Haemoptysis

Coughing up blood originating from the respiratory tract below the level of the larynx.

History

NB Make sure to differentiate between

  • true haemoptysis,
  • pseudohaemoptysis (coughing up blood not coming from below the larynx e.g. bleeding from gums/nose etc that has been partially aspirated and coughed up)
  • haematemesis (vomiting up blood from the GI tract)

In the history:

  • Ask about the onset, progression and timing
    • Did it come on at rest or exertion, sudden vs gradual, decreasing or increasing with time etc
  • Was it fresh red blood, dark blood, frothy, pink, stained sputum etc?  How much blood?
    • NB it can often be difficult to quantify the amount of blood but it is important to try.  Massive Haemoptysis is defined as haemoptysis significant enough to cause asphyxia (i.e. impairs oxygenation of the blood) i.e. NOT by volume of blood
      • the volume of haemoptysis that is classed as ‘massive’ varies from person to person
        • ranges from 100-600ml/24 hours, but in general, anything greater than 250ml/24 hours should be admitted and closely monitored with an ABCDE approach
  • Were there any associated symptoms?
    • Acute cough, sputum and a temperature/fever is suggestive of infection
    • Chronic cough +/- sputum (with underlying lung disease) could indicate chronic bronchitis or bronchiectasis
    • Pleuritic chest pain and shortness of breath could indicate pulmonary embolism
      • Ask also about leg pain
    • Night sweats, fatigue, weight loss +/- changing cough could be signs of cancer
      • +fever could be tuberculosis
    • Bleeding elsewhere?
      • Haematuria may suggest reno-pulmonary disease syndromes e.g. Goodpastures disease/Wegeners granulomatosis
      • Bruising/petechial rash may suggest other bleeding problems
    • Any breathlessness- in particular when lying down (orthopnoea) or being woken from sleep (paroxysmal nocturnal dyspnoea)- both suggestive of congestive heart failure
      • Frothy pink sputum is a classic picture in CHF also (pulmonary oedema)
  • Ask about past medical history?
    • COPD and asthma
    • TB
    • DVT/PE
    • Heart disease/ MIs
  • Ask about drugs
    • Warfarin
    • Clopidogrel
      • Take a full PMHx and RHx
  • Ask about Family History
    • TB/ pneumonia/ URTI/ LRTI
    • Cancer
    • Other
  • Ask about travel history
    • Long-haul flights
    • Exposure to protozoal infections or other tropical diseases
  • Ask about smoking history and alcohol history.
  • Ask about occupational history/exposure

On Examination

Do a full general and cardio-respiratory examination

  • General
    • Look from the end of the bed- is the patient well/unwell? (And do they require an ABCDE approach)
      •  Does the patient appear cachexic
        • Also look for any inhalers, sputum pots, blood-stained tissues etc
    • Look at the hands for clubbing (cancer/bronchiectasis)
      • Look for other signs, e.g. nicotine,
    • Feel the radial pulse and comment on rate; rhythm; strength/volume; character
    • Take a blood pressure
    • Look for any abnormal pigmentation of the skin
    • Look at the face for any pallor/cyanosis
      • Look in the mouth for any signs of gum/dental disease
      • Look at the eyes for any signs of Horners syndrome
    • Do a full neck examination for lymphadenopathy
      • Also look at the JVP and feel for a central trachea
  • Chest
    • Inspect
      • Check resp rate and nature of breathing
      • Look for chest expansion (symmetrical)
      • Any scars, chest abnormalities (e.g. pigeon chest/barrel chest)
    • Palpate
      • Chest expansion
        • Ask the patient to breathe out and place your hands around the ribcage such that your thumbs are just touching in the midline (this should be done quite firmly to ensure movement with chest expansion).  Ask the patient to breathe in deeply and check that the thumbs move apart.
      • Apex beat
        • Using the palmar aspect of your fingers, palpate roughly over the 4th-8th ribs in the mid-axillary line and move medially until you can palpate the most lateral point of the apex beat (normally 5th IC space, mid-clavicular line).  Use two fingertips to localise the apex beat.
      • Heaves/thrills
        • Feel with the hand over the left sternal edge (vertically) and across the sternum over rib 2-3 for any vibrations of heaves/thrills
    • Percuss
      • Comparing sides, percuss down the chest over lungs zones on the front and back
        • NB it may be easier to wait to percuss/auscultate the back until after examination of the front has been done
    • Tactile vocal fremitus
      • Place the medial aspect of your hand over the 2nd, 4th and 6th intercostal spaces, comparing sides.  Each time, ask the patient to speak (usually the word “ninety-nine”, but others are fine)
        • Vocal fremitus (vocal vibrations felt) is usually very fine or absent.  It can be increased over areas of consolidation and decreased over areas of effusion/collapse
    • Auscultate the heart over the 4 valve anatomical areas and over Erb’s point with both the bell and the diaphragm
        • Aortic- Right 2nd IC space, parasternally (near the ascending aorta)
        • Pulmonary- Left 2nd IC space, parasternally (nearest the infundibulum)
        • Erb’s point- Left 3/4th IC space, parasternally (point where S2 is best heard)
        • Tricuspid- Left 5th IC space, parasternally
        • Mitral- Left 5th IC space, mid-clavicularly (or apex beat)
      • Special positions for auscultation of diastolic murmurs
        • To listen for mitral stenosis
          • Listening with the bell in the mitral area, ask the patient to turn onto their left side (about 45-60°)
        • To listen for pulmonary insufficiency (and aortic regurgitation)
          • Listening with the diaphragm in the pulmonary and aortic areas, ask the patient to sit forward, take a deep breath in and breathe all the way out, hold it there (you listen), and breathe in again.
    • Auscultate over the front and back lung zones, comparing sides.
      • Normal breath sounds (vesicular breathing) are quiet and gentle.
        • Note if breath sounds are normal volume or quiet (reduced air entry)
      • Bronchial breathing is harsher, often higher pitched and poor/tubular in quality, often with gaps between the inspiratory and expiratory phase.
        • Suggests consolidation or fibrosis.
      • Note any crackles or fine crepitations, any wheeze (‘musical expiratory sounds’, any pleural rub (‘creaking sound’); any stridor (harsh inspiratory sound)

To listen to some examples, see here (for lung sounds) and here (for heart sounds)

    • Vocal resonance/Whispering pectoriloquy
      • Ask the patient to whisper (usually “ninety-nine” again) and simultaneously listen to the lung zones
      • Normally the voice is muffled through lung.  In areas of consolidation, the voice will become louder/clearer

Investigations

  • CXR- possibly the most useful to confirm the clinical diagnosis suspected from the history and examination
    • Other imaging investigations e.g. CT (non contrast, contrast +/- CT pulmonary angiogram) may be requested if appropriate
  • FBC should be checked for anaemia, WCC.  Other tests, e.g. CRP, U&Es, LFTs/Coagulation may also be appropriate
  • ECG +/- Echocardiogram may be useful, particularly if there is a suspected cardiac cause of haemoptysis
  • Bronchoscopy is often useful in evaluating the site of bleeding (+ biopsies of suspicious lesions may be taken)

Differential Diagnosis

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  • Trachea or bronchus:
    • Malignancy
      • Bronchogenic carcinoma
      • Endobronchial metastatic tumour
      • Kaposi’s sarcoma
      • Carcinoid tumour
    • Bronchitis
    • Bronchiectasis
    • Broncholithiasis
    • Airway trauma
    • Foreign body
  • Lung parenchyma:
    • Lung abscess
    • Pneumonia – bacterial (egStaphylococcus aureusPseudomonas aeruginosa) or viral (eg influenza)
    • Tuberculosis (TB)
    • Fungal infection and mycetoma
    • Hydatid cysts
    • Goodpasture’s syndrome
    • Pulmonary haemosiderosis
    • Wegener’s granulomatosis
    • Lupus pneumonitis
    • Lung contusion
    • “Crack” lung
  • Vascular:
    • Arteriovenous malformation
    • Aortic aneurysm
    • Pulmonary embolism (PE)
    • Mitral stenosis
    • Other cause of pulmonary venous hypertension, eg left ventricular failure (LVF)
    • Trauma
    • Iatrogenic (eg chest drain malposition, secondary to pulmonary artery catheter manipulation)
  • Other:
    • Pulmonary endometriosis
    • Congenital or acquired systemic coagulopathy, eg leukaemia
    • Anticoagulant or thrombolytic agents
    • Factitious haemoptysis
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