Hemoptysis - Symptoms, Diagnosis, and Treatment

Introduction

Hemoptysis means "coughing up blood." The expectoration of blood or blood mixed with sputum originates below the vocal cords from the tracheobronchial tree or pulmonary parenchyma as a result of pulmonary or bronchial hemorrhage. The blood can appear as dots with small patches of blood, streaks, or massive amounts. It can be classified as massive and non-massive hemoptysis based on the volume of blood expectorated. Massive hemoptysis is the expectoration of more than 100 ml to 1000 ml of blood expectorated within 24 to 48 hours. Massive hemoptysis can be defined as the expectoration of at least 200 ml within 24 hours or 50 ml per episode.

What Is True Hemoptysis and Pseudohemoptysis?

A pseudohemoptysis or false hemoptysis can be defined as the expectoration of blood from different sources other than bronchial or pulmonary systems. When red-colored sputum is seen without the presence of red blood cells due to the presence of a red pigment forming, gram-negative bacteria known as Serratia marcescens infection, the condition is known as pseudohemoptysis or false hemoptysis. It originates above the vocal cords and is not mixed with sputum. At the same time, true hemoptysis can be defined as the expectoration of blood or blood mixed with sputum that originates below the vocal cords from the tracheobronchial tree.

What Is the Difference Between Hemoptysis and Hematemesis?

Hemoptysisis coughing up blood, whereas hematemesis is vomiting of blood, usually from the digestive system. A variety of reasons that can cause vomiting of blood are: peptic ulcers, gastritis, malignant stomach tumors, gastric and esophageal varices seen in cases of liver failure, a Mallory - Weiss tear, or a tear in the part of the esophagus due to forceful coughing or vomiting.

Even alcohol and NSAIDs (non-steroidal anti-inflammatory drugs) can cause hematemesis that can lead to anemia and, most importantly, can also cause shock due to massive blood loss. In the case of hemoptysis, the blood usually looks bright red and is frothy in consistency. In contrast, in the case of hematemesis, the blood can be either bright red if it is fresh blood or have a coffee-ground color and consistency from older bleeds. An esophagogastroduodenoscopy is helpful for the diagnosis of hematemesis. Injection sclerotherapy and endoscopy band ligation is the mainstay of treatment in hematemesis.

What Are the Causes of Hemoptysis?

Hemoptysis can occur as a result of different causes, which include:

• Infections include bronchitis, pneumonia, lung abscess, bronchiectasis, and tuberculosis.

• Neoplasia such as bronchial carcinoma.

• Cardiovascular causes such as lung infarction and mitral stenosis ultimately lead to congestive cardiac failure.

• Vascular causes such as pulmonary embolism.

• Autoimmune disorders such as Wegener's granulomatosis or granulomatosis with polyangiitis, microscopic polyangiitis, systemic lupus erythematosus, Goodpasture disease, Churgh - Strauss syndrome.

• Drug-related causes, such as patients on anticoagulants and antiplatelets.

• Others- foreign body aspiration.

What Are the Other Signs and Symptoms Apart From Hemoptysis?

The other signs and symptoms to look for are:

• Shortness of breath.

• Chest pain.

• Weight loss.

• High fever.

• Night sweats.

What Are Risk Factors for Hemoptysis?

The risk factors include:

• History of smoking.

• HIV (human immunodeficiency virus) patients.

• Patients on immunosuppressants.

What Are the Diagnostic Tests to Be Carried Out?

The different diagnostic tests that can be carried out include:

• Physical Examination: a proper detailed physical examination can help diagnose many pulmonary diseases.

• Chest X-Ray and Computed Tomography (CT) Scan: It can easily identify any peculiarity of the lungs, whether a mass is present, accumulation of fluid or air, or any kind of lung congestion. It is considered the first line of investigation for patients complaining of hemoptysis.

• Pulmonary Arteriography: To visualize the blood flow within the lungs.

• Sputum Culture: Look for any microbial pathology in the sputum sample.

• Bronchoscopy: It is an endoscopic method to visualize the airways directly using a thin, light-weighted, flexible tube that can be advanced quickly into the small airways and bronchioles.

• Complete Blood Count (CBC): It is a method to calculate the number of red blood cells and white blood cells, along with platelets.

• Urine Analysis: A simple urine test may help diagnose hemoptysis's cause.

• Arterial Blood Gas Analysis: It measures arterial oxygen, carbon dioxide, and pH. The calculation can be done with the help of the Henderson-Hasselbach equation, where pH is directly proportional to bicarbonate ions and indirectly proportional to carbon dioxide.

• Pulse Oximetry: It is a probe that checks the oxygen saturation level of the blood.

• Blood Chemistry Profile: It is done to measure the number of electrolytes.

How Is Hemoptysis Treated?

In patients with massive hemoptysis and hemodynamic instability; airway patency, breathing, and circulation are maintained first. The patient lies in a lateral decubitus position with the affected lung in a dependent position to avoid any pooling of blood or fluid in the unaffected lung. A chest radiograph is vital for patients with non-massive hemoptysis with no hemodynamic instability.

Conclusion

Coughing is important for a clear airway and should not be suppressed with cough suppressants or antitussive drugs. But the presence of blood in the cough is alarming and indicative of a serious and potentially lethal type of infection or malignancy. The amount of blood is quite useful in determining the severity of the disease. Hemoptysis can be mild or severe. If mild hemoptysis is seen, it might get corrected by itself or when the underlying condition is treated. But severe hemoptysis does not get corrected by itself. To have good airway patency, intubation or tube insertion is necessary for hemodynamically unstable patients. Hemodynamic instability, abnormal gaseous exchange, cardiopulmonary comorbidities, and lesions are at high risk of massive bleeding. A chest radiograph is considered the initial diagnostic tool for a hemodynamically stable patient with hemoptysis. Hemoptysis can be due to various reasons, many of which are treatable. Early diagnosis and intervention are required for the disease to not progress further.