Haemoptysis ( coughing up blood )
Haemoptysis is expectoration of blood from the lower respiratory tract below the glottis.
In primary care the common causes of haemoptysis are acute and chronic bronchiectasis , TB , lung cancer , pneumonia and bronchiectasis ( BMJ best practice )
Infections – common cause in up to 60-70 % cases Pulmonary tuberculosis Pneumonia Bronchiectasis Chronic bronchitis Periodontal disease Sinusitis Tracheitis Lung abscess Fungal infections HIV.
Neoplasm -Lung cancer Lung metastasis Endobronchial tumours.
Vascular – AV malformations Arterio-bronchial fistula Ruptured thoracic aneurysm.
Autoimmune – Systemic lupus erythematosus Goodpasture syndrome Wegener’s granulomatosis.
Cardiovascular – Pulmonary hypertension Pulmonary embolus LVF Severe mitral stenosis.
Trauma – complications of procedures as transbronchial lung biopsy , FNAC Lung contusion , penetrating injury Oral trauma epistaxis.
Children – lower resp tr infections bronchiectasis ( particularly in cystic fibrosis ) foreign body aspiration congenital cardiopathy.
Drugs – crack cocaine anticoagulants / antiplatelet
Haematological – coagulopathies thrombocytopenia plateket dysfunction
Iatrogenic/ Idiopathic or cryptogenic diagnosis of exclusion can be seen in 7 % to 34 % of cases.
Terminology – From Greek – spitting blood ( haima is blood and ptysis is spitting )
Pseudohaemoptysis – expectorated blood that does not arise from the lungs or the bronchial tubes blood aspirated into the lungs for e.g from nasopharynx , sinuses or oral cavity This can be from the gastrointestinal tract and upper respiratory tract.
Haematemesis – vomiting of fresh or altered blood nausea and vomiting coffee ground appearance ie blood tends to be darker and may contain mixed food particles.
Non- massive – heterogenous criteria – what is massive or non-massive important to remember that lungs have dual blood supply
Massive haemoptysis- Ill defined criteria as to what is massive / severe haemoptysis -it can be usually based on ○ amount of blood expectorated in the last 24-48 hrs for e.g 100-600 mls in 24 hrs ○ the consequence of blood loss ○ interventions used to control the situation Major medical emergency One of the most challenging conditions encountered in critical care Massive haemoptysis is seen in less than 5 % of cases but mortality exceeds 50 %
Assessment – r/o pseudohemoptysis colour / consistency ( persistent , recurrent ) severity – is it ○ blood-streaked sputum ○ gross haemoptysis ○ massive haemoptysis time frame ( intermittent / constant ) ensure that the patient is haemodynamically stable comorbid conditions medications ( for e.g anticoagulants ) travel history ( infections )
CVS – orthopnoea ankle/ leg swelling known heart problems.
Cancer – enquire about constitutional symptoms risk factors for lung cancer occupational exposure toxic contact In the US about 20 % of patients with lung cancer will experience some degree of haemoptysis during their disease course
Pulmonary embolism/ infarction – sudden onset with associated symptoms as SOB , pleuritic chest pain ,tachypnoea , tachycardia , leg swelling and associated risk factors ( see chart on PE )
Examination – An examination in case of non-massive haemoptysis may be normal CVS status Respiratory system Vitals as temp , HR , RR , oxygen , BP Nutritional status Finger clubbing , lymph nodes , skin ( bruising , pallor rash etc ) R/O criteria for admission as ○ high risk massive bleed ○ gas exchane abnormalities for e.g RR > 30 oxygen saturation < 88 % ○ haemodynamic instability reflected by tachycardia , tachyhpnoea , hypotnesion ○ co-existant other respiratory patholgies for e.g previous pneumonectomy , COPD ○ other comorbidities as IHD , need for anticoagulants / anti platelet agents.
Investigations – sputum for microscopy , culture and acid fast bacilli ( if infectious cause suspected ) cytology – neoplasm ESR – can be elevated in infections , autoimmune conditions and may be elevated in neoplasia FBC (may indicate infection , anaemia or an underlying haematological condition as leukemia ) Us&Es , clotting screen consider vasculitis screen by asking for ANCA or ANA urinalysis ( vasculitis , glomerulonephritis )
Cardiac- ECG , Echo
CXR – important first line imaging & recommended for all ( cheap and easily accessible ) may give clues to conditions as TB , malignancy , bronchiectasis , aspergilloma and lung abscess it may fail to reveal a cause in up to 46 % of patients as much as 10 % of pulmonary malignancies are occult on CXR , 96 % of which will be detected by CT CXR has limited sensitivity in determining the the side of bleeding Consider CT if the patient is at risk of malignancy for e.g age > 40 and > 30 pack yrs smoking.
Specialist tests – CT chest- type of CT indicated will differ based on clinical situation Angio MDCT Diagnostic bronchoscopy
Referral – Despite haemoptysis being a common complain ( prevalence is difficult to estimate ) there are currently no national guideline to help with managing patients presenting to primary care with haemoptysis Once we have excluded criteria for admission management is aimed at finding an underlying cause In younger patients with no associated co-morbidities / risk factors and the coughing is secondary to vigorous coughing – reassurance with safety netting may adequate Low risk patient with a normal CXR consider close monitoring and appropriate oral antibiotics on outpatient basis as clinically indicated ○ ie treat and refer to a specialist persistent haemoptysis or high risk malignancy- refer promptly
PATIENT INFORMATION
Information from Top Doctors co UK Coughing up blood (haemoptysis): what is it, symptoms, causes, prevention and treatment | Top Doctors
NHS on haemoptysis Coughing up blood (blood in phlegm) – NHS (www.nhs.uk)
Patient UK – an excellent review Coughing Up Blood (Haemoptysis) | Causes, Diagnosis and Treatment | Patient
NI Direct on blood in phlegm Coughing up blood (blood in phlegm) | nidirect
Medline Plus coughing up blood Coughing up blood: MedlinePlus Medical Encyclopedia
References
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- Larici, Anna Rita et al. “Diagnosis and management of hemoptysis.” Diagnostic and interventional radiology (Ankara, Turkey) vol. 20,4 (2014): 299-309. doi:10.5152/dir.2014.13426
- Assessment of Haemoptysis BMJ Best Practice Assessment of haemoptysis – Diagnosis Approach | BMJ Best Practice
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