Haemoptysis Flashcards
What can haemoptysis be confused with? (3)
• Haematemesis: brownish-red blood that is vomited from the gastrointestinal (GI) tract.
• Epistaxis (nosebleed): particularly posterior nosebleeds.
• Bleeding gums: combined with a cough, this may be confused with true
haemoptysis.
How can you check a patient presenting with haemoptysis is really haemoptysis? (6)
Ask them where they think the blood is coming from (e.g. initially from nose), colour (darker = partially digested), clots and history of N&V, gastric disease and alcoholism
How should you assess a history of alcoholism?
CAGE questions
Have you ever felt you need to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Have you ever needed an Eye-opener to steady your nerves in the morning?
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1st I causes of haemoptysis? (5)
pulmonary tuberculosis (TB), bronchitis, pneumonia, lung abscess, mycetoma
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N causes of haemoptysis? (2)
Neoplastic: primary lung cancer, metastatic lung cancer
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V causes of haemoptysis? (5)
Vascular: pulmonary infarction (embolism), left ventricular failure, bleeding diathesis, arteriovenous malformation, vascular–bronchial fistula
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2nd I causes of haemoptysis? (7)
Inflammatory: Wegener’s disease, Goodpasture’s syndrome, systemic lupus erythematosus, hereditary haemorrhagic telangiectasia (Osler–Weber–Rendu syndrome), polyarteritis nodosa, microscopic polyangiitis
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T causes of haemoptysis? (3)
Traumatic: iatrogenic (lung biopsy, post-intubation), wounds (broken rib)
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E causes of haemoptysis? (1)
Endocrine: (none)
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D causes of haemoptysis?
Degenerative: bronchiectasis
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M causes of haemoptysis? (1)
Metabolic: (none)
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D causes of haemoptysis? (2)
Drugs: warfarin (bleeding diathesis), crack cocaine use
Mnemonic for causes of haemoptysis
Infective Neoplastic Vascular Inflammatory Traumatic Endocrine (none) Degenerative Metabolic (none) Drugs
Most common causes of haemoptysis
Infection and exacerbations of COPD
What is the must exclude diagnosis of haemoptysis
Lung cancer
What questions should you ask initially about haemoptysis once confirmed that it is haemoptysis? (3)
What is he coughing up? (Frank blood blood, blood streaked sputum, pink frothy sputum)
How much is he coughing up? Quantify (teaspoon, tablespoon, eggcup…)
How suddenly did it start and has it got worse progressively?
What does frank blood haemoptysis suggest? (6)
Frank blood: this is suggestive of a vascular problem such as a ruptured
blood vessel (invasive cancer, bronchiectasis, TB, mycetoma), a ruptured
arteriovenous malformation, or a vascular–bronchial fistula.
What does blood-streaked sputum haemoptysis suggest? (2)
any infection of the lungs can cause this; however, in the context of chronic production of large volumes of sputum this
would suggest bronchiectasis.
What does pink frothy sputum haemoptysis suggest? (1 and due to 3 examples)
This suggests pulmonary oedema (secondary to, for
example, left ventricular failure, CHF or severe mitral stenosis).
What can the volume of haemoptysis suggest?
Massive haemoptysis can be caused by erosion of a pulmonary blood vessel.
What can the speed of onset and progression of haemoptysis suggest? (Sudden and gradual 2)
Sudden onset is consistent with pulmonary embolism (PE) or erosion of a cancer into a large pulmonary blood vessel. Gradual onset argues for a progressive condition such as lung cancer or bronchiectasis.
What other (sets of) symptoms should you ask someone presenting with haemoptysis about? (6)
Cough productive of sputum? - Lower RTI, bronchiectasis, lung cancer
Fever - Lower RTI, TB, Carcinoma
Weight loss - lung cancer TB
Pleuritic chest pain - PE, pneumonia
SOB - PE, CHF
Haematuria/oliguria - Goodpastures, vasculitides, SLE
What questions about someones past history should you ask with haemoptysis? (11)
Smoking history
Exposure to asbestos/other inhaled industrial substances
Prior lung disease
Did he grow up abroad or travel abroad recently?
Anticoagulant meds/bleeding tendency?
Change to voice?
RF for DVT/PE: Prolonged best rest/long haul flight? Blood vessel damage from trauma or surgery? Malignancy? FHx of vascular disease? Painful swollen limb/leg?
What does haemoptysis with a cough productive of sputum suggest? (5)
Lower RTI (pneumonia, bronchitis, TB…)
Bronchiectasis
Lung cancer
What does haemoptysis with a fever suggest? (5)
Lower RTI (pneumonia, bronchitis, TB…)
TB
Carcinoma
What does haemoptysis with night sweats suggest? (2)
TB or carcinoma
What does haemoptysis with pleuritic chest pain suggest? (2)
PE
Pneumonia that has spread to the chest
What does haemoptysis with SOB suggest? (2)
PE with sudden onset
CHF with gradual onset
What does haemoptysis with haematuria/oligurua suggest? (3, 1 has 3 examples)
− Goodpasture’s syndrome, an autoimmune condition where autoantibodies
attack the lungs and the glomeruli in the kidneys. This is important to identify early since the patient progresses rapidly to irreversible renal failure
− Vasculitides, e.g. Wegener’s granulomatosis, microscopic polyangiitis,
polyarteritis nodosa
− Systemic lupus erythematosus.
What extra-pulmonary manifestations of lung cancer should you ask about with haemoptysis? (5 sets)
Extra-pulmonary manifestations:
Bone pain (bone mets)
Dull, aching, swollen wrists and ankles (HPOA)
Cushinoid features, muscle weakness, oedema, skin hyperpigmentation (Lung SCC secreting ACTH)
Polyuria, polydipsia, hypotonia, hyporeflexia, muscle weakness (hypercalcaemia -> bone mets, PTH secreting lung cancer)
Muscle weakness - Eaton-Lambert syndrome
What does this extra-pulmonary manifestation of lung cancer suggest:
Bone pain
Bony mets
What does this extra-pulmonary manifestation of lung cancer suggest:
Dull, aching, swollen wrists/ankles
hypertrophic pulmonary osteoar-
thropathy (HPOA), a rare disorder most commonly seen in patients with
lung cancer
What does this extra-pulmonary manifestation of lung cancer suggest:
Cushingoid features, muscle weakness, oedema, skin hyperpigmentation
if there is a small cell carcinoma secreting ectopic adrenocortico- tropic hormone (ACTH)
What does this extra-pulmonary manifestation of lung cancer suggest:
Polyuria, polydipsia, hypotonia, hyporeflexia, muscle weakness
hyper- calcaemia secondary to bone metastases or PTH-related peptide (PTHrP)- secreting lung cancer
What does this extra-pulmonary manifestation of lung cancer suggest:
Muscle weakness
especially proximal muscles i.e. difficulties stand- ing and walking), autonomic dysfunction (e.g. dry mouth, constipation, urinary retention?) Eaton–Lambert syndrome is a rare neuromuscular disorder most commonly seen in patients with small cell lung cance
What does haemoptysis with exposure to asbestos or other inhaled substances suggest? (3)
Mesothelioma, asbestosis, lung cancer
What does haemoptysis with prior lung disease suggest? (3)
This may indicate a chronic condition, such as TB or bronchiectasis, or a vulnerability to repeated infections (e.g. pneumonias) that you may wish to investigate further.
What Ix should you requesting someone presenting with haematemesis? (12)
Oxygen saturations for assessing severity of disease
FBC for anaemia
CRP
Clotting screen for a bleeding disorder exacerbating/causing haemoptysis
U&E’s for renal involvement (Goodpasture’s, Wegener’s granulomatosis)
Calcium, phosphate and ALP for bone mets
Liver enzymes
Urine test
CXR
What Ix should you make if you suspect TB and why? (3)
Obtain specimens or tissue to culture
Skin sensitivity and T cell based assays are only useful to spot latent TB and say nothing about disease activity - only used to see in contact tracing to see if somebody who has been exposed to open TB has been infected.
What signs are you looking for in a chest radiograph of someone presenting with haematemesis?
Mass lesion/nodule Diffuse alveolar infiltrates Hilar lymphadenopathy Lobar or segmental infiltrates Patchy alveolar infiltrates
What do mass lesion/nodule suggest on a chest radiograph? (5)
carcinoma, TB, granuloma, abscess, vasculitides, e.g. Wegener’s granulomatosis
What do diffuse alveolar infiltrates suggest on a chest radiograph?
pulmonary oedema
What do suggest on a chest radiograph? (3)
carcinoma, infection (if accompanying infiltrates), TB
What do lobar or segmental infiltrates suggest on a chest radiograph? (4)
pneumonia, PE, obstructing carcinoma, TB
What do suggest on a chest radiograph? (4)
bleeding disorders, Goodpasture’s syndrome, idiopathic pulmonary haemosiderosis
What are some of the main indications of TB? (Hx 6, examination 5, Ix 3)
Hx: chronic (productive) cough, fevers, night sweats, weight loss, travel abroad, haemoptysis
Exam: pyrexia, consolidation (dullness to percussion, increased vocal resonance), pleural effusion, reduced expansion, reduced breath sounds
Ix: WCC raised, CRP raised, calcification on CT
What are some of the main indications of PE? (Hx 10, examination 1, Ix 2)
Hx: pleuritic chest pain, breathlessness, haemoptysis, smoking, exercise intolerance, swollen limb, immobile for a prolonged period, venous thromboembolism, trauma/surgery, malignancy
Exam: tachycardia
Ix: Oxygen sats, ECG
What are some of the main indications of pneumonia? (Hx 4, examination 4, Ix 3)
Hx: fever, cough productive of sputum, haemoptysis, pleuritic chest pain
Exam: dull percussion, crackles in lung, tachycardia,. tachypnoea
Ix: oxygen sats, WCC, CRP
What are some of the main indications of bronchiectasis? (Hx 7, examination 3)
Hx: haemoptysis, chronic cough productive of sputum (as in classic bronchiectasis, although this does not exclude bronchiectasis), productive of mucus,
wheeze, dyspnoea, poor exercise tolerance, Hx of recurrent respiratory illness
Exam: clubbing, crackles, wheeze
What are the Well’s criteria for PE (7) and what Ix does it indicate?
Whether to do D-dimer (<4) or CTPA (>4) Clinical signs+symptoms of DVT 3 points PE is the most likely diagnosis 3 point Heart rate > 100 1.5 points Immobilisation >3 days or surgery in the last 4 weeks 1.5 points Previously diagnosed PE or DVT 1 point Haemoptysis 1 point Malignancy diagnosed in the last 6 months 1 point
In someone with TB, in addition to reviewing need for resuscitation, what are the other 6 steps you need to take)
1) Ensurethatmicrobiologyknowtolookforacid-fastbacilli(i.e.usingaZiehl–Nielson or silver stain). Bear in mind that M. tuberculosis is a very slow-growing bacterium and it can therefore take many weeks before a positive result is obtained on culture.
2) TB is a notifiable disease so you must notify the authorities for contact tracing. They may vaccinate contacts with Bacille Calmette–Guérin (BCG) and, rarely, provide prophylactic therapy.
3) Place the patient in isolation to prevent further spread.
4) Test her for HIV, as although she most likely acquired TB during her childhood she may have acquired it more recently secondary to HIV infection which has implications for prognosis and management.
5) Look for signs of spread to other organs. Check particularly for meningeal irritation, bone or joint pain particularly in weight-bearing joints (e.g. Pott’s fracture in the spinal column), dysuria or pelvic pain (genitourinary infection), or abdominal pain.
6) If the diagnosis is confirmed, refer the patient to the TB service, which offers specialized care for such patients.
Mx for TB?
rifampicin and isoniazid for the first 4 months, pyrazinamide and ethambutol for the first 2 months.
What is primary ciliary dyskinesia?
an autosomal recessive disorder that affects the protein machinery used by epithelial cells to rhythmically beat their cilia and by spermatozoa to rhythmically beat their tails.
Consequences of primary ciliary dyskinesia? (5)
- Bronchiectasis, due to an inability to clear mucus from the lungs.
- Rhinitis and sinusitis, due to an inability to clear mucus from the nasal sinuses.
- Otitis media (both secretory and acutely infective) due to an inability to clear mucus from the middle ear, down the Eustachian tube.
- Male infertility, due to sperm immotility. Females are usually fertile because passage of the oocyte along the Fallopian tubes is more dependent on peri- stalsis of the Fallopian tubes than on the movement of the ciliae that line these tubes.
- Situs inversus. The rhythmical beating of cilia is thought to play an impor- tant part in setting up the usual pattern of body asymmetry during embryo- genesis. Many patients with PCD have their organs on the ‘other side’ (e.g. dextrocardia).
What is Kartagener’s syndrome
Bronchiectasis, sinusitis, and situs inversus with PCD
What indicates pulmonary renal syndrome
The combination of haemoptysis and glomerulonephritis (the presence of red cell casts (clumps of red cells that have squeezed through the glomeruli)) should alert you to the possibility of a pulmonary–renal syndrome.
What does haemoptysis with glomerulonephritis (the presence of red cell casts (clumps of red cells that have squeezed through the glomeruli)) indicate?
Pulmonary-renal syndrome
What is the difference between transudate and exudate? What causes it (7 and 3)?
The protein content
• A transudate is defined as having <25 g/L of protein. Transudates are low in protein because they are the result of fluid alone squeezing into the pleural space, either due to increased hydrostatic pressure in the lung vasculature (heart failure, fluid overload, constrictive pericarditis) or due to reduction in the oncotic pressure which usually keeps fluid in the vasculature (reduced serum protein due to liver failure, malabsorption/malnutrition, nephrotic syndrome).
• An exudate is defined as having >35 g/L of protein. Exudates are rich in protein because they are the result of cells in the pleural space: either pathogens (infection), inflammatory cells, or malignant cells.
Causes of clubbing: Cardiovascular 5 Respiratory 8 GI 6 Other 2
• Cardiovascular − Infective endocarditis (subacute bacterial endocarditis) − Congenital cyanotic heart disease − Atrial myxoma − Axillary artery aneurysm − Brachial arteriovenous fistula • Respiratory − Pulmonary fibrosis − Suppurative lung diseases: abscess, empyema, cystic fibrosis, bronchiectasis − Bronchial carcinoma, mesothelioma − TB • Gastrointestinal − Inflammatory bowel disease − Cirrhosis − Malabsorption, e.g. coeliac disease − Gastric lymphoma − Liver abscess − Liver or bowel cancer • Other − Congenital clubbing − Thyroid acropachy
Lung neoplasm classifications?
As for all neoplasms, lung neoplasms can at first be divided into benign and malignant. Malignant tumours in turn can be classified as primary or secondary. Broadly speaking, the primary malignant lung cancers are then classified in two groups based on histology:
1) Non-small cell lung cancer (NSCLC, 80%)
− Subdivided into adenocarcinoma (30–40%), squamous (20–30%), large cell carcinoma (10%), and
others (5%)
2) Small cell lung cancer (SCLC, 20%)
Haemoptysis is more common in squamous cell carcinoma, which usually affects lung tissue closer to the hilar region and thus the blood has relatively little distance to travel before being coughed up.
Which cancers commonly metastasise to the lungs? (5)
Colorectal
• Breast
• Renal
• Female genital tract: cervix, ovary
What ectopic secretion are associated with lung cancers?
ADH - leading to hyponatraemia
ACTH - leading to Cushing’s syndrome
PTHrP - leading to hypercalcaemia
Common extra-pulmonary sites of manifestation of TB? (3) What does each cause (3, 2, 1)
- Bone: osteomyelitis, septic arthritis, Pott’s disease (in the spine)
- Neurological: meningitis, intracranial granulomas
- Renal: granuloma
Differentials for a solitary coin lesson on CXR? (7)
Parenchymal tumour: benign, primary lung cancer, secondary lung cancer • Lymph node: lymphoma • Granuloma: TB, sarcoidosis • Abscess • Hamartoma • Foreign object
What signs should you be looking for in general inspection of someone presenting with haemoptysis and what does it suggest? (4)
− Hoarse voice: ?invasion of recurrent laryngeal nerve by cancer
− Purpuric rash or petechiae: ?vasculitis affecting lungs
− Cushingoid appearance (moon face, buffalo hump on neck, fat on abdomen, wasted limbs): ?lung cancer secreting ACTH
− Cachexia
What signs should you be looking for in the hands of someone presenting with haemoptysis and what does it suggest? (3)
3 Clubbing: ?lung cancer, lung abscesses, bronchiectasis
− Tar stains: ?smoker
− Wasting of the dorsal interossei: ?invasion of T1 nerve root by apical lung
cancer (Pancoast tumour)
What signs should you be looking for in the arms of someone presenting with haemoptysis and what does it suggest?
Hypotonic, hyporeflexive, weak arms: ?hypercalcaemia due to bone
metastases from lung cancer
What signs should you be looking for in the neck of someone presenting with haemoptysis and what does it suggest? (3)
2− Cervical lymphadenopathy, non-tender: ?TB, bronchial carcinoma
− Left supraclavicular lymphadenopathy (Virchow’s node): ?GI malignan-
cy which may have metastasized to the lungs
2 − Tracheal deviation: ?lung collapse secondary to a large mass such as a
tumour or abscess
What signs should you be looking for in the chest of someone presenting with haemoptysis and what does it suggest? (5)
− Asymmetrical lung expansion: ?lung pathology in side of reduced
expansion
3 − Dullness to percussion: ?pneumonia, lung abscess, pleural effusion due
to cancer
2− Stridor:?tumour or foreign body obstructing bronchus
3− Crackles: ?pneumonia, left ventricular failure, bronchiectasis
3− Pleural rub: ?mesothelioma, pleuritis from pneumonia, distal PE causing
infarction and associated pleurisy
What signs should you be looking for in the abdomen of someone presenting with haemoptysis and what does it suggest?
Hepatomegaly: ?liver malignancy which can spread to the lungs, and vice
versa
What signs should you be looking for in the face of someone presenting with haemoptysis and what does it suggest? (6)
− Swollen face: ?obstruction of superior vena cava by tumour
− Bleeding from oral or nasal mucosa: ?source of blood, i.e. not true
haemoptysis
− Saddle nose: ?Wegener’s granulomatosis
− Horner’s syndrome (miosis, ptosis ,and anhydrosis, i.e.small pupil, droopy
eyelid, and lack of sweating): ?invasion of the sympathetic supply to the face
by apical lung cancer
− Jaundice: ?liver cancer which has spread to the lungs or vice versa
− Focal neurology: ?brain metastases from lung cancer
What signs should you be looking for in the legs of someone presenting with haemoptysis and what does it suggest? (4)
Unilateral signs of DVT? A DVT may have caused a PE. Look for a uni-
laterally inflamed leg, unilateral pitting oedema, tenderness over the deep veins or distended, non-varicose superficial veins.
