Haemoptysis Flashcards
What may haemoptysis be confused with
Haematemesis
Epistaxis
Gum bleeding
How can you help the patient to distinguish haemoptysis from other symptoms
Where do they think the blood is coming from
What is the colour of the blood coming out
History of nausea, vomiting, gastric disease or alcoholism
How do you assess for alcoholism
CAGE
Cut down - have you tried to cut down, do you want to cut down
Annoyance - do you get annoyed when people ask
Guilty - do you feel guilty about the amount you drink
Eye-opener - is alcohol an eye opener in the morning
A positive response to each questions scores 1 point
Why is haemoptysis an important symptom to investigate
May be the presenting symptom for life-threatening lung disease
Massive haemoptysis (>100mL to >1000mL over 24 hours) can lead to asphyxiation or shock
Red flag
What diagnoses should you be concerned about in haemoptysis
INVITED MD
Infective - TB, bronchitis, pneumonia, abscess, mycetoma
Neoplastic - primary or metastatic lung cancer
Vascular - PE, LHF, bleeding diathesis
Inflammatory - granulomatosis with polyangiitis , SLE, Goodpasture’s
Traumatic - iatrogenic, wounds
Degenerative - bronchiectasis
Drugs - warfarin, crack cocaine
What questions should be asked about a patient presenting with haemoptysis
What is being coughed up? (frank blood, bloody streaks, frothy)
How much is being coughed up
How suddenly did it start, has it gotten worse progressively?
What does the kind of blood being coughed up suggest
Frank -vascular problems e.g. erosion of blood vessel (invasive cancer, bronchiectasis, TB, rupture arteriovenous malformation, vascular-bronchial fistula
Streaks - Infections, TB, bronchiectasis
Frothy - Pulmonary oedema due to Left heart failure, Left ventricular failure
What does the onset of haemoptysis signify
Sudden onset - PE or erosion of cancer into pulmonary vessel
Gradual onset - progressive e.g. bronchiectasis
What associated symptoms should be asked about for haemoptysis and what is each indicative of
Sputum production - LRTI (pneumonia, bronchitis, TB), bronchiectasis Fever - LRTI Night sweats - TB Weight loss - Lung cancer and TB Pleuritic chest pain - PE or pneumonia SOB - PE or HF (depends on onset) Haematuria - rare conditions
What does haematuria in the presence of haemoptysis suggest
Rare conditions that affect the lung and kidneys - pulmonary-renal syndromes
Goodpasture’s syndrome
Vasculitides e.g. granulomatosis with polyangiitis, polyarteritis nodosa
SLE
What should be asked about social history for haemoptysis
Smoking history
Exposure to asbestos or other inhaled industrial substances e.g. silica, coal, radon, arsenic
Grow up or travel abroad - has he been vaccinated for TB
Risk factors for DVT
What signs should be looked for at the end of the bed for haemoptysis
Hoarse voice- invasion of recurrent laryngeal nerve by cancer
Cachexia
Purpuric rash or petechiae - vasculitis affecting lungs
What signs should be looked for in the hands for haemoptysis
Clubbing - lung cancer, abscess, bronchiectasis
Tar staining
Wasting of the dorsal interossei - invasion of T1 nerve root by Pancoast’s tumour
What signs should be looked for in the arms for haemoptysis
Hypotonic, hyporeflexic, weak arms are suggestive of hypercalcaemia due to bone metastases from lung cancer
What signs should be looked for in the face for haemoptysis
Swollen face - obstruction of SVC by tumour
Bleeding from oral or nasal mucosa - may not be true haemoptysis
Saddle nose - granulomatosis with polyangiitis
Horner’s - Pancoast’s tumour
Jaundice - liver cancer mets
Focal neurology - brain mets from lung
What signs should be looked in the neck for haemoptysis
Cervical lymphadenopathy - TB, bronchial carcinoma
Left supraclavicular lymphadenopathy (Virchow’s node) - GI mets
Tracheal deviation - pleural effusion secondary to cancer
What signs should be looked for in the chest for haemoptysis
Asymmetrical lung expansion
Dullness to percussion - pneumonia, abscess, malignant, pleural effusion
Stridor - tumour or foreign body obstructing bronchus
Crackles - pneumonia, LHF, bronchiectasis
Pleural rub - mesothelioma, pleuritis for pneumonia
What signs should be looked for in the abdomen and legs for haemoptysis
Hepatomegaly - malignancy
Unilateral signs of DVT - PE
Which investigations should be ordered for haemoptysis presentaiton
Sats + obs
FBC - anaemia due to malignancy, WCC for infection
CRP - infection, inflammation and malignancy
Clotting - bleeding disorder that leads to haemoptysis
U&Es - renak involvement
Calcium, phosphate, Alk phos - bone mets
Liver enzymes - liver involvement of a cancer
Urinalysis - haematuria, sign of renal involvement
CXR
What signs would you look for on CXR for haemoptysis
Mass lesion/nodules - carcinoma, TB, abscess, vasculitides
Diffuse alveolar infiltrates - pulmonary oedema
Hilar lymphadenopathy - carcinoma, infection, TB
Lobar or semental infiltrates - pneumonia, infarction due to PE, TB, adenocarcinoma
Patchy alveolar infiltrates - bleeding disorders, Goodpasture’s
Lobar collapse - obstructing carcinoma
What investigations should be done to confirm lung cancer
Cytology of sputum and bronchoscope washings
Tissue biopsy (CT-guided percutaneous fine needle biopsy or bronchoscopy)
CT scan - staging
Bone scan - look for bone mets
What scoring system can be used for DVT/PE suspicion
Wells criteria
>4 merits CTPA to investigate
<4 - D-dimer for exclusion
Geneva score as alternative
What is the management plan for someone with suspected TB
- ABCDE
- Ensure microbiology know to test for acid-fast bacilli i.e. with Ziehl-Nielson
- Notify the authorities for contact tracing
- Place patient in isolation
- Test for HIV
- Look for signs of spread to other organs e.g. meningeal irritation, bone or joint pain particularly in weight-bearing joints, dysuria or pelvic pain, abdo pain
- Refer to TB service if dianogsis confirmed
What is the treatment for TB
Depends on likelihood of drug-resistant strains
Long-term regimen of 4 antibiotics: rifampicin and isoniazid, pyrazinamide and ethambutol
What should patients starting rifampicin be warned about
Will cause orange urine
Will make oral contraceptiv pills less effective
What are the consequences of primary ciliary dyskinesia
Bronchiectasis Rhinitis and sinusistis Otitis media Male infertility Situs inversus
What is Kartagener’s triad
Bronchiectasis, sinusitis, situs inversus
What is the management of primary ciliary dyskinesia
Regular physiotherapy
Regular or prophylactic antibiotics
Mucolytics
What are the respiratory causes of clubbing
Pulmonary fibrosis
Suppurative lung disease: abscess, empyemna, cystic fibrosis, Bronchiectasis
Bronchial carcinoma, mesothelioma
TB
What is the difference between transudate and exudate
Transudate - <25 g/L protein as they are due to fluid squeezing into the pleural space
Exudate >35 g/L protein
What are the cause of transudate pleural effuision
Increased hydrostatic pressure in lung vasculature (HF, fluid overload, constrictive pericarditis)
Reduced oncotic pressure (reduced serum protein due to liver failure, malabsorption, nephrotic syndrome)
What are the causes of exudate pleural effusion
Due to cells in the pleural space, either pathogens (infection), inflammatory cells or malignant cells
What is Lights criteria
Protein in pleural fluid effusion is 25-35 g/L
Is exudate if:
Protein / serum protein >0.5
Lactate dehydrogenase (LDH) / serum LDH < 0.6
LDH > 2/3 upper limit normal serum LDH
How are lung neoplasms classified
Benign
Malignant: primary and secondary
Primary: Non small cell lung cancer, small cell lung cancer
What can non small cell lung cancer be divided into and what is treatment
Adenocarcinoma, squamous, large cell carcinoma + others
Squamous - most likely haemoptysis (hilar location)
Localised - surgery and radiotherapy
Responds poorly to chemo, poor prognosis
What is the treatment for small cell lung cancer
responsive to chemo, although rapid relapse is common
Given mainly as it improves symptoms rather than mortality
Which cancers most commonly metastasise to the lungs
Colorectal
Breast
Renal
Cervix and ovary
Note: metastatic cancers rarely cause haemoptysis as they tend to be deep in the interstitium than endobronchial
What are the extrapulmonary manifestations of lung cancer
Bone mets -> bone pain
Hypertrophic pulmonary osteoarthropathy -> dull, aching, swollen wrists/ankles
Ectopic ACTH secretion -> Cushingoid, facial weakness, oedema, skin hyperpigmentation
Hypercalcaemia -> secondary to bone mets, PTH-related peptide-secreting cancer -> confusion, polyuria, polydipsia, hypotonia and reflexia muscle weakness
Eaton-Lambert syndrome (small cell lung cancer)
What ectopic endocrine secretions are associated with lung cancers
Small cell lung carcinomas - ADH -> hyponatraemia
ACTH -> Cushing’s
Squamous cell carcinoma - PTHrP -> hypercalcaemia
What extrapulmonary site does TB commonly affect
Lymph nodes: (cervical or mediastinal)
Bone: osteomyelitis, septic arthritis, Pott’s
Neurological: meningitis, intracranial granuloma
Renal: granuloma
What are the differentials for a solitary coin lesion on CXR
Parenchymal lung tumour Lymphoma Granuloma (TB, sarcoidosis) Abscess Hamartoma Foreign object
