Haemoptysis

Timing Questions:

since when, sudden/gradual, getting worse, how often, new or previous episodes, when was the first time it occurred?

 

Confirm if patient definitely means coughing blood rather than vomiting.

Ask about black stool (melaena) in case it is actually vomiting blood.

 

Character:

colour, consistency, quantity (streaks/teaspoon/egg cup/soaking how many tissues), mixed with sputum or not. What is the sputum like?

 

Any bleeding from elsewhere? Eg. urine, stool, nose, gums

 

CVS and Resp Systems review questions:

 

CP (+pleuritic)

SOB, orthopnoea, PND, exercise tolerance, syncope, presyncope, ankle swelling, palps

Cough, sputum (colour, amount, smell etc). Do you produce sputum without haemoptysis?

Wheeze

Fever/chills/night sweats

Leg swelling

Cardiac Risk factors: cholesterol, hypertension, diabetes, smoking, family history

PMH cardiac: MI, TIA/stroke, PVD. Ever had exercise tolerance test/angiogram/ecg etc? Known heart problems?

Fx cardiac problems

PE/DVT risk factors: surgery, pregnant, fractures, cancer, bedbound/recent illness limiting mobility, PMH DVT/PE, Fx DVT/PE, contraceptive pill/HRT, long flights, Fx/PMH clotting problem

PMH respiratory problems eg. COPD

Fx resp problems

 

TB questions: fever/sweats/weight loss/anorexia/lumps and bumps, TB contacts, travel, country of origin, PMH TB or HIV/ Fx TB

 

Skin rash/joint symptoms/eye symptoms/blood in urine/epistaxis (vasculitis/lupus)

 

Weight loss (how much over how long)/headache/bone pain/smoking history/changing cough (lung cancer)

 

PMH: lung/cardiac/kidneys/thoracic procedure or surgery/bleeding disorder, cancer

 

Dx: aspirin, NSAIDs, antiplatelets drugs, anticoagulants

 

Fx: blood clots, haemoptysis/brain aneurysms/epistaxis/GI bleeding (Osler Weber rendu), lung problems

 

Sx: smoking, alcohol, cocaine+IV drug use, travel history, sexual history,  occupational exposure to chemicals/asbestos

 

Systems Review

 

ICE

 

Causes of haemoptysis

 

Neoplastic:

Lung cancer/mets/carcinoid/ HIV with kaposis sarcoma of the airways

 

Infective:

Bronchitis

Bronchiectasis including cystic fibrosis

Infective exacerbation of COPD

Lung abscess

TB

Pneumonia eg. Bacterial, viral, fungal and mycetoma, necrotising, parasitic eg. paragonimus westermani, aspergilloma.

Hydatid cysts

UTRI abnormalities eg. Polyps

 

Cardiac:

Heart failure, tricuspid endocarditis, valve disorder eg. mitral stenosis, congenital heart disease

 

Vascular:

PE

Pulmonary AVM eg. Osler weber rendu syndrome

Bronchovascular fistula eg. aortic aneurysm eroding into airway

 

Inflammatory/rheumatic:

Goodpastures disease

Granulomatosis with polyangitis (Wegeners) and other vasculitides eg. polyarteritis nodosa

Lupus or antiphospholipid syndrome

Ehlers danlos

Behcet’s disease

 

Disorders of coagulation:

Anticoagulant/antiplatelet drugs

ITP, TTP, HUS, DIC, von willebrand disease

 

Miscellaneous:

Iatrogenic eg. aortobronchial fistula due to stent/graft, bronchoscopy

Drugs and toxins- cocaine

Trauma

Catamenial hemoptysis (intrathoracic endometriosis)

Foreign bodies

Idiopathic pulmonary hemosiderosis

Dieulafoy disease

Cryptogenic haemoptysis

 

 

 

 

Investigations depending on most likely cause

FBC, U+E, CRP, clotting, Calcium

Urine dip

CXR

Spiro

Blood cultures, HIV test

Sputum culture+ AFBs

Serologic tests for fungal infection eg. Histoplasma Ag, cryptococcal Ag, beta-D-glucan

ANA, ANCA, antiGBM, anticardiolipin, antiphospholipid antibodies, ESR

CT/HRCT/CTangio

Bronchoscopy+ samples for histology, cytology, microbiology

BAL

BNP,ECG, echo

D dimer, CTPA

Biopsy- kidney/skin/lung (transthoracic needle aspiration or VATS/thoracotomy)

 

Written by Dr Sarah Kennedy

 

Resources used to write this document include those listed in the references section of this webpage and also:

 

https://www.uptodate.com/contents/etiology-and-evaluation-of-hemoptysis-in-adults?source=search_result&search=hemoptysis&selectedTitle=1~150#H296832427