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HEMOPTYSIS
- Bharat Chukka
- Mar 20
- 5 min read
Updated: Mar 24
UNDERSTANDING HEMOPTYSIS AND WHEN TO SEEK HELP:
HEMOPTYSIS is 'coughing out blood' from a source located below the vocal cords of RESPIRATORY SYSTEM i.e larynx, trachea ,bronchi and lungs. It can range from minor streaks to massive amounts of blood loss which endangers life. This symptom causes panic in the patient causing him to seek medical advice immediatly.
In terms of QUANTITY, hemoptysis can be MILD(less than 20 ml), MODERATE(20 to 200 ml) or MASSIVE (> 200 ml )in 24 hrs.
But the danger of hemoptysis is not actual blood loss or EXSANGUINATION, but more often ASPHYXIATION due to blocking of the central airways (dead space) by about '150ml of blood' which is enough to prevent gas exchange and death. Hence it is called LIFE THREATENING HEMOPTYSIS.
WHAT ARE THE RED FLAG SIGNS IN A CASE OF HEMOPTYSIS?
Signs of Respiratory Distress such as rapid breathing, breathlessness, low SpO2 or PaO2 levels.
Hemodynamic instability with falling Blood Pressures (<90 mm of Hg Systolic) , High heart rate (>100 /mt), loosing conciousness.
THE BLOOD SUPPLY TO LUNGS : More than 90 % of the blood supplied to the lungs comes from PULMONARY ARTERIES.
Rest of the blood supply is provided by BRONCHIAL ARTERIES.
WHY IS IT IMPORTANT?
The hemoptysis due to PULMONARY arteries (low pressure system) causes less blood loss. But hemoptysis due to BRONCHIAL arteries (high pressure system) causes greater
blood loss and therefore DANGEROUS unless controlled immediately.
APPROACH TO A CASE OF HEMOPTYSIS BY PULMONOLOGIST:
FIRST STEP is to confirm the source:
(THE BIG THREE CAUSES - GIT/ENT/CARDIORESPIRATORY CAUSES)
Since the bleeding primarily seems to be coming out of mouth, the origin has to be differentiated among ENT ( Ear,Nose,Throat) causes, GIT (GastroIntestinalTract) causes and CARDIOPULMONARY ( Heart and Lung) causes.
HOW TO DIFFERENTIATE?
Determination of the source:
IN GIT CAUSES: The symptoms include nausea, vomitings, abdominal pain ,coffee ground color of the vomitus, black stools and history of Chronic Liver disease or a Peptic Ulcer disease which suggest blood loss due to HEMETEMESIS.
IN ENT CAUSES: Associated history of EPISTAXIS (nose bleed due to nasal polyps, tumors, sinusitis ) or Bleeding Gums, Gingivitis, are suggestive of an ENT source or upper respiratory tract , called as SPURIOUS HEMOPTYSIS.
IN CARDIORESPIRATORY CAUSES: Associated cough, breathlessness, chest pain, fever, excess sputom may suggest a CARDIAC/PULMONARY source.
WHAT ARE THE CAUSES OF HEMOPTYSIS?
NEXT STEP is diagnose the source:
1. Most common cause is INFECTION. Of all infections, Pulmonary Tuberculosis(TB) is most common, especially in countries like India. Others are Necrotising Pneumonia, Lung Abscess, Acute Bronchitis, Fungal pneumonias due to ASPERGILLUS or MUCOR, Parasitic diseases.
2. MALIGNANCIES : Lung cancer, Carcimoid tumours, Lung secondaries like Renal Cell Carcinoma, Choriocarcinoma, Malignant melanoma.
3. AIRWAY DISEASES : Bronchiectasis, Broncholithiasis, Cystic Fibrosis.
CARDIOVASCULAR CAUSES which mimic pulmonary diseases and need to be differentiate are Mitral Stenosis, CHF, Pulmonary thrombo embolism,Pulmonary infarcts, Primary pulmonary hypertension (PPH), Ruptured Intra Thoracic aneurysms of great vessels.
AUTOIMMUNE DISEASES: Include Pulmonary Renal syndromes like Good pasture's syndrome( Anti GBM disease), ANCA associated vasculitis like MPA , GPA( Wegner's),EGPA, others like SLE, HS pupura, Bechet's disease.
INVESTIGATIONS TO IDENTIFY THE CAUSE:
1. Complete Blood Profile
2. Urine analysis ( Pulmonary Renal syndromes)
3. Sputum for Gram's staining, AFB,Culture and Sensitivity (for Infective causes)
4. Serology for Auto Antibodies.
5. Chest X ray: To identify the cause of bleeding such as cavity, lung absess, mass leision.
6.Chest CT scan: It provides more information about the lesions in lung parenchyma, airways and blood vessels more precisely..
7.CT Scan with Contrast (CECT) and CTPA: These tests are necessary to identify the source of bleeding vessel more accurately, whether it is in Bronchial and Pulmonary arterial system, to identify Pulmonary Thrombo Embolism, AVM, Aneurysms and Vasulitis syndromes.
8.Bronchoscopy: To localise the source of bleeding , to detect endobroncheal leisons and to rule out other Upper Airway causes. It also allows to take samples for tissue pathology and cultures.
CRYPTOGENIC HEMOPTYSIS
In 1/3rd of the cases,, despite appropriate investigations no cause can be traced. It is called 'Cryptogenic Hemoptysis'.
HOW DOES A PULMONOLOGIST MANAGE A CASE OF HEMOPTYSIS?
The initial approach to a patient with hemoptysis consists of "A,B,C "
A is Airway protection.
B is Breathing.
C is Circulation.
'A & B 'AIRWAY PROTECTION AND BREATHING : It begins with positioning of the patient in such a way that the 'Good, Nonbleeding Lung ' is protected.
"THE BAD LUNG DOWN ,THE GOOD LUNG UP."
The patient is placed in lateral decubitis position with bleeding lung down so that the good lung remains safe. By this step, spilling of the blood into the good lung is prevented by gravity effect. The good lung will take part in oxygen exchange and dangerous hypoxia can be prevented.
In CRITICAL situations, where the Central airways are threatened to be blocked by the blood clots or profuse bleeding, INTUBATION may be necessary with Large Bore ETT (EndoTrachealTube) to facilitate sucking of thick blood clots or MAIN STEM intubation into good lung allowing ventilation and oxygen exchange.
CONTROL OF BLEEDING
Further control of the bleeding is attempted by FLEXIBLE or RIGID BRONCHOSCOPY With the bleeding site identified ,instillation of cold saline in 50 ml aliquots or Topical Epinephrine or thrombin or fibrin sealant is applied directly to the bleeding site. Laser therapy, APC are used for arresting bleeding due to malignancies.
Balloon Tamponade is a method, attempted with a 4 French Forgarty balloon catheter which may successfully arrest the bleeding.
GOLD STANDARD IS BRONCHEAL ARTERY EMBOLISATION(BAE) :
In this an Interventional Radiologist, after cathetrization, injects PVA (PolyVinylAlcohol)
particles or Gelatin foam,Thrombin, Glue or Coils to block the bleeding bronchial artery. In 90 % of the cases, bleeding control can be achived.
In UNCONTROLLED hemoptysis, inspite of all the efforts, the final resort is surgical proceedures like segmentectomy or lobectomy or pneumonectomy where the part of the lung responsible for the bleeding is removed.
2. 'C'. It is 'CIRCULATION 'Support for HEMODYNAMIC STABILITY with Intravenus fluids,Vasopressors, Blood transfusions, PCC, FFP etc and Injection vitamin K.
WHETHER ITS A TINY STREAK OR LARGE AMOUNTS, HEMOPTYSIS IS YOUR RESPIRATORY SYSTEM'S WAY OF ASKING FOR A 'CHECK-UP' .
GET A THOROUGH EVALUATION AT OUR 'BHARAT CHEST CARE CLINIC' IN VISAKHAPATNAM, WHERE ADVANCED TECHNOLOGY IS USED TO DIAGNOSE AND TREAT .
VISIT DR.BHARAT FOR EXPERT LUNG CARE.
CONTACT US NOW.
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