Hemoptysis

 

Hemoptysis

PKGhatak,MD

Hemoptysis was considered the confirmation of Consumption - a disease of the ancient world. Even if a patient was wasting away but did not have hemoptysis the condition was called by something else than consumption. This practice went on till Dr. Robert Koch discovered a bacterium and demonstrated conclusively that the bacteria was responsible for the disease called consumption. Later on, that bacteria were named Mycobacteria tuberculosis and the disease is known as pulmonary tuberculosis (TB). Hemoptysis continued to be the primary symptom of TB patients. The incidence of hemoptysis began to fall in 1945 with the introduction of Streptomycin and Para-amino salicylic acid (PAS). And subsequently, fell further in 1954 onwards with the use of Isoniazid and Ethambutol.

Hemoptysis is defined as coughing up any amount of blood, the quantity of blood is not included in the definition. Massive hemoptysis is defined as losing 200 ml or more of blood, between 5 and 200 ml of blood loss is considered moderate, and anything 5 ml or less is considered as minimal hemoptysis.

It should be kept in mind that the trachea, bronchus and all its branches are supplied by the arteries of the systemic circulation. And because the systemic circulation operates at high pressure, the blood loss becomes massive in a very short period of time, if a moderate sized vessel wall is breached.

In every case of hemoptysis, details should be taken about nose bleeds, use of anticoagulants (blood thinner), antiplatelet agents, and history of aspiration, and history of blood disorders.

Common Causes of hemoptysis.

Inflammation/ infection of the trachea and bronchial tree accounts for 25 % of hemoptysis, Carcinoma of lung and lung metastasis – 20%, Bronchiectasis - 10% Cardiovascular and Pulmonary emboli - 10 %, lung contusion from automobile accidents and other conditions -35 %.

Reported causes of Hemoptysis: -

Lung cancer, narcotizing pneumonia, cystic fibrosis, COPD, pulmonary emboli/infraction, lung abscess, bronchiectasis, TB, fungal infection, pneumonic plague, sinusitis, acute bronchitis, bronchovascular fistula, congestive heart failure, bleeding diathesis, arteriovenous malformation, hereditary hemorrhagic telangectasia, endometrial tissue metastasis in lungs, bronchlolithiasis, mitral stenosis, severe pulmonary hypertension, pulmonary edema, Wegener granuloma, microscopic polyangiitis, aspergilloma, foreign bodies, Goodpasture syndrome, cocaine other recreational drug use, bronchoscopic biopsy, trauma to chest wall causing bruised lungs from automobile accidents, Anticoagulant and antiplatelet therapy.

Presenting symptoms.

Patients often experience a sensation of heaviness in the chest and something gurgling inside the chest before they cough up blood. The blood brought up may contain gritty brocholiths, blood and pus in cases of lung abscess. Recurrent hemoptysis is usual in TB and bronchiectasis patients. Streaks of blood and rusty sputum are present in bacterial pneumonia cases.

Diagnosis and Treatment.

Like any emergency situation - triage, quick assessment, securing a patent airway and prevention of aspiration, positioning the patient in bed with the involved side down, reassurance and relieving fear, is followed by tests and imaging.

In the case of massive hemoptysis, the initial attempt is made to control bleeding. If the patient's history does not suggest blood disorder or coagulation/platelet dysfunction, then an immediate bronchoscopy with rigid and fiberoptic bronchoscope is performed under general anesthesia. Localizing the source of bleeding is essential. If the bleeding site is detected then the bleeding vessel is cauterized by laser or electro-cauterization or argon plasma coagulation. If the bleeding site is distal to the fiberoptic bronchoscope and the scope cannot be advanced further then tamponade is achieved by radiopaque surgical dressings or by a balloon catheter.

After controlling bleeding, an Angio-CT is obtained. If the bleeding vessel is identified then embolization of the vessel is carried out. If that fails, then surgical excision of the lesion or lobectomy is required.

In a previous generation, hemoptysis from cavitary TB was successfully controlled by therapeutic pneumothorax. In rural communities of some poor countries, this treatment is still carried out. The therapeutic pneumothorax for the treatment of pulmonary TB in the 1910s was advanced by Dr. Carlo Forlanini of Italy. For his efforts he was nominated for the Nobel Prize in Medicine 20 times between 1912 and 1932; his sponsors were not discouraged because Dr. Robert Koch was nominated for the Nobel Prize in Medicine 50 times before he was awarded the Nobel Prize in 1905.

In a patient who is not actively bleeding, a CT of the chest is performed in the hope that localizing the disease would be possible; often CT is negative. Fiberoptic bronchoscopy is performed to detect cancer or any source of bleeding.

In cases of minimal but recurrent bleeding, the bleeding usually stops after 6 months. These patients are followed for cancer surveillance.

Bleeding from pulmonary hypertension and mitral stenosis, congestive heart failure, pulmonary edema, infectious causes, etc. are treated medically and supplemented by surgery where applicable.

Embolization of arteriovenous malformation is useful therapy. Recurrence of pulmonary emboli is treated with anticoagulant. All other treatable medical conditions are appropriately treated. 

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