Introduction:
Thick mucus coughed up from the airway is known as phlegm. It is thicker than usual and may form due to some illness or irritation. The process of coughing up blood from the lungs or bronchial tubes is known as hemoptysis. It may range from a few streaks of blood to large amounts. It can be a symptom of an underlying medical condition and can be a sign of a serious problem. Common causes of blood in phlegm include infections, lung cancer, pulmonary embolism (a condition where one or more lung arteries get blocked by blood clots), and other conditions that affect the lungs. Treatment depends upon the underlying cause.
What Is Blood in Phlegm?
The phlegm is the thick mucus secreted from the tracheobronchial tree (including the trachea, the bronchi, and the bronchioles). It can be due to some underlying disease or irritation factors. Some pathological conditions may result in blood in the phlegm, called hemoptysis. The blood-containing mucus is expectorated from the pulmonary parenchyma (large numbers of alveoli in the lungs, which creates a large surface area for gas exchange) or the tracheobronchial tree. Depending upon the amount of blood lost in phlegm, it can be massive or non-massive. In massive hemoptysis, 200 milliliters of blood is lost in 24 hours, or 50 milliliters of blood is lost per episode. Of all the hemoptysis cases, only five percent account for massive hemoptysis. However, if identified, it is a serious symptom with more than 50 % mortality and needs immediate medical attention.
How to Diagnose Haemoptysis?
During clinical examination, when a patient presents with blood in phlegm, the clinician must differentiate between true hemoptysis and pseudo hemoptysis. The clinical condition of the patient and the amount of blood loss are assessed initially and based on the findings, the cause of bleeding is identified.
Pseudohemoptysis is the expectoration of blood from the upper respiratory tract or the upper gastrointestinal tract, whereas true hemoptysis is the expectoration of blood from the lower respiratory tract. Therefore, the possibility of pseudo hemoptysis is ruled out while examining a patient.
What Are the Causes of Hemoptysis?
The presence of blood in phlegm or hemoptysis can occur due to multiple causes. The common causes of hemoptysis:
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Infective Causes:
Pneumonia (fluid-filled lungs) is one of the most common infective causes of blood in phlegm. These patients display signs of infection, such as fever, chest pain, and productive cough. Another common cause is mycobacterium tuberculosis infection (bacteria responsible for tuberculosis infection).
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Neoplastic Causes:
Cancerous lesions of the lungs can lead to hemoptysis. They can be due to primary pulmonary lesions (tumors that primarily form from the lung tissues) and metastatic lesions (cancer spread from a distant part of the body). If malignancy is suspected, the physician should look for a history of kidney, breast, cervical, ovarian, and gastrointestinal cancer to rule out metastasis.
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Vascular Causes:
Pulmonary embolism (a condition where one or more lung arteries are blocked by a blood clot, mostly caused by blood clots that travel from the legs and rarely from other parts of the body) is the main vascular cause of hemoptysis. The patient should be evaluated for a history of recent surgery or immobilization.
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Autoimmune Causes:
Some autoimmune diseases are associated with hemoptysis. Wegner’s granulomatosis (causes inflammation of the blood vessels) and systemic lupus erythematosus (an inflammatory disease caused by the attack of the immune system on its tissues) are some autoimmune diseases that may show signs like blood in phlegm and require specialist evaluation.
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Drug-Related Causes:
Anticoagulants (retards or inhibits blood coagulation) and antiplatelet agents (medications that prevent blood clots from forming) cause hemoptysis.
How to approach a Patient with Hemoptysis?
The physician should take a proper history of the patient with hemoptysis to narrow down the possible causes. Firstly the blood in phlegm is ruled out for pseudohemoptysis. It is also necessary to quantify the amount of blood lost through the expectorate and identify any complications of blood loss. The vital signs should be monitored and documented. In case of massive bleeds, gas exchange abnormality, hemodynamic instabilities (increased heartbeat, increased rate of breathing, decreased blood pressure), respiratory comorbidities (chronic obstructive pulmonary disease, previous pneumonectomy), etc., demands admission to the emergency department or referral to specialists.
All the patients presented with hemoptysis are advised for chest radiography. It reveals pleural abnormalities and parenchymal (lung tissue) involvement. Other diagnostic techniques include
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Bronchoscopy (a procedure to examine the lungs and air passages).
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Multidetector computed tomography ( computed tomography with a two-dimensional detector providing a more detailed view).
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Multidetector computed tomographic angiography (used for assessing the cardiovascular system before and after treatment).
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Digital subtraction angiography (detects blood flow in the brain by providing an image of the blood vessels within the brain).
How to Manage Patients with Hemoptysis?
When a patient presents with steaks of blood in the phlegm (non-massive hemoptysis), a chest radiograph is sufficient to diagnose the cause, and no additional tests are required. A CT (computed tomography) scan is advised when there is an increased risk of malignancy.
In Chest Radiography:
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The presence of infiltrate indicates the presence of an infectious disease. Antibiotics are administered depending on the organisms. The condition resolves a repeat chest radiograph taken six to eight weeks later. However, if the condition does not resolve, a CT scan is advised, and the patient is referred to a specialist.
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If a mass or other parenchymal disease is detected in the chest radiograph, the patient is further advised for a computed tomography scan of the thorax; if a specific diagnosis of neoplasm or any other lesion is obtained, further evaluation and treatment is carried out based on that. However, if no specific diagnosis is obtained, the patient is advised for bronchoscopy (examination of the air passages ) examination and referred to a specialist.
In case of massive blood loss, the patient may have hemodynamic instability, in such cases, priority is given to managing the airway, circulation, and breathing. The patient is placed in the lateral decubitus (a patient lies on his or her side) position keeping the affected lung in a dependent position to prevent blood pooling in the opposite lung. Further management for massive blood loss should be carried out in a hospital setting.
Conclusion:
Hemoptysis is a common presentation in a regular healthcare setting. A careful evaluation of the severity of the condition and status of the patient must be made to check the life-threatening complications that it can lead to. A detailed medical and personal history and a thorough clinical examination are necessary to diagnose the underlying cause accurately. Proper management is possible only if the cause is identified.
