HEMOPTYSIS
True hemoptysis must be distinguished from epistaxis and hematemesis . If the blood is bright red and
alkaline (use nitrazine paper to test) and the nasal passages and posterior
pharynx are clear, then it is probably hemoptysis.
Anatomy is the basic science to apply to develop a differential
diagnosis of hemoptysis. Beginning at the larynx and working down the
trachea, bronchi, and alveoli, one can quickly recall the major causes of
hemoptysis using the cross-index of the various etiologies as in Table
36. Laryngitis is an infrequent cause of hemoptysis, but laryngeal
carcinoma may cause it. TB of the larynx used to be a common cause but it is
not often seen today. A foreign body such as a chicken bone lodged in the
larynx or trachea should always be considered, especially in children.
Additional etiologies of hemoptysis that one might encounter in the trachea
are ulceration and rupture of an aortic aneurysm or a carcinoma of the
esophagus with a tracheoesophageal fistula. Hereditary telangiectasia may
lead to hemoptysis anywhere along the tracheobronchial tree. In the
bronchi, carcinoma, TB, and bronchiectasis become prominent causes. These
are probably the most common causes of chronic hemoptysis in the adult.
In the alveoli the acute causes of hemoptysis—pneumonia
(pneumococcal and Friedlander, especially), and pulmonary embolism or
infarctions—are encountered. CHF may cause a foamy hemoptysis. Carcinoma,
TB, fungi, parasites, and trauma are also important. Collagen diseases,
Goodpasture syndrome, and primary hemosiderosis should be looked for in the
elusive cases.
Approach to the Diagnosis
The differential diagnosis of hemoptysis can be narrowed considerably
by the clinical picture. Acute hemoptysis with chest pain would suggest
pulmonary embolism. A chronic cough with occasional hemoptysis suggests
neoplasm, TB, or bronchiectasis. Hemoptysis with chills and fever suggests
pneumonia, but one should always keep pulmonary embolism in mind. Hemoptysis
with dyspnea, edema, or cardiomegaly suggests mitral stenosis or CHF. The
sputum is usually foamy in cases of CHF. Hemoptysis with purpura or bleeding
from other sites should suggest a systemic disease or coagulation disorder.
The initial workup of hemoptysis includes a CBC, urinalysis, sedimentation
rate, chemistry panel, sputum smear and culture, EKG and chest x-ray. If a
pulmonary embolism is suspected, arterial blood gas analysis and a lung scan
are ordered. Pulmonary angiography may also be necessary. If routine studies
and the clinical picture suggest pneumonia, nothing more may need to be done
other than a careful follow-up. If CHF is suspected, a circulation time may
be done, but a cardiology consult and echocardiogram would be more
definitive. What would you do if it was your heart?
If a bronchogenic neoplasm or bronchiectasis is suspected, a pulmonary
consult and bronchoscopy would be ordered. Bronchiectasis can be identified
with a CT scan of the chest also. If TB is suspected, a tuberculin test is
performed, and sputum is cultured for AFB and possibly Guinea pig
inoculation performed.
Other Useful Tests
-
Papanicolaou smears of sputum (neoplasm)
- Coagulation studies
- Apical lordotic views (TB)
- Spirometry (chronic bronchitis and emphysema, CHF)
- ECG (CHF, mitral stenosis)
- Scalene node biopsy (carcinoma of the lung)
- Lung biopsy (neoplasm, pneumoconiosis, collagen disease)
- Coccidioidin skin test
- Histoplasmin skin test
- Blastomycin skin test
CASE PRESENTATION #43
A 41-year-old nurse presents with a history of intermittent
blood-streaked sputum for the past 2 months. She is a 20-year smoker
and has had a chronic cough which has become more and more productive in the
past 2 years. She was hospitalized 1 year ago for bronchopneumonia.
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Blood-stained phlegm
Read excerpts from these other book chapters related to Blood-stained phlegm:
Medical Books Excerpts
- HEMOPTYSIS
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
- [ read ]
- Hemoptysis
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Hemoptysis
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Hemoptysis
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Hemoptysis
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Hemoptysis
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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