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 haemosiderosis
 Sudden : PE, acute LVF
 Progressive : bronchiectasis, lung ca
• Colour
 Bright red/ brown/ pink, frothy sputum
• Quantity
 Massive : lung ca, bronchiectasis, TB, lung cavity
 Less 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

Cardiovascular
(Pulmonary HTN) Bleeding diatheses
Respiratory

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)