
1) may be presenting symptoms for life threatening lung disease
2) Massice haemoptysis (>100ml to 1000ml over 24 hrs) may be life threatening itself, usually through asphyxiation but also shock
it is a “red flag” symptoms
**What are your differential diagnoses for haemoptysis?
INVITED MD:
Infective: TB, bronchitis, pneumonia, lung abscess, myceteoma
Neoplastic: primary lung cancer, metastatic lung cancer
Vascular: PE, left ventricular failure, arteriovenous malformation, vascular-bronchial fistula
Inflammatory: Wegener’s disease, Goodpasture’s syndrome, SLE, hereditary haemorrhagic telangiectasia, polyarteritis nodosa, microscopic polyangiitis
Traumatic: iatrogenic e.g. lung biopsy, wounds e.g. broken rib
Degenerative: bronchiectasis
Drugs: warfarin (bleeding diathesis), crack cocaine use
What are the most common causes in your DDx?
Infection and exacerbations of COPD, but these should never be assumed to be the cause
What must you exclude from your DDx?
Lung cancer
Does haemoptysis always have an identifiable cause?
No - up to a third of cases have no identifiable cause
What questions do you need to ask about the haemoptysis?
What is he coughing up? Frank blood?- vascular
Blood-streaked sputum? - infection
Pink frothy sputum? pulmonary oedema
How much is he coughing up?
How suddenly did it start? Has it got worse progressively?
Sudden- PE/erosion of cancer into large blood vessel
Gradual- lung cancer/bronchiectasis
What are other important associated symptoms with haemoptysis you need to ask about?
Cough productive of sputum? - LRTI e.g. pneumonia, bronchitis, TB, bronchiectasis or lung cancer
Fever? - LRTI, night sweats- TB/carcinoma
Weight loss? lung cancer and TB
Pleuritic chest pain? - PE/pneumonia spread to pleura
SOB? assess exercise tolerance - sudden could be PE, gradual - HF
Haematuria and or/oliguria? Some RARE conditions affect BOTH LUNGS and KIDNEYS - causing pulmonary-renal syndrome.
Main causes of pulmonary-renal syndrome: Goodpasture’s syndome (Autoimmune where Abs against type IV collagen- attacks lungs and glomeruli in kidneys), Vasculitides e.g. granulomatosis with polyangiitis, SLE
What are the key features of Hx you’d ask for someone with haemoptysis?
Smoking history? - most significant risk factor for lung cancer. Quantify
Exposure to asbestos or other inhaled indstrial substances? e.g. silica, coal, arsenic
Prior lung disease? TB/bronchiectasis chronic
Did he grow up abroad or travel recently? TB vaccinated?
Does he have risk factors for a DVT/PE? Includes prolonged stasis, blood vessel damage from recent trauma/surgery, malignancy
On anticoagulant medications/known bleeding tendencies? Can increase risk/magnitude of internal haemorrhage
What signs should you particularly look for on examination?
Hoarse voice? recurrent laryngeal erosion from cancer
purpuric rash/petechiae: vasculitis affecting lungs
cushingoid appearance? lung cancer secreting ACTH
In hands: clubbing (lung ca, abscesses, bronchiectasis), tar stains, dorsal interossei wasting (T1 nerve root compressed by pancoast tumour)
Arms: hypotonic, hyporeflexice, weak arms- hypercalcaemia due to bone metastases from lung ca
Face: bleeding from nose/oral mucosa, saddle nose, horner’s syndrome, jaundice
Neck: cervical lymphadenopathy, non-tender - ?TB, bronchial carcinoma. Vichow’s node-?GI malignancy metastases. Tracheal deviation
Chest: asymmetrical lung expansion, dullness to percussion, stridor, crackles, pleural rub (mesothelioma, pleuritis from pneumonia, distal PE…)
Abdo- hepatomegaly
Legs- unilateral signs of DVT?
**What initial Investigations should you request for haemoptysis? Why
Oxygen saturations - check severity of underlying pulmonary disease causing haemoptysis
FBC: anaemia- magnitude/duration of bleeding, raised WCC-infection?
CRP- increased in infection, inflammation, malignancy
Clotting screen - bleeding disorder may be exacerbating if not directly causing the haemoptysis
U&Es - for renal involvement e.g. goodpastures syndrome
Calcium, phosphate and ALP for bone metastasis from primary lung ca
Liver enzymes for liver involvement of a cancer
Urinalysis- haematuria, suggesting pulmonary-renal syndrome
imaging: CXR
What signs would you look for on a CXR?
Mass lesion/nodule: carcinoma, TB, granuloma, abcess, vasculitides e.g. Wegener’s granulomatosis
Diffuse alveolar infiltrates: pulmonary oedema
Hilar lymphadenopathy: carcinoma, infection, TB
Lobar/segmental infiltrates: pneumonia, PE, obstructing carcinoma, TB
Patchy alveolar infiltrates: bleeding disorders, goodpasture’s syndrome
How would you manage haemoptysis acutely and in the longer term?
Always check need for resuscitation (ABC).
If large haemoptysis (>150mls), suction, lie on same side as lesion, vol replacement, blood Xmatch
Minor haemoptysis (<150mls): refer to resp medicine/other specialities if indicated by history. Referred to MDT for management.
