Introduction
The most common cause of hemoptysis is tuberculosis; both active and post-tubercular sequelae can result in hemoptysis. Other non-tubercular causes, such as malignancy, bronchiectasis, and bronchitis, are leading causes of hemoptysis. The severity of the hemoptysis is usually classified based on the amount of blood that spits out in 24 hours. Hemoptysis was traditionally classified as
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Mild - 30 milliliters.
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Moderate - 31 to 100 milliliters.
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Severe - 100 to 600 milliliters.
What Leads to Hemoptysis?
Several disorders can cause hemoptysis, such as:
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Bronchitis - It is a condition in which the tubes carrying the air to the lungs get inflamed and filled with mucus due to a virus or bacteria and smoking. It is a common cause associated with recurrent coughing, wheezing, and low-grade fever, and it breaks down the mucosal lining. Purulent sputum can be seen, which appears as a thick, opaque, and yellowish-white discharge.
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Tuberculosis - A serious infection in the lungs caused by mycobacterium tuberculosis bacteria. This bacteria forms cavities in the airway walls. It is associated with unexplained weight loss, purulent sputum, which appears as a thick, opaque, and yellowish-white discharge, and a history of mycobacterial exposure.
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Bronchiectasis - It is a condition in which the airways of the lungs become damaged and widened due to an infection. The surrounding supporting tissues in the lungs get damaged, causing infection or fibrosis, leading to a copious amount of sputum production. Clubbing of the fingers (abnormal rounding of the finger and toe nail end) can be seen.
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Lung Cancer - It is mostly associated with smokers, and if the disease is in the advanced stage, the patient may experience unaccountable weight loss. Around 60 percent of patients will develop hemoptysis with lung cancer.
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Pneumonia - A form of respiratory infection due to various kinds of viruses, bacteria, and fungi in which the lungs fill with liquid and pus and is associated with high fever, cough, and chest pain.
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Mitral Stenosis - It is a form of heart disease characterized by the narrowing of the mitral valve. Mild hemoptysis can be seen with ‘pink frothy’ sputum.
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Other Causes - Aspergilloma (a form of mass that develops in the lung cavities due to a fungal infection), tumor, trauma, lung abscess, embolism, autoimmune diseases, and alveolar hemorrhage.
How Is Hemoptysis Evaluated?
Various laboratory tests are available that can be done which help in the diagnosis, such as sputum, blood, and urine test, X-rays, computed tomography (CT scan), and bronchoscopy (a procedure in which a thin tube is inserted through the nose or mouth into the throat and passed to the lungs which allow the doctor to have a clear view). Other than that, it is mostly case-dependent and is explained below.
In case, the condition is non-massive, and there are normal findings on chest radiography.
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If there is no risk of cancer and no history that is suggestive of lower respiratory tract infection, then the patient is observed for two to six weeks. After six weeks, if there is a recurrence of hemoptysis, then a chest computed tomography will be done, and a pulmonologist will be consulted, but if there is a cessation of bleeding, no further evaluation is required.
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If there is no risk of cancer but a history suggestive of lower respiratory tract infection, the patient will be considered for oral antibiotics. If the hemoptysis reoccurs after antibiotic therapy, a chest computed tomography with the consultation of a pulmonologist will be done.
In case the condition is massive, a history and physical examination of the patient will be taken to rule out the pseudo-hemoptysis and hematemesis (vomiting of blood).
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In chest radiography, if infiltration is seen, then the patient will be monitored under antibiotics, and again if there is resolution, chest radiography will be repeated after six to eight weeks. After eight weeks, if the resolution is normal, then there will be no further evaluation, but if it is abnormal, then a pulmonologist will be consulted.
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In case a mass is detected, then computed tomography will be done, and bronchoscopy will be performed along with consultation with a pulmonologist.
How to Manage Hemoptysis?
The management mostly depends on the causes and quantity of the blood. For an elderly patient and their family member, hemoptysis can be accompanied by significant anxiety, which can hamper the management. But with the help of a healthcare professional, it is possible to achieve the following methods-
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A proper history is essential to determine the color and consistency of the blood, whether it is bright red or frothy; it is different from hematemesis (vomiting of blood), which usually shows brown or black blood. It will also help in diagnosing the cause of hemoptysis like if there is purulent sputum, it can be suggestive of pulmonary infection, and if it is without pus, it can be a sign of tuberculosis or lung cancer.
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Proper airway control and steps to limit the hemorrhage spread are important. Regardless of the intubation status, the patient is immediately placed into a position where the suspected bleeding lung is in the dependent position.
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Bronchial artery embolization (BAE), rigid and flexible bronchoscopy, and surgery serve as potential treatment options to provide definitive control of hemorrhage.
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Patients with life-threatening hemoptysis are not typically candidates for non-invasive ventilation intubation, especially with a full face mask, since the risk of aspirating blood is high. A topical vasoconstrictive agent through bronchoscopy, usually epinephrine 1:20000 or vasopressin, is infused through a bronchoscope which directly flows to the bleeding source and slows or stops the bleeding.
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Intravenous or inhaled tranexamic acid may have some benefits in patients with hemoptysis.
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Bronchial artery embolization (BAE) is a procedure in which X-rays are used to examine the arteries of the lungs, which allows a doctor to detect which artery is bleeding.
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Single lung ventilation is an option in patients with life-threatening bleeding. It is the mechanical separation of both lungs that allows ventilation of one lung, and the other lung can be treated by the surgeon. The goal of single-lung ventilation is to protect the non-bleeding lung from the spillage of blood, thereby maintaining oxygenation and ventilation of the unaffected lung. Thus a patient whose right lung is bleeding will have the left mainstem bronchus intubated, whereas a patient whose left lung is bleeding will have the right mainstem bronchus intubated.
Conclusion
Irrespective of the amount of blood, hemoptysis is an alarming sign, and whenever the patient is coughing up blood, it should be taken seriously, and the patient should seek medical advice right away. It poses a more serious problem in the older population due to their comorbidities and can lead to more severe complications. But with the diagnostic measures available and proper treatment modalities, it can be managed.
