Hemoptysis
Summary/Definition
Haemoptysis is the discharge of sputum with blood from bronchi or lungs when coughing. In haemoptysis, it is important to identify the organ that is the source of the problem – the larynx, lungs, bronchi, gastrointestinal tract, oesophagus, gums, nose, etc. If the blood in hemoptysis is accompanied by coughing and has a bright scarlet colour, then most likely it is bleeding from the lungs or bronchi. If hemoptysis is accompanied by vomiting and has a dark red colour, it is less likely that it is bleeding from the upper respiratory tract, but this assumption requires verification. The volume of haemoptysis is not related to the severity of the underlying disease. At the onset of symptoms, it is difficult to predict the duration and clinical course of haemoptysis, so it is better to test for the causative organism immediately and prepare for an increase in the volume and duration of haemoptysis. The rate of haemoptysis is more important than the total volume secreted. If the blood comes out at a rate of about 150ml/hour, there is a high risk of filling the airways and causing asphyxia. More than 40 diseases are known to cause haemoptysis. The main ones are pulmonary tuberculosis, bronchiectasis, lung abscess, chronic bronchitis and lung cancer. Lung cancer, pulmonary tuberculosis and bronchiectatic disease are known to be the main causes of the disease, especially in people over 50 years of age.
Symptoms
When blood is discharged with coughing, there may be single streaks or massive haemorrhage. When haemoptysis occurs, it is important to first identify the source of the bleeding: respiratory tract, lungs, bronchi, etc. And also to differentiate hemoptysis from vomiting blood, which can occur in the upper respiratory tract, oesophagus or stomach. When bleeding from the respiratory tract – blood is bright red in colour, mixed with frothy sputum, pH (acid-base balance) – strongly alkaline. In vomiting with blood – blood is dark red in colour, often mixed with food and has an acidic pH level. Haemoptysis of more than 100-600 ml per day is called “massive haemorrhage” and is a life-threatening situation requiring urgent treatment.
Diagnostics
The cause of haemoptysis is determined by diagnosing the chest condition with chest X-ray, computed tomography(CT), bronchoscopy, high resolution computed tomography(HRCT), etc. The possibility of lung cancer, especially in middle-aged and elderly patients, should not be overlooked. In the case of massive haemoptysis, the first thing to do is to determine the clinical condition of the patient and ensure airway patency to avoid suffocation or shock. The goal of all treatments in haemoptysis is the complete elimination of symptoms. When bleeding from the lungs or bronchi is confirmed, careful history taking, physical examination, chest X-ray, chest radiography computed tomography (CT) and other diagnostic methods should be used to immediately identify the source of bleeding, and then immediate treatment should be given to stop the bleeding.
The medical examination should determine how long ago the symptoms may have occurred and the source of the bleeding: bronchi, upper respiratory tract, or gastrointestinal bleeding. In addition, it is necessary to assess the degree of haemoptysis and the rate of blood loss to understand how much emergency treatment is needed. Also check other associated symptoms: the amount of sputum, the presence of pus in the sputum, fever, chest pain and difficulty breathing. On physical examination, the doctor checks the respiratory rate, listens for breathing between the ribs, looks for cyanosis (lividity of the lips), etc. to assess how difficult breathing is, whether there is wheezing, whistling, or hoarseness of the voice. Computed tomography (CT) scan of the chest, bronchoscopy, and bronchial and pulmonary angiography are needed to identify lesions.
Treatment and course of the disease
What type of medical care is needed depends on the rate of bleeding and the effect of haemoptysis on oxygen exchange. In case of massive haemoptysis, endotracheal intubation and artificial ventilation should be performed to maintain proper gas exchange in the lungs. First of all, it is necessary to provide the patient with emergency care for haemostasis, followed by diagnosis of the site and cause of bleeding, as well as to determine the need for surgical resection. In cases of non-massive haemoptysis, administration of styptic agents may reduce the volume of haemoptysis and the need for additional procedures. The acupuncture may further aggravate haemoptysis, so coughing is better controlled with anti-cough medication. If hemoptysis is suspected to be caused by a bacterial infection, a microbiological test should be performed and an appropriate antibiotic prescribed. Another way to stop bleeding is to insert a balloon catheter into the lungs through a bronchoscope. The balloon catheter applies pressure to the bleeding area, stopping the blood. Other clinical methods to control or treat bleeding include laser light therapy, electrocoagulation, embolisation therapy and surgical resection.
