Hemoptysis

Definition

Hemoptysis is the coughing up of blood or bloody sputum from the lungs or airway. It may be either self-limiting or recurrent. Massive hemoptysis is defined as 200-600 mL of blood coughed up within a period of 24 hours or less.

Description

Hemoptysis can range from small quantities of bloody sputum to life-threatening amounts of blood. The patient may or may not have chest pain.

Causes and symptoms

Hemoptysis can be caused by a range of disorders:

• Infections. These include pneumonia; tuberculosis; aspergillosis; and parasitic diseases, including ascariasis, amebiasis, and paragonimiasis.
• Tumors that erode blood vessel walls.
• Drug abuse. Cocaine can cause massive hemoptysis.
• Trauma. Chest injuries can cause bleeding into the lungs.
• Vascular disorders, including aneurysms, pulmonary embolism, and malformations of the blood vessels.
• Bronchitis. Its most common cause is long-term smoking.
• Foreign object(s) in the airway.
• Blood clotting disorders.
• Bleeding following such surgical procedures as bronchial biopsies and heart catheterization.

Diagnosis

The diagnosis of hemoptysis is complicated by the number of possible causes.

Patient history

It is important for the doctor to distinguish between blood from the lungs and blood coming from the nose, mouth, or digestive tract. Patients may aspirate, or breathe, blood from the nose or stomach into their lungs and cough it up. They may also swallow blood from the chest area and then vomit. The doctor will ask about stomach ulcers, repeated vomiting, liver disease, alcoholism, smoking, tuberculosis, mitral valve disease, or treatment with anticoagulant medications.

Physical examination

The doctor will examine the patient's nose, throat, mouth, and chest for bleeding from these areas and for signs of chest trauma. The doctor also listens to the patient's breathing and heartbeat for indications of heart abnormalities or lung disease.

Laboratory tests

Laboratory tests include blood tests to rule out clotting disorders, and to look for food particles or other evidence of blood from the stomach. Sputum can be tested for fungi, bacteria, or parasites.

X ray and bronchoscopy

Chest x rays and bronchoscopy are the most important studies for evaluating hemoptysis. They are used to evaluate the cause, location, and extent of the bleeding. The bronchoscope is a long, flexible tube used to identify tumors or remove foreign objects.

Imaging and other tests

Computed tomography scans (CT scans) are used to detect aneurysms and to confirm x-ray results. Ventilation-perfusion scanning is used to rule out pulmonary embolism. The doctor may also order an angiogram to rule out pulmonary embolism, or to locate a source of bleeding that could not be seen with the bronchoscope.

In spite of the number of diagnostic tests, the cause of hemoptysis cannot be determined in 20-30% of cases.

Treatment

Massive hemoptysis is a life-threatening emergency that requires treatment in an intensive care unit. The patient will be intubated (the insertion of a tube to help breathing) to protect the airway, and to allow evaluation of the source of the bleeding. Patients with lung cancer, bleeding from an aneurysm (blood clot), or persistent traumatic bleeding require chest surgery.

Patients with tuberculosis, aspergillosis, or bacterial pneumonia are given antibiotics.

Foreign objects are removed with a bronchoscope.

If the cause cannot be determined, the patient is monitored for further developments.

Prognosis

The prognosis depends on the underlying cause. In cases of massive hemoptysis, the mortality rate is about 15%. The rate of bleeding, however, is not a useful predictor of the patient's chances for recovery.

KEY TERMS

Aneurysm— A sac formed by the dilation of the wall of an artery, vein, or heart; it is filled with clotted blood or fluid.

Angiography— A technique for imaging the blood vessels by injecting a substance that is opaque to x rays.

Aspergillosis— A lung infection caused by the mold Aspergillus fumigatus.

Intubation— The insertion of a tube into a body canal or hollow organ, as into the trachea or stomach.

Pulmonary embolism— The blocking of an artery in the lung by a blood clot.

Resources

BOOKS

Stauffer, John L. "Lung." In Current Medical Diagnosis and Treatment, 1998, edited by Stephen McPhee, et al., 37th ed. Stamford: Appleton & Lange, 1997.

Hemoptysis

Description

Hemoptysis is the coughing up of blood or bloody sputum from the respiratory tract. The blood can come from the nose, mouth, throat, airway passages leading from the lungs, or the lungs.

Hemoptysis can range from small quantities of blood-stained sputum to life-threatening amounts of blood. Massive hemoptysis is defined as the spitting up of so much blood that it interferes with the patient's breathing. Generally, this is 200 to 600 or more milliliters of blood coughed up within a 24 hour period. Massive hemoptysis is considered a medical emergency. Up to 75 percent of patients with massive hemoptysis die from asphyxiation (lack of oxygen) caused by too much blood in the airways.

Hemoptysis refers specifically to the spitting up of blood that comes from the respiratory tract. Often when persons spit up blood, they are not spitting up blood from the respiratory tract, but from somewhere else. When the blood comes from somewhere other than the respiratory tract, such as from a bloody nose or from the gastrointestinal tract, this is called pseudohemoptysis. Vomiting up blood from the gastrointestinal tract, called hematemesis, is one type of pseudohemoptysis. It is important to distinguish between true hemoptysis and pseudohemoptysis because they often involve very different parts of the body and the treatments are radically different.

Causes

Hemoptysis is caused by a variety of medical conditions including tuberculosis, bronchitis, bronchiectasis, pneumonia , and respiratory tract trauma. It is also caused by many forms of lung and respiratory tract cancers, such as: bronchial carcinoma , bronchial adenoma , respiratory tract hemangioma, and occasionally by metastatic cancer to the lungs.

Treatments

The goal of treatment for patients with hemoptysis is to stop the bleeding as soon as possible while also treating the cancer or other underlying disorder that is causing the hemoptysis.

Hemoptysis generally will stop spontaneously and no treatment is necessary, apart from reassurance of the patient that this condition will resolve on its own. Therefore, the general treatment for hemoptysis is to keep the patient calm and to ensure complete bed rest.

If the coughing that accompanies the hemoptysis is troublesome or aggravating the condition, cough suppressants may be recommended.

In cases of massive hemoptysis, the placement of a tube in the respiratory tract (intubation) may be necessary to allow for adequate airflow into and out of the respiratory tract. A bronchoscopy may be performed, not only to clear the airway of blood, but also to assist in diagnosing the endobronchial cause of the hemoptysis. When large amounts of blood have been lost, the patient may also require intravenous (IV) fluids and/or a blood transfusion.

In the most severe cases of hemoptysis, surgery to remove the cancer that is causing the spitting up of blood may be necessary to relieve the symptoms of hemoptysis. Other treatment modalities include PDT (photodynamic therapy).

Alternative and complementary therapies

Inhalation of the fumes of a tea made from the bark of the wild cherry (Prunus virginiana ) tree has been an herbal remedy for many respiratory tract ailments, including tuberculosis and hemoptysis among the Native Americans for centuries.

Hydrazine sulfate, a naturally occurring monoamine oxidase inhibitor (MAOI), has also been suggested as a treatment for hemoptysis.

Resources

BOOKS

Idell, Steven."Hemoptysis" In Current Diagnosis 9, edited by Rex B. Conn, et al. Philadelphia: W. B. Saunders Company, 1997.

ORGANIZATIONS

The Alliance for Lung Cancer (ALCASE). 1601 Lincoln Avenue, P. O. Box 849, Vancouver, WA 98666. Telephone 1-800-298-2436. Fax 360-735-1305. Internet <http://www.alcase.org>

American Lung Association (ALA). 1740 Broadway, New York, NY 10019. Telephone 1-212-315-8700. Internet <http://www.lungusa.org>

Paul A. Johnson, Ed.M.

KEY TERMS

Bronchial carcinoma

—Cancer arising from the bronchi, the major vessels that convey air to and from the lungs to the mouth and nose.

Bronchial adenoma

—A tumor arising in the linings of the bronchi.

Hemangioma

—A tumor of the blood vessels that is usually present at birth. When these occur on a visible portion of the skin, they are called "birth-marks." When they occur within the respiratory tract, they may lead to hemoptysis.

Sputum

—Material ejected from the lungs, bronchi, or trachea, through the mouth.