1. A case of haemoptysis
ERWEB Case

2. History
Megan Jones is a 50 year old woman who presents to the Medical Admissions Unit coughing blood-stained sputum.

3. What aspects of this patient's story will need to be explored in more detail from a disease perspective?

4. What aspects of this patient's story will need to be explored in more detail from a disease perspective?
Where did the blood come from? (cough, vomit or spit)
Patients may claim to have coughed up blood, but on closer evaluation it becomes apparent that they actually have haematemesis or epistaxis.
When did the haemoptysis start and what volume is it?
Work up and initial management of massive haemoptysis (>200mls/24 hours) is different from non-massive haemoptysis. Massive haemoptysis occurs infrequently but however is a medical emergency when it does occur.
Are there symptoms of respiratory failure or hypotension?
Has the patient had it before?

5. What is the differential diagnosis of the most common causes of haemoptysis?

6. What is the differential diagnosis of the most common causes of haemoptysis?
Bronchiectasis (including cystic fibrosis)
Malignancy
Infections:
Pneumonia or lung abscess TB
Aspergilloma
Acute or chronic bronchitis
Pulmonary emboli (PE)
Wegener's granulomatosis, Goodpasture's syndrome
Coagulopathy:Underlying coagulation disorderOn anti-coagulants
Left atrial hypertension

7. What are the aspects of the history that would help differentiate the cause of the haemoptysis?

8. What are the relevant features to look for on examination?

9. What are the relevant features to look for on examination?
General features:
Degree of distress, Respiratory rate, Pulse, BP, Temperature, O2 saturations, Pallor
Other aspects:
Clubbing - bronchogenic carcinoma or bronchiectasis
Lymphadenopathy - bronchogenic carcinoma
Nasal passage - ulcerations seen with Wegener's granulomatosis
Chest examination:
Evidence of lobar collapse or consolidation
crepitations, or pleural effusion – infections or malignancy

10. How would you investigate this patient further?

11. How would you investigate this patient further?
Bloods:
FBC, CPR, ESR
Urea & electrolytes
ANCA - for Wegener's granulomatosis.
Anti-glomerular basement membrane - for Goodpasture's syndrome.
Blood cultures - if infection suspected.
Coagulation screen.
Chest X-ray
Sputum:
microscopy and culture, and cytology. If indicated
three early morning sputums should be sent for AFBs (TB).
Urine: cells and casts (Wegener's granulomatosis and Goodpasture's syndrome)
CT scan chest (with high resolution slices +/- CT pulmonary angiogram)
Bronchoscopy with washings and biopsies
ENT examination of nasal mucosa (for Wegener's granulomatosis)

12. How would you manage this patient acutely?

13. How would you manage this patient acutely?
Most of the time haemoptysis is not a medical emergency.
Supportive, including intravenous rehydration and oxygen as required.
Specific treatment directed towards the underlying cause e.g. antibiotics for infection, corticosteroids and cyclophosphamide for Wegener's granulomatosis.
If massive haemoptysis
secure the airway and control the breathing.
senior and experienced anaesthetists and surgeons (ENT and/or cardiothoracic).

14. Megan Jones was diagnosed with community-acquired pneumonia.
Her clinical signs were these: Respiratory rate: 32 breaths / min Diastolic blood pressure: 55mmHg Serum urea: 9mmol/L

15. Is the decision to use oral antibiotics correct?

16. Megan Jones’ clinical signs suggest a severe community acquired pneumonia. She scores one point each for serum urea > 7mmol/L, diastolic blood pressure < 60mmHg and respiratory rate >30 breaths/minute

According to the antibiotic guide, the first choice therapy for a patient aged less than 60 years like Megan is a combination of two antibiotics:
Co-amoxiclav 1.2G IV three times a day
Erythromycin 1G IV four times a day

17. Revised chart

18. How would the therapy prescribed need to change if Megan developed acute renal impairment (eGFR 25ml/min/1.73m2)? 


19. Renal antibiotic guidelines SPC Coamoxiclav
How would the therapy prescribed need to change if Megan developed acute renal impairment (eGFR 25ml/min/1.73m2)? 

BNF
Renal antibiotic guidelines
SPC
Coamoxiclav
Reduce dose if eGFR < 30ml/min/1.73m2
Reduce dose to 1.2G every 12 hours if GFR 10-30ml/min
If ClCr 10-30ml/min, initial dose of 1.2G and then 600mg given twice daily 
Erythromycin
Max 1.5G daily in severe renal impairment – risk of ototoxicity
Use normal dose if GFR is 20-50ml/min
No information

20. Megan’s new drug chart