Haemoptysis Case Studies

Clinical assessment and causes
Haemoptysis is a common and non-specific feature of many lung diseases. It can be a sign of significant underlying lung disease. In up to one-third of cases, no cause will be found. An early assessment of the likely underlying cause needs to be made and investigated accordingly.
Diagnostic approach to haemoptysis
Small volume haemoptysis is a commonly encountered problem in the out-patient department. It can be safely and efficiently investigated as an out-patient. Massive haemoptysis is usually encountered in the accident and emergency department or in a patient already on the ward, with known underlying lung disease. The approaches to small volume and massive haemoptysis are different.
History
Past history
Examination
May be normal or show signs of underlying lung disease, e.g. bronchiectasis, bronchial carcinoma, or symptoms of circulatory collapse.
In practice the usual differential diagnosis lies between:
Malignancy
Bronchiectasis
Tuberculosis/infection
PE.
Causes of haemoptysis
Common
Bronchial tumour (benign, e.g. carcinoid or malignant). Haemoptysis is a common presenting feature of bronchogenic malignancy, indicating endobronchial disease, which may be visible endoscopically
Bronchiectasis. Small volume haemoptysis is a common feature of bronchiectasis, particularly during exacerbations. It can be a cause of massive haemoptysis, from dilated and abnormal bronchial artery branches that form around bronchiectatic cavities
Active tuberculosis. Haemoptysis occurs in cavitating and non-cavitating disease, active disease and inactive disease (bronchiectatic cavity, e.g. containing mycetoma)
Pneumonia (especially pneumococcal)
Pulmonary thromboembolic disease
Vasculitides/alveolar haemorrhage syndromes, e.g. Wegener's granulomatosis, SLE, Goodpasture's syndrome
Warfarin with any of the above.
P.23

Rare
Lung
Autoantibodies–ANCA, anti-GBM, ANA (if vasculitis suspected)
Sputum cytology and M, C, & S and AFB if infection suspected
CXR may show mass lesion, bronchiectasis, consolidation, or an AVM
CT chest should be done prior to bronchoscopy, as prior knowledge of the site of abnormality leads to increased pick up rates at bronchoscopy. Similarly, a definitive diagnosis, e.g. AVM, may be made from the CT, obviating the need for further investigations. This depends on local resources, CT may miss an upper airway abnormality, but bronchoscopy should not
Bronchoscopy to visualize airways and localize the site of bleeding. May also be therapeutic, for example if a bleeding tumour can be injected with vasoconstricting agent or catheter inserted for tamponade (see massive haemoptysis)
Transbronchial biopsies—if vasculitis suspected.
Second-line investigations
Usually done if first-line investigations fail to demonstrate a cause
CTPA to exclude PE
Bronchial angiogram Diagnostic and therapeutic. Rare for the actual bleeding site to be identified; more often the bleeding site is assumed from visualizing a mesh of dilated and tortuous vessels, e.g. around a bronchiectatic cavity. Usually done during an episode of bleeding, to maximize the chance of identifying the site of