8. Haemoptysis

Question 1

What other symptoms may be mistaken for haemoptysis?

Answer 1

Haematemesis
Nose-bleed
Bleeding gums

Question 2

Use the surgical sieve to construct a differential diagnosis for haemoptysis.

Answer 2

Infection

• TB
• Pneumonia (e.g. Klebsiella)
• Lung abscess
• Mycetoma
• Bronchitis

Neoplastic
- Lung cancer

Vascular

• PE
• Left ventricular failure
• Bleeding diathesis
• Arteriovenous malformation
• Vascular-bronchial fistula

Inflammatory/Autoimmune

• Granulomatosis with polyangiitis
• Goodpasture’s syndrome
• SLE
• Osler-Weber-Rendu syndrome
• Polyarteritis nodosa

Trauma
- Iatrogenic

Endocrine

Degenerative
- Bronchiectasis

Metabolic

Drugs

• Warfarin
• Crack cocaine use

Question 3

Which of the mechanisms listed in the surgical sieve is the most common cause of haemoptysis?

Answer 3

Infection

Question 4

List three key features of the history of presenting complaint.

Answer 4

Describe what you are coughing up.
How much was coughed up?
Did the haemoptysis occur suddenly or come on gradually?

Question 5

Which differentials are associated with coughing up frank blood

Answer 5

Suggest vascular problem (e.g. erosion of cancer into a blood vessel)

Question 6

Which differentials are associated with coughing up blood-streaked sputum

Answer 6

Lung infections can cause this

Chronic production of large amounts of blood-stained sputum suggests bronchiectasis

Question 7

Which differentials are associated with coughing up frothy sputum

Answer 7

Pulmonary oedema

Question 8

Which disease is classically associated with the production of a large amount of sputum?

Answer 8

Bronchiectasis

Question 9

List some causes of sudden-onset haemoptysis.

Answer 9

PE

Erosion of cancer into a blood vessel

Question 10

List a cause of gradual-onset haemoptysis.

Answer 10

Bronchiectasis (and other progressive diseases)

Question 11

List some important symptoms that may be associated with haemoptysis. State the underlying pathology that may cause the symptoms.

Answer 11

Cough productive of sputum – suggests lower respiratory tract infection or bronchiectasis
Fever – associated with lower respiratory tract infections
Weight loss – systemic feature of lung cancer and TB
Pleuritic chest pain – PE or pneumonia
Shortness of breath – clarify whether it is sudden-onset (e.g. PE) or gradual-onset (e.g. heart failure)
Haematuria/Oliguria

Question 12

Why is it important to ask about renal symptoms (haematuria/oliguria)?

Answer 12

Pulmonary-renal syndromes can cause haemoptysis

Question 13

List the main causes of pulmonary-renal syndrome.

Answer 13

Vasculitides (e.g. Granulomatosis with polyangiitis)
SLE
Goodpasture’s syndrome

Question 14

List some key features of the past medical history.

Answer 14

Smoking 
Exposure to asbestos and other inhaled substances 
Prior lung disease (e.g. TB)
Growing up abroad and recent travel 
Risk factors for DVT/PE 
Anticoagulant use or bleeding diathesis

Question 15

List some respiratory causes of clubbing.

Answer 15

Lung cancer
Bronchiectasis
Interstitial lung disease
Empyema

Question 16

Which respiratory disease can cause wasting of the dorsal interossei?

Answer 16

Pancoast lung tumours can invade the T1 nerve root

Question 17

Which metabolic imbalance is important to watch out for in patients with potential lung cancer?

Answer 17

Hypercalcaemia of malignancy
This is due to spread of the cancer to bone
NOTE: keep and eye out for signs of hypercalcaemia (e.g. hypotonia, Hyporeflexia, weak arms)

Question 18

What symptom can occur as a result of obstruction of the superior vena cava by an apical lung tumour?

Answer 18

Swelling of the face, neck and arms

Question 19

List some signs of respiratory pathology that can be seen in the neck.

Answer 19

Cervical lymphadenopathy

Tracheal deviation

Question 20

List some blood tests that may be useful in investigating a patient with haemoptysis.

Answer 20

FBC – check for anaemia, raised WCC
CRP
Clotting screen
U&Es – renal derangement may raise suspicion of pulmonary-renal syndrome

Question 21

Why might it be useful to perform urinalysis on a patient presenting with haemoptysis?

Answer 21

Haematuria may increase index of suspicion of pulmonary-renal syndrome

Question 22

What form of imaging is most useful in a patient presenting with haemoptysis?

Answer 22

CXR – look for mass lesions, diffuse alveolar infiltrate, hilar lymphadenopathy etc.

Question 23

Why might it be useful to check calcium, phosphate and ALP in a patient with haemoptysis?

Answer 23

Bone metastases can lead to hypercalcaemia

Question 24

Which criterion is used to decide the next step in the management of a patient presenting with a possible PE?

Answer 24

Wells criteria

Question 25

How is the Wells score interpreted?

Answer 25

4+ = CTPA | < 4 = D-dimer to rule out PE

Question 26

Describe the typical presentation of a tuberculosis patient.

Answer 26

History of growing up/recent travel to a TB-endemic region Haemoptysis Night sweats Weight loss

Question 27

Outline the management plan for TB.

Answer 27

4 months: rifampicin + isoniazid | 2 month: ethambutol and pyrazinamide

Question 28

Describe the typical presentation of a patient with bronchiectasis.

Answer 28

Recurrent cough productive of large amounts of green/rusty sputum with occasional haemoptysis

Question 29

Which imaging modality is most useful for diagnosing bronchiectasis?

Answer 29

CT chest – shows dilated bronchi

Question 30

What is primary ciliary dyskinesia?

Answer 30

Autosomal recessive disorder that affects the protein machinery used by epithelial cells to beat their cilia

Question 31

What are the consequences of primary ciliary dyskinesia?

Answer 31

``` NOTE: most consequences are due to the inability of the cilia to clear mucus Bronchiectasis Rhinitis and sinusitis Otitis media Male infertility (sperm are immobile) Situs inversus (Kartagener’s syndrome) ```