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Flashcards in Haemoptysis Deck (13):

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?

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.