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Flashcards in Haemoptysis Deck (13):
1

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)?

2

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

3

**What are your differential diagnoses for haemoptysis?

INVITED MD:
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

4

What are the most common causes in your DDx?

Infection and exacerbations of COPD, but these should never be assumed to be the cause

5

What must you exclude from your DDx?

Lung cancer

6

Does haemoptysis always have an identifiable cause?

No - up to a third of cases have no identifiable cause

7

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

8

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

9

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

10

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?

11

**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

12

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

13

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.