SN9 SHORT NOTE 5M

Write a short note on haemoptysis.

General Medicine · Final Professional

Definition

Expectoration of blood from the respiratory tract below the larynx.
MASSIVE (life-threatening) haemoptysis — variously > 200–600 mL in 24 hours, or any volume causing haemodynamic instability, airway obstruction or gas exchange impairment.
The volume matters less than the effect: patients with massive haemoptysis DROWN — they do not exsanguinate, and this determines the entire approach.

HAEMOPTYSIS versus HAEMATEMESIS

Feature	HAEMOPTYSIS	HAEMATEMESIS
Preceded by	Coughing	Nausea and vomiting
Colour	BRIGHT RED	Dark, "coffee-ground"
Consistency	FROTHY, MIXED WITH SPUTUM	With food particles
pH	ALKALINE	ACIDIC
Past history	Lung disease	Peptic ulcer, liver disease, alcohol
Afterwards	Blood-streaked sputum for days	MELAENA

Also exclude "pseudohaemoptysis" from the nasopharynx, gums or oropharynx — always examine the nose, mouth and throat.

Causes

Category	Causes
INFECTIVE	PULMONARY TUBERCULOSIS — the commonest cause in India (active disease, healed cavity, bronchiectasis, Rasmussen aneurysm); bronchiectasis; lung abscess; necrotising pneumonia; aspergilloma in an old cavity
NEOPLASTIC	BRONCHOGENIC CARCINOMA (especially central squamous cell); carcinoid; metastases
VASCULAR	PULMONARY EMBOLISM with infarction; MITRAL STENOSIS; acute LV failure (pink frothy sputum); arteriovenous malformation (hereditary haemorrhagic telangiectasia)
VASCULITIC	GRANULOMATOSIS WITH POLYANGIITIS; anti-GBM (GOODPASTURE'S) disease; microscopic polyangiitis; SLE — causing DIFFUSE ALVEOLAR HAEMORRHAGE
HAEMATOLOGICAL/IATROGENIC	Anticoagulants and thrombolytics, thrombocytopenia, DIC
OTHER	Trauma, foreign body, post-bronchoscopy, catamenial, cocaine, idiopathic (up to 20%)

In India the three commonest causes are TUBERCULOSIS, BRONCHIECTASIS and BRONCHOGENIC CARCINOMA — all three must be actively excluded.

Assessment

History:

quantify the volume
duration
fever, night sweats and weight loss (TB, malignancy)
chronic purulent sputum (bronchiectasis)
pleuritic pain and dyspnoea (PE)
orthopnoea (cardiac)
smoking
anticoagulants
past TB.

Examination:

haemodynamic status and oxygenation FIRST
then clubbing, supraclavicular nodes, cachexia
chest signs (a fixed monophonic wheeze suggests obstruction)
cardiac signs of mitral stenosis
nasal and oral examination
signs of vasculitis (rash, sinusitis, haematuria).

Investigations

CBC, coagulation profile, grouping and cross-match, renal function and urinalysis (haematuria and casts — pulmonary-renal syndrome)
Chest X-ray — normal in 20–30%
CT CHEST / CT ANGIOGRAPHY — the key investigation: identifies bronchiectasis, cavities, masses and aspergilloma, and maps the bronchial arterial supply for embolisation
SPUTUM for AFB and CBNAAT (mandatory in India), bacterial and fungal culture, and cytology
BRONCHOSCOPY — localises the bleeding side and allows therapeutic intervention; RIGID bronchoscopy is preferred in massive haemoptysis for suction, airway control and tamponade
Echocardiography; CTPA for PE; ANCA, anti-GBM and ANA where alveolar haemorrhage is suspected (DLCO is characteristically RAISED in alveolar haemorrhage)

Management

MILD: treat the cause — antitubercular therapy, antibiotics, management of bronchiectasis or malignancy, review of anticoagulation; correct coagulopathy.

MASSIVE HAEMOPTYSIS — an emergency, in this order:

1. AIRWAY, BREATHING, CIRCULATION — high-flow oxygen, two large-bore cannulae, cross-match, correct coagulopathy, stop anticoagulants

2. POSITION THE PATIENT WITH THE BLEEDING SIDE DOWN (lateral decubitus) — the single most important immediate manoeuvre, protecting the healthy lung by gravity

3. PROTECT THE AIRWAY — early intubation with a large-bore tube; selective intubation of the non-bleeding lung or a double-lumen tube if expertise allows

4. TRANEXAMIC ACID — intravenous or nebulised

5. BRONCHOSCOPY — localise and apply local measures: iced saline lavage, topical adrenaline or tranexamic acid, balloon tamponade with a Fogarty catheter, endobronchial blockers

6. BRONCHIAL ARTERY EMBOLISATION — THE DEFINITIVE TREATMENT, controlling bleeding in 80–90%. Over 90% of massive haemoptysis arises from the high-pressure BRONCHIAL (systemic) circulation. Main risk: spinal cord infarction

7. SURGERY — for failure of embolisation or specific lesions (aspergilloma, AVM, trauma); high mortality as an emergency

DANGER / REMEMBER

In massive haemoptysis the patient dies of ASPHYXIATION, not blood loss — the priority is the AIRWAY, and the first action is to position the bleeding side DOWN. Sitting the patient upright, or laying them bleeding-side-up, floods the healthy lung and can kill within minutes. Never send an actively bleeding patient unaccompanied to radiology, and secure the airway before transfer.

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