Haemoptysis Flashcards
(41 cards)
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
