Haemoptysis

Haemoptysis

Minci © 2007

• Part 1 : Overview of haemoptysis

• Part 2 : Overview of common conditions causing haemoptysis.

Part 1

• Defined as the expectoration of blood or blood-stained sputum. Usually frothy, alkaline and bright red.

• Haematemesis is the vomiting of blood.

• Malaena occurs if enough blood is swallowed.

Pathophysiology• Lung has dual blood supply.

– Pulmonary arterial circulation : low pressure, gas exchange.

– Bronchial arteries : high pressure, supply nutrients to lung parenchyma and major airways. (inflammation erosion, malignant invasion, rupture of pulmonary artery aneurysm)

• Rarely caused by elevated pulmonary venous pressure. Such as in mitral stenosis.

HPC• Onset

Child : likely idiopathic pulmonary haemosiderosisSudden : PE, acute LVFProgressive : bronchiectasis, lung ca

• ColourBright red/ brown/ pink, frothy sputum

• Quantity Massive : lung ca, bronchiectasis, TB, lung cavityLess severe : bronchitis, pneumonia, pulmonary

oedema, MS, PE, acute LVF.

Associated symptoms

• Dyspnoea? Respiratory pathology

• Chest pain? Is it pleuritic? Suggestive of PE

• Cough? Haemoptysis + purulent sputum = bronchiectasis/ pulmonary oedema.

• Associated hematuria or oliguria? Goodpasture’s syndrome

Other factors• Recent severe URTI• Smoker• Risk in developing PE• Recent invasive procedure• Asthmatic? Aspergillosis? Can present with

haemoptysis.• Hx of bronchitis• Ethnicity and country of origin• Risk factors for acute LVF – HTN, MI• Anticoagulant therapy• Suffering form bleeding diathesis• Significant recent weight loss

Causes

Respiratory

Cardiovascular (Pulmonary HTN) Bleeding diatheses

Traumatic Infective Neoplastic Vascular Parenchyma

Most common diagnosis

• Bronchial carcinoma

• Pulmonary embolism

• Mitral stenosis

• Tuberculosis

• Bronchiectasis

Part 2

Bronchial Carcinoma• Risk factors: Smoking, exposure to asbestos,

chromium, arsenic, iron oxides, radiation.• Symptoms : Cough (80%), haemoptysis (70%),

dyspnoea (60%), chest pain (40%), recurrent pneumonia, anorexia, weight loss.

• * Presentations show signs associated with cancer in the lung, direct spread, metastases and non-mets extrapulmonary manifestation*

• Signs : Cachexia, anaemia, clubbing. • Chest signs: may be none, consolidation,

collapse, pleural effusion.

• Investigations;– FBC, LFT, U&Es– Cytology : Sputum and pleural fluid– CXR : peripheral circular opacity, hilar

enlargement, consolidation, lung collapse, pleural effusion, bony secondaries.

– Bronchoscopy: histological Dx and assess operability

– CT : to stage the tumour– Bone scan : for suspected metastases– Lung Function Tests

Management

• Surgery

• Radiation therapy for cure

• Chemotherapy

• Radiation therapy for symptoms

• Laser therapy, endobronchial irradiation and tracheobronchial stents.

Pulmonary Embolism

• Symptoms : Acute breathlessness, pleuritic chest pain, haemoptysis, dizziness, syncope.

• Assess risk factors and family history.

• Signs : Pyrexia, cyanosis, tachypnoea, tachycardia, hypotension, raised JVP,pleural rub, pleural effusion.

• Investigations :– FBC, U&Es, baseline clotting– CXR : Normal, oligaemia of affected segment,

dilated pulmonary artery, linear atelectasis, small pleural effusion, wedge-shaped opacities or cavitation.

– ECG : normal or slow tachycardia, RBBB, RV strain ( inverted T in V1 to V4). Classical SIQIIITIII pattern is rare.

– ABG show low PaO2 and low PaCO2, high pH.– CTPA or if unavailable, opt for VQ scan.– D-Dimer

D-Dimer• specific degradation products of cross-linked fibrin that are released when the

endogenous fibrinolytic system attacks the fibrin matrix of fresh venous thromboemboli.

• The absence of a raised concentration of D-dimer implies that there is no fresh thromboembolic material undergoing dissolution in the deep veins or in the pulmonary arterial tree.

• Sensitive but not specific.• Conditions in which there may be a raised D-dimer include:

– PE– DVT– DIC– Post-op

• Occurs in patients with severe infection, trauma or inflammatory disorders.– Heart : Acute MI, acute CVA, unstable angina, AF– Lung : Pneumonia– Blood : Vasculitis, sickle cell crisis, – Cancer.– Increase age, pregnancy or smoking.

Management

• Anticoagulate with LMWH – fragmin (≥5d) and commence oral warfarin (3-6 months). Aim for INR 2-3.

• Consider vena caval filter• Prevention :

– Heparin to immobile patients– TED stockings– Women stop HRT– If there’s family Hx Ix for thrombophilia.

Mitral Stenosis• Symptoms : dyspnoea, fatigue, palpitations, CP,

haemoptysis, chronic bronchitis• Signs : Malar flush, low-volume pulse, AF.

Tapping, undisplaced apex beat (palpable S1)• Loud S1, opening snap, rumbling mid-diastolic

murmur (heard best in expiration, pt lie on left side), Graham Steell murmur.

• More severe the stenosis, longer the diastolic murmur, the closer the opening snap is to S2.

• Complications : Pulmonary HTN, emboli, pressure from large LA on local structures hoarseness, dysphagia, bronchial obstruction, IE.

• Investigations :– ECG : AF, P-mitrale if in sinus rhythm, RVH,

progressive RAD.– CXR : LA enlargement, pulmonary oedema, MV

calcification.– Echo : Diagnostic – Cardiac catheterization

• Mx :– AF : anti-arrhythmics, anticoagulation– Diuretics– balloon valvuloplasty, open mitral valvotomy, valve

replacement,– Oral penicillin as prophylaxis for recurrent rheumatic

fever.

Tuberculosis

• Discussed in another presentation.

Bronchiectasis

• Causes : Congenital, Post-infection, other.

• Symptoms : persistent cough, copious purulent sputum, intermittent haemoptysis

• Signs : finger clubbing, coarse inspiratory crepitations, wheeze.

• Complications : pneumonia, pleural effusion, pneumothorax, haemoptysis, cerebral abscess, amyloidosis.

• Investigation:– Sputum : culture– CXR : cystic shadows, thickened bronchial walls

(tramline and ring shadows)– HRCT chest– Spirometry : pattern?– Bronchoscopy– Other test : serum Ig, CF sweat test

• Mx :– Postural drainage : 2x daily– Abx : Pseudomonas (oral ciprofloxacin/ IV Abx)– Bronchodilators (nebulised salbutamol for asthmatics,

COPD, CF, ABPA)– Corticosteroids (prednisolone)– Surgery (local disease/ control severe haemoptysis)