Pulmonary Hemorrhage - Causes, Diagnosis, and Treatment

Introduction

The term hemorrhage refers to internal or external bleeding. Pulmonary means relating to or affecting the lungs. Pulmonary hemorrhage is a condition that causes acute or intermittent bleeding from the lungs or blood vessels of the respiratory system. In 70 percent of the cases, it results in mortality. Immediate evaluation, stabilization of the patient, and necessary measures are required in these cases. This article will discuss pulmonary hemorrhage, its types, causes, symptoms, evaluation, and treatment methods.

What Are the Types of Pulmonary Hemorrhage?

Pulmonary hemorrhage may be classified into two types based on the origination of the bleeding: focal and diffuse pulmonary hemorrhage.

• Focal Pulmonary Hemorrhage (Localized): This type of pulmonary hemorrhage refers to the hemorrhage that arises from a particular bleeding site of the lung. They range from a specific, focused spot in the lung to a whole lobe.

• Diffuse Pulmonary Hemorrhage: This type of pulmonary hemorrhage refers to the hemorrhage that originates from the bleeding of micro vessels of the lung and is diffused. It can sometimes lead to the accumulation of alveoli (small air sacs where transfusion between oxygen and carbon dioxide takes place) and affects the air exchange.

What Causes Pulmonary Hemorrhage?

There are many possible causes of pulmonary hemorrhage, making it difficult to diagnose the underlying cause of the bleeding. In most cases, in 90 percent of patients, pulmonary hemorrhage occurs due to increased airway pressure, commonly due to reduced lung compliance, airway obstruction, or an increase in airway resistance. Other common causes of diffuse pulmonary hemorrhage include:

• Patients with bleeding disorders such as thrombocytopenia or DIC. Thrombocytopenia refers to the condition with decreased platelets (a type of blood vessel promoting blood clots). Disseminated intravascular coagulation (DIC) is a critical condition affecting the body's blood clotting mechanism.

• Cardiac failure.

• 25 percent of cases occur due to tuberculosis.

• Chronic use of cocaine.

• Immune disorders include pulmonary renal syndrome (a condition characterized by kidney failure and impairment of the respiratory tract) and vasculitis.

Common causes of localized pulmonary hemorrhage include:

• Pulmonary embolism (a condition with blockage along a lung artery by a blood clot).

• Bronchogenic carcinoma (lung cancer).

• Acute bronchitis.

• Ruptured aneurysm (aneurysm refers to weakening or bulging in an area of an artery).

• Local trauma.

• Bronchiectasis (a condition that causes damage to the lung's airway).

What Are the Symptoms of Pulmonary Hemorrhage?

Pulmonary bleeding may sometimes be mistaken for gastrointestinal bleeding. Common symptoms of pulmonary hemorrhage:

• Fever.

• Difficulty breathing (dyspnea).

• Loss of weight.

• Due to blood loss, the patient may develop anemia.

• Fatigue.

• Sometimes patients may develop acute respiratory failure.

• Coughing up blood (hemoptysis). This condition may not be seen in all cases.

• Other symptoms depend on the underlying cause of the disease.

How Is Pulmonary Hemorrhage Diagnosed?

Since it is a life-threatening condition, the evaluation of patients with pulmonary hemorrhage is critical, requiring immediate assessment and necessary care for the patients.

• The healthcare provider will perform a detailed history taking by asking questions about the characteristics and onset of hemoptysis, medical history, chronic history, and drug history.

• The clinician will evaluate the patient to rule out the non-pulmonary causes of pulmonary bleeding.

• The doctor will assess the airway, breathing, and circulation during the initial assessment in acute conditions.

• The doctor will evaluate the patient's symptoms, such as cough, dyspnea, and blood loss.

• Lungs and the airway passages may be assessed using bronchoscopy (a flexible or rigid thin tube passed down through the mouth or nose into the lungs).

• The healthcare provider may perform a chest X-ray to visualize the lungs and evaluate the origin of the bleeding.

• A lung biopsy may be performed, which involves removing a sample tissue from the lungs to examine it under a microscope.

• The doctor will perform other tests such as a complete blood count, urine analysis, platelet count, coagulation studies (to measure the ability of blood to clot), and serologic tests (to evaluate the presence of antibodies in the blood).

• A basic metabolic panel (BMP) test may be performed to evaluate the body's chemical balance and metabolism.

• Other imaging tests, such as computed tomography (CT), are performed to diagnose the underlying cause of pulmonary hemorrhage.

How Is Pulmonary Hemorrhage Treated?

The management of pulmonary hemorrhage depends on the severity of the bleeding and the underlying cause of it.

• In cases of acute pulmonary hemorrhage, the doctors will immediately work on stabilizing the patient's airway and controlling the blood loss. The patient might require ventilatory support to assist with breathing and immediate blood transfusion in such conditions.

• In patients with a drug history of anticoagulants, reversing the medication effect helps ease the bleeding.

• Fiber-optic bronchoscopy is used to determine the origination of bleeding and to clear the airway blood clots.

• Rigid bronchoscopy is also used to determine the source of the bleeding and to ventilate the non-bleeding lung. It is also used in intra-bronchial therapeutic techniques.

• An endobronchial blocker, also known as a bronchial blocker, is a device used in ventilating the non-bleeding lung and blocking the bleeding side of the lung. It is placed with the help of a fiber-optic bronchoscopy. After intubation, they can be inserted through the main stem of the bronchus (the two large airway tubes that carry the air from the windpipe to the lung).

• A surgical procedure called bronchial artery embolization involves injecting small particles into the bleeding site, which helps in ceasing the bleeding.

• In cases where the bleeding site is easily reachable other therapeutic measures such as laser, cryotherapy (cold therapy), electrocautery (a procedure that uses electric current to stop bleeding), or plasma coagulation (a medical procedure that uses argon to stop bleeding) may be performed.

• Rarely the patients may require surgical intervention. Due to the increased mortality rate of this condition, patients may require surgical removal of the affected lobe. This is considered the last option of treatment.

Conclusion

Pulmonary hemorrhage is a condition that involves bleeding in the lungs or from the blood vessels of the lung. It may be localized or diffuse bleeding. Acute cases of pulmonary hemorrhage have increased mortality rates. Hence, it requires immediate attention, evaluation, and definitive care. Many causes can lead to pulmonary hemorrhage. Proper evaluation of the cause of the bleeding is necessary for the management of the bleeding. Sometimes the cause of the condition's cannot be evaluated. In such cases are idiopathic pulmonary hemorrhage. Surgical removal of the bleeding area of the lung is considered the last resort in managing pulmonary hemorrhage.