An Overview of Hemoptysis

Introduction:

Hemoptysis is the expectoration or coughing up of blood from the respiratory tract. Hemoptysis is different from vomiting blood, as it involves coughing up blood from the lower respiratory tract. Thus, it is usually mixed with respiratory secretions and mucus (sputum). A person can cough up a few streaks of blood with mucus (sputum or phlegm) or a lot of pure blood. Symptoms such as breathing difficulty and fever may also be present along with hemoptysis. Minor hemoptysis requires careful evaluation and management at the hospital or emergency department and is not a threat to the person’s life. However, if a person coughs up a large quantity of blood, exceeding 600 milliliters per 24 hours, it is called massive hemoptysis and requires emergency medical care. Prompt medical intervention can help to prevent complications such as suffocation and death due to the lack of oxygen.

What Causes Hemoptysis?

Coughing up blood can be scary, but streaks of blood in the sputum are usually not serious. Minor respiratory problems such as infections can cause hemoptysis. Hemoptysis is also seen in some major health issues, and it is important to visit a doctor when one coughs up blood. The common causes due to which one can cough up blood include the following:

1. A severe cough or a persistent cough for a long duration.

2. Infections of the lungs and respiratory tracts (airway), such as pneumonia, chest infections, and bronchitis (inflammation of the smaller branches of the windpipe).

3. Bronchiectasis, where the airway or respiratory tract widens and produces more secretions and mucus.

4. Lower respiratory tract infections (common in children).

5. Aspiration of foreign objects (a common cause seen in children).

However, hemoptysis can indicate serious health problems such as:

1. Lung cancer.

2. Blood clots in the lung.

3. Serious fungal infections such as aspergillosis.

4. Tuberculosis.

5. Heart failure and valve problems (rare).

Lung cancer, bronchiectasis (widening and more mucus in the airway), and some infections such as pneumonia and tuberculosis can lead to life-threatening massive hemoptysis. In addition, some conditions, such as human immunodeficiency virus infections (HIV), smoking, and the use of medications such as immunosuppressive drugs, increase the risk of coughing up blood in patients with serious medical problems.

When Does Hemoptysis Require Emergency Care?

If you have mild hemoptysis or coughing up a few streaks of blood, it is not an emergency. However, one must visit a doctor and get it checked. Chest pain and rapid heart rate, and breathlessness, along with hemoptysis, indicate serious lung problems such as pulmonary embolism (blood clots in the lung affecting lung function). Prompt emergency medical attention is required in case of:

1. Coughing up large amounts of blood (massive hemoptysis).

2. Shortness of breath or breathing difficulty along with hemoptysis.

3. Symptoms of severe blood loss such as dizziness, rapid heart rate, weakness, thirst, and excessive sweating.

4. Pain in the chest and upper back, along with hemoptysis.

5. A significant drop in blood pressure with hemoptysis.

How Are the Causes of Hemoptysis Diagnosed?

The doctor will ask several questions about the medical history, examine, and recommend several diagnostic tests to identify the cause of coughing up blood. The various tests can include the following:

1. Pulse oximetry.

2. Chest X-ray.

3. Blood tests such as hemoglobin levels, complete blood count, platelet count, tests to assess blood clotting abnormalities, and blood oxygen and carbon dioxide levels (arterial blood gas).

4. Urine tests.

5. Electrocardiogram (to check the heart).

6. Chest computed tomography (CT).

7. Biopsy of the lungs (especially if cancer is suspected).

8. Bronchoscopy (a tube is inserted to check if the airway is clear).

9. Lung scan.

10. Tests to check blood flow through the lungs.

How Is Hemoptysis Managed in the Emergency Department?

For severe hemoptysis with underlying debilitating diseases, get medical help immediately or rush to the emergency department. Do not attempt to treat them at home with medications to stop the cough. Bleeding in the airway can cause clots to form and block the airway (passage to the lungs). Coughing is a protective reflex in these cases and helps the bleeding to get out before clot formation. However, if medications to stop coughs are administered, they can prevent the blood from leaving the airway and facilitate clot formation, thus worsening breathing problems. Treating the underlying cause (such as infection or heart failure) usually helps patients get better. The following is done to manage hemoptysis in the emergency department.

1. Oxygen is administered to ensure that there is sufficient oxygen in the patient’s blood to be supplied to all body parts and vital organs.

2. If the patient’s blood pressure is low, ringer’s solution or normal saline is given to raise the blood pressure initially.

3. Blood tests are done to determine the patient’s blood type, and a blood transfusion is done if needed.

4. Fresh frozen plasma and platelets are administered if needed in patients with bleeding and clotting disorders (such as thrombocytopenia or low platelet count).

5. The patient is made to lie down and positioned to prevent blood entry into the unaffected lung.

6. Cough suppressants such as Hydrocodone and other opioids are given after careful consideration of the benefit for the patient.

7. Suppose the patient stops breathing due to respiratory failure or cannot clear the secretions and blood in the airway due to unconsciousness. In that case, a tube is inserted through the nose or mouth into the airway to help the patient breathe and get sufficient oxygen. An endotracheal tube with a large diameter of eight millimeters is usually used in such cases.

8. If the patient’s airway is blocked with a large clot, it is removed using a procedure called bronchoscopy (a tube inserted to help remove clots).

9. If a large important blood vessel is causing the bleeding, the emergency personnel perform bronchial artery angiography and embolization. In this procedure, an X-ray is used to visualize the blood vessels in the lungs. Once the bleeding artery is identified, it is blocked to stop the bleeding.

10. A drug called Tranexamic acid is used to treat hemoptysis that does not resolve with treatment of the underlying cause.

11. Surgery is used as the last option to stop continuous or severe bleeding and remove diseased tissue or cancer from the lungs.

Patients with moderate to severe hemoptysis need hospital or intensive care unit admission.

Patients with mild hemoptysis with serious medical conditions are also admitted to intensive care, as these patients have a higher risk of severe hemoptysis that might require emergency care. A pulmonologist or thoracic surgeon's advice is needed for deciding whether particular interventions and imaging, such as computed tomography, bronchoscopy, or angiography for bronchial artery embolization, might be needed. The patients are usually transferred to another facility if trained experts are not available at the time. During discharge, the patients are given a prescription for medications such as bronchodilators, cough suppressants, or antibiotics, depending on the cause of the hemoptysis. The patients must visit the doctor frequently for close follow-up if they are at high risk of serious diseases such as cancer.

Conclusion:

Hemoptysis is coughing up blood from the airway or the respiratory tract. Mild streaks of blood with mucus are usually harmless. However, the patient must visit a doctor for a check-up. Suppose a person coughs out lots of blood and is experiencing chest pain, breathing difficulty, low blood pressure, or rapid heart rate. In that case, prompt medical intervention is required as these can be due to life-threatening medical emergencies such as pulmonary embolism or heart failure. Treating the underlying cause, such as infections, clots, or heart problems, can help the patient feel better.