Hemoptysis Explained

Hemoptysis
Synonyms:Haemoptysis, coughing up of blood
Field:Pulmonology
Symptoms:Spitting blood or bloody sputum
Complications:Pulmonary aspiration, choking
Causes:bronchitis, lung cancer, certain infections
Differential:epistaxis (combined with post-nasal drip)

Hemoptysis or haemoptysis is the discharge of blood or blood-stained mucus through the mouth coming from the bronchi, larynx, trachea, or lungs. It does not necessarily involve coughing. In other words, it is the airway bleeding. This can occur with lung cancer, infections such as tuberculosis, bronchitis, or pneumonia, and certain cardiovascular conditions. Hemoptysis is considered massive at 300mL. In such cases, there are always severe injuries. The primary danger comes from choking, rather than blood loss.[1]

Diagnosis

Differential diagnosis

The most common causes for hemoptysis in adults are chest infections such as bronchitis or pneumonia. In children, hemoptysis is commonly caused by the presence of a foreign body in the airway. Other common causes include lung cancers and tuberculosis. Less common causes include aspergilloma, bronchiectasis, coccidioidomycosis, pulmonary embolism, pneumonic plague, and cystic fibrosis. Rarer causes include hereditary hemorrhagic telangiectasia (HHT or Rendu-Osler-Weber syndrome), Goodpasture's syndrome, and granulomatosis with polyangiitis. A rare cause of hemoptysis in women is endometriosis, which leads to intermittent hemoptysis coinciding with menstrual periods in 7% of women with thoracic endometriosis syndrome.[4] Hemoptysis may be exacerbated or even caused by overtreatment with anticoagulant drugs such as warfarin.

Blood-laced mucus from the sinus or nose area can sometimes be misidentified as symptomatic of hemoptysis (such secretions can be a sign of nasal or sinus cancer, but also a sinus infection). Extensive non-respiratory injury can also cause one to cough up blood. Cardiac causes like congestive heart failure and mitral stenosis should be ruled out. The origin of blood can be identified by observing its color. Bright-red, foamy blood comes from the respiratory tract, whereas dark-red, coffee-colored blood comes from the gastrointestinal tract. Sometimes hemoptysis may be rust-colored.

Massive hemoptysis and mortality

Although there are reports that the fatality rate is as high as 80%, the mortality rate for hospitalized hemoptysis patients is 9.4% (with n=28539), calculated from the data in the article by Kinoshita et al.[23] This is probably the most reasonable figure considering the overwhelming number of cases.

The general definition of massive hemoptysis is more than 200 ml within 24 hours, but there is a wide range in the literature (100-600 ml). Considering that the total volume of the tracheal and bronchial lumen is about 150 cc,[24] [25] it may be reasonable to define massive hemoptysis as 200 ml, which is a little more than 150 ml, in terms of setting the threshold for fatal hemoptysis. More than 400ml/day is not adequate for screening purposes.

Treatment

Treatment depends on the underlying cause. Treatments include iced saline, and topical vasoconstrictors such as adrenaline or vasopressin. Tranexamic acid was proved to improve in-hospital mortality. Selective bronchial intubation can be used to collapse the lung that is bleeding. Also, endobronchial tamponade can be used.[26] Laser photocoagulation can be used to stop bleeding during bronchoscopy. Angiography of bronchial arteries can be performed to locate the bleeding, and it can often be embolized.[27] Bronchial artery embolization (BAE) is the first line treatment nowadays.[28] [29] [30] [31] [32] Surgical option is usually the last resort and can involve removal of a lung lobe or removal of the entire lung. Cough suppressants can increase the risk of choking.[1]

Further reading

Notes and References

  1. Book: Sabatine MS . Pocket medicine. 2014. Aspen Publishers, Inc. [S.l.]. 978-1451193787. Fifth.
  2. Web site: Hemoptysis. The Lecturio Medical Concept Library . 24 July 2021.
  3. Book: Richard F.LeBlond . Diagnostics . US . McGraw-Hill Companies, Inc. . 978-0-07-140923-0 . 2004 .
  4. McCann MR, Schenk WB, Nassar A, Maimone S . Thoracic endometriosis presenting as a catamenial hemothorax with discordant video-assisted thoracoscopic surgery . Radiology Case Reports . 15 . 9 . 1419–1422 . September 2020 . 32642009 . 7334551 . 10.1016/j.radcr.2020.05.064 .
  5. https://health.google.com/health/ref/Lung+cancer+-+small+cell Google Health – Google
  6. https://health.google.com/health/ref/Lung+cancer+-+non-small+cell Google Health – Google
  7. Web site: Sarcoidosis Signs & Symptoms – Sarcoidosis – HealthCommunities.com . 2010-02-05 . https://web.archive.org/web/20090221145513/http://www.pulmonologychannel.com/sarcoidosis/symptoms.shtml . 2009-02-21 . dead .
  8. https://health.google.com/health/ref/Pulmonary+tuberculosis Google Health – Google
  9. Web site: Histoplasmosis Symptoms – Diseases and Conditions – Mayo Clinic . 2010-02-05 . https://web.archive.org/web/20130531010442/http://www.mayoclinic.com/health/histoplasmosis/DS00517/DSECTION=symptoms . 2013-05-31 . live .
  10. Web site: Pneumonia. The Lecturio Medical Concept Library . 27 August 2020. 1 July 2021.
  11. Book: Dorland's illustrated medical dictionary . 2 May 2011 . Saunders/Elsevier . 9781416062578 . 593 . 32nd.
  12. Ware LB, Matthay MA . Clinical practice. Acute pulmonary edema . N. Engl. J. Med. . 353 . 26 . 2788–96 . December 2005 . 16382065 . 10.1056/NEJMcp052699.
  13. Web site: Endometriosis. The Lecturio Medical Concept Library . 25 July 2021.
  14. Web site: Foreign Body Aspiration. The Lecturio Medical Concept Library . 25 July 2021.
  15. Altaie R, Ditizio F, Fahy GT . Microscopic polyangitis presenting with sub-acute reversible optic neuropathy . Eye (Lond) . 19 . 3 . 363–5 . March 2005 . 15272290 . 10.1038/sj.eye.6701479 . free . 10379/8830 . free .
  16. Web site: Granulomatosis with Polyangiitis. www.mayoclinic.org. Mayo Foundation for Medical Education and Research. 3 March 2018. https://web.archive.org/web/20171222133353/https://www.mayoclinic.org/diseases-conditions/granulomatosis-with-polyangiitis/symptoms-causes/syc-20351088. 22 December 2017. live.
  17. Web site: What Is Churg–Strauss Syndrome? . WebMD . 30 January 2019 . 8 March 2020.
  18. Web site: Hemoptysis Causes – Hemoptysis – HealthCommunities.com . 2010-02-05 . https://web.archive.org/web/20090123040911/http://www.pulmonologychannel.com/hemoptysis/causes.shtml . 2009-01-23 . dead .
  19. Web site: Other Causes of Hemoptysis – Hemoptysis – HealthCommunities.com . 2010-02-05 . https://web.archive.org/web/20090608070815/http://www.pulmonologychannel.com/hemoptysis/other-causes.shtml . 2009-06-08 . dead .
  20. Web site: Mitral Stenosis. The Lecturio Medical Concept Library . 24 July 2021.
  21. Hunt. Beverley J.. Bleeding and Coagulopathies in Critical Care. New England Journal of Medicine. 370. 9. 2014. 847–859. 0028-4793. 10.1056/NEJMra1208626. 24571757.
  22. Hughes . JP . Stovin . PG . Segmental pulmonary artery aneurysms with peripheral venous thrombosis. . British Journal of Diseases of the Chest . January 1959 . 53 . 1 . 19–27 . 10.1016/S0007-0971(59)80106-6 . 13618502.
  23. Kinoshita T, Ohbe H, Matsui H, Fushimi K, Ogura H, Yasunaga H . Effect of tranexamic acid on mortality in patients with haemoptysis: a nationwide study . Critical Care . 23 . 1 . 347 . November 2019 . 31694697 . 6836388 . 10.1186/s13054-019-2620-5 . free .
  24. Patwa A, Shah A . Anatomy and physiology of respiratory system relevant to anaesthesia . Indian Journal of Anaesthesia . 59 . 9 . 533–41 . September 2015 . 26556911 . 4613399 . 10.4103/0019-5049.165849 . free .
  25. Davidson K, Shojaee S . Managing Massive Hemoptysis . Chest . 157 . 1 . 77–88 . January 2020 . 31374211 . 10.1016/j.chest.2019.07.012 . 199388328 .
  26. Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC . Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis . Chest . 127 . 6 . 2113–8 . June 2005 . 15947328 . 10.1378/chest.127.6.2113 .
  27. Uppsala Academic Hospital . Guidelines for treatment of acute lung diseases. . August 2004 . Hanson C, Karlsson CA, Kämpe M, Lamberg K, Lindberg E, Boman LM, Stålenheim G .
  28. Woo S, Yoon CJ, Chung JW, Kang SG, Jae HJ, Kim HC, Seong NJ, Kim YJ, Woo YN . 6 . Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles . Radiology . 269 . 2 . 594–602 . November 2013 . 23801773 . 10.1148/radiol.13130046 . 21597160 .
  29. Ishikawa H, Hara M, Ryuge M, Takafuji J, Youmoto M, Akira M, Nagasaka Y, Kabata D, Yamamoto K, Shintani A . 6 . Efficacy and safety of super selective bronchial artery coil embolisation for haemoptysis: a single-centre retrospective observational study . BMJ Open . 7 . 2 . e014805 . February 2017 . 28213604 . 5318547 . 10.1136/bmjopen-2016-014805 .
  30. Ryuge M, Hara M, Hiroe T, Omachi N, Minomo S, Kitaguchi K, Youmoto M, Asakura N, Sakata Y, Ishikawa H . 6 . Mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation: a single-centre retrospective observational study . European Radiology . 29 . 2 . 707–715 . February 2019 . 30054792 . 6302874 . 10.1007/s00330-018-5637-2 .
  31. Panda A, Bhalla AS, Goyal A . Bronchial artery embolization in hemoptysis: a systematic review . Diagnostic and Interventional Radiology . 23 . 4 . 307–317 . 2017-07-07 . 28703105 . 5508955 . 10.5152/dir.2017.16454 .
  32. Olsen KM, Manouchehr-Pour S, Donnelly EF, Henry TS, Berry MF, Boiselle PM, Colletti PM, Harrison NE, Kuzniewski CT, Laroia AT, Maldonado F, Pinchot JW, Raptis CA, Shim K, Tong BC, Wu CC, Kanne JP . 6 . ACR Appropriateness Criteria® Hemoptysis . Journal of the American College of Radiology . 17 . 5S . S148–S159 . May 2020 . 32370959 . 10.1016/j.jacr.2020.01.043 . 218520816 .

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