219 - Haemoptysis

Question 1

What is haemoptysis?

Answer 1

Coughing up blood or bloody sputum

Question 2

What pH would haemoptysis be if you tested it?

Answer 2

Alkaline

Question 3

What pH would haematemesis be if you tested it?

Answer 3

Acidic

Question 4

Where could the blood have originated in haemoptysis?

Answer 4

Bronchial arteries - despite small proportion of CO, they are at high pressure, so lots of blood could come from them.
Capillaries
Pulmonary arteries - receive all the CO but at very low pressure

Question 5

What investigations would you do for someone with haemoptysis?

Answer 5

CXR
FBC + clotting
ABG
Sputum

Question 6

What would you do in a situation of massive haemoptysis?

Answer 6

Emergency - risk of aspiration
protect airway
O2
IV access
FBC, clotting, X match
CXR
reverse any coagulopathy
maintain Bp <100 systolic

• give: tranexamic acid, nebulised adrenaline
• nurse on bleeding side down

Question 7

What 3 classes of disease could cause haemoptysis?

Answer 7

Airway disease
Vascular disease
Parenchymal disease

Question 8

What types of airway disease could cause haemoptysis?

Answer 8

Bronchitis - esp. smokers
Bronchogenic carcinoma
Metastatic cancer
Bronchiectasis
Sarcoidosis

Question 9

What types of vascular disease could cause haemoptysis?

Answer 9

Pulmonary infarction

Increase in pul venous pressure- heart failure, mitral stenosis

Question 10

What parenchymal diseases may cause haemoptysis?

Answer 10

Infection - TB, pneaumonia, aspergilloma

Autoimmune - vasculitis, CVD

Question 11

What is the most common cause of maternal death in the UK?

Answer 11

Thromboembolic disease

Question 12

What makes up virchow’s triad of thrombosis risk?

Answer 12

Venous stasis
Injury to vessel wall
Increased blood coaguability

Question 13

Where do most thromboemboli come from?

Answer 13

75% from deep venous system in legs and pelvis

= DVT

Question 14

What score can you use for DVT risk?

Answer 14

Well’s score

Question 15

What are the signs of a DVT?

Answer 15

Local pain/tenderness 
eg. Calf tenderness
Swelling
Pain on dorsiflexion - Homan's sign
Fever?

Question 16

What investigations are done for a ? DVT?

Answer 16

Doppler U/S
CT scan
D-dimer blood test

Question 17

How do you manage someone with a DVT?

Answer 17

LMWH - eg. clexane (enoxaparin)

Warfarin - 3/12 if known cause, 6/12 if unknown

Question 18

What is a Pulmonary embolism?

Answer 18

Obstruction of a blood vessel in the lung by a clot or foreign substance

Question 19

How likely is it for a DVT to embolise?

Answer 19

20%

Question 20

What are the symptoms of a PE?

Answer 20

SOB
Pleuritic pain
Haemoptysis (usually small amounts)
Dizziness
Syncope
Anxiety

Question 21

What are the signs of a PE?

Answer 21

Dyspnooea
tachycardia
Pleuritic pain
Cyanosis
Pyrexia
AF
low BP
Raised JVP

Question 22

What investigations would you do for a ? PE

Answer 22

ABG
CXR
ECG
D-Dimer

Then probably do
CT pulmonary angiogram

Could do
V/Q scan
Bedside echo
Pul arteriogram

Question 23

What are the outcomes of a massive PE?

Answer 23

Big clot, lodges in bifercation of PA - haemodynamically compromised
- high mortality

Question 24

What are outcomes of an acute minro PE?

Answer 24

Smaller clot so wedges more distally - can cause a wedge infarction - pleuritic pain + fever

Question 25

What are paradoxical emboli?

Answer 25

IF the pt has an atrial septal defect the clot could get into the systemic circulation - cause stroke, go into kidneys, cause acute limb infarction.

Question 26

What is the mamagement of a PE?

Answer 26

Acutely - O2, fluids, analgesia, heparin (clexane), ?tPA if massive. Rarely sugery - embolectomy LT: warfarin. ? IVC filter

Question 27

What prophylaxis is there for PE?

Answer 27

Clexane for all immobile pts Stockings Stop HRT/pill post op

Question 28

What is bronchiectasis?

Answer 28

Abnormal/permenant dilation of 1 or more bronchi

Question 29

How id bronchiectasis diagnosed?

Answer 29

Radiologically - broncho bigger than vessel next to it

Question 30

What are the symptoms/signs of bronchiectasis?

Answer 30

``` Chronic bronchial sepsis - sputum breathlessness polyphonic wheeze clubbing coarse mid insp crackles Respiratory failure? ```

Question 31

What causes bronchiectasis?

Answer 31

cycle of lung injury -> infection -> inflammation - Inherited: Cystic fibrosis, kartangers (immotile cilia) - Acquired: childhood pneumonia, chronic obstruction (foreign body), aspiration, ABPA - allergic broncho-pul aspergillosis...

Question 32

What is the treatment for bronchiectasis?

Answer 32

Physio Antibiotics for exacerbations bronchodilators

Question 33

Pulmonary hypertenstion can be classified into 4 main groups, what are they?

Answer 33

- PAH - Pul. arterial hypertension - Pulmonary venous hypertension - Pul hypertension assoc with hypoxemia - Pul hypertension due to chronic thromboembolic disease

Question 34

What is Pul arterial hypertension?

Answer 34

Narrowing of blood vessels connected to and withint he lungs - causes fibrosis - this increases the work load on the R ventricle and causes RHF - "cor pulmonale"

Question 35

What are the symptoms of pul. arterial hypertension?

Answer 35

``` Usually silent until RHF develops Dyspnoea fatigue palpitations chest pain cough syncope ```

Question 36

How do you diagnose pul. arterial hypertension?

Answer 36

Measure the pressures using a venous catheter Mean pul. arterial pressure >25mmHg Pulmonary capillary wedge pressure 3 wood units

Question 37

What treatment options are there for pulmonary arterial hypertension?

Answer 37

Remodelling therapy - endothelin receptor antagonist Vasodilation - O2, calcium channel blockers Anti-inflammatory - NO donors, prostacyclins Anticoagulatns

Question 38

What is pulmonary venous hypertension?

Answer 38

L sided heart disease of valvular disease means the heart isn't pumping as efficiently, so blood pools int he lungs + a back pressure is created in the pulmonary system -> get pulmonary oedema + Pleural effusions

Question 39

What is pul hypertension assoc. with hypoxemia?

Answer 39

A protective response to low o2 - stops blood going to that bit of the lung - constricts. due to COPD, interstitial lung disease, sleep-disordered breathing, high altitude chronically

Question 40

What is pulmonary hypertension due to chronic thomboembolic disease?

Answer 40

After multiple obstructions from thrombi - causes vessels to constrict - increases pressure.

Question 41

What can cause a cavitating lung mass?

Answer 41

``` Carcinoma Lung abscess Rheumatoid nodule Septic embolus Vasculitis with granulomatosis Bronchogenic cyst Hydatid cyst ```

Question 42

What could consolidation on a CXR be caused by?

Answer 42

``` Infection Water/Oedema Blood Inflammation Tumour Proteinaceous fluis ```