Hemoptysis is the coughing up of
blood
Blood is a body fluid in the circulatory system of humans and other vertebrates that delivers necessary substances such as nutrients and oxygen to the cells, and transports metabolic waste products away from those same cells. Blood in the cir ...
or blood-stained
mucus
Mucus ( ) is a slippery aqueous secretion produced by, and covering, mucous membranes. It is typically produced from cells found in mucous glands, although it may also originate from mixed glands, which contain both serous and mucous cells. It ...
from the
bronchi,
larynx
The larynx (), commonly called the voice box, is an organ in the top of the neck involved in breathing, producing sound and protecting the trachea against food aspiration. The opening of larynx into pharynx known as the laryngeal inlet is about ...
,
trachea
The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air- breathing animals with lungs. The trachea extends from t ...
, or
lung
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of ...
s. In other words, it is the airway bleeding. This can occur with
lung cancer
Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Lung carcinomas derive from transformed, mali ...
, infections such as
tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, ...
,
bronchitis, or
pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severit ...
, and certain cardiovascular conditions. Hemoptysis is considered massive at . In such cases, there are always severe injuries. The primary danger comes from
choking, rather than
blood loss
Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, ...
.
Diagnosis
* Past history, history of present illness, family history
** history of tuberculosis, bronchiectasis, chronic bronchitis, mitral stenosis, etc.
** history of
cigarette smoking, occupational diseases by exposure to silica dust, etc.
* Blood
** duration, frequency, amount
** Amounts of blood: large amounts of blood, or is there blood-streaked sputum
** Probable source of bleeding: Is the blood coughed up, or vomited?
* Bloody
sputum
** color, characters: blood-streaked, fresh blood, frothy pink, bloody gelatinous.
* Accompanying symptoms
** fever, chest pain, coughing, purulent sputum, mucocutaneous bleeding, jaundice.
* Imaging examination
** chest X-ray, CT scan and 3D reconstruction images or CT virtual bronchoscopy, bronchial angiography.
* Laboratory tests
** blood test: WBC
** Sputum: cells and bacterial examinations, sputum culture
* Bronchial fiber endoscopy
Differential diagnosis
The most common causes for hemoptysis in adults are chest infections such as
bronchitis or
pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severit ...
.
In children, hemoptysis is commonly caused by the presence of a
foreign body
A foreign body (FB) is any object originating outside the body of an organism. In machinery, it can mean any unwanted intruding object.
Most references to foreign bodies involve propulsion through natural orifices into hollow organs.
Foreign b ...
in the
airway
The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa.
Air is breathed in through the nose t ...
. Other common causes include
lung cancer
Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Lung carcinomas derive from transformed, mali ...
s and
tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, ...
. Less common causes include
aspergilloma,
bronchiectasis
Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Symptoms typically include a chronic cough with mucus production. Other symptoms include shortness of breath, coughing up blood, and chest ...
,
coccidioidomycosis,
pulmonary embolism,
pneumonic plague, and
cystic fibrosis
Cystic fibrosis (CF) is a rare genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine. Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections. Ot ...
. Rarer causes include
hereditary hemorrhagic telangiectasia (HHT or Rendu-Osler-Weber syndrome),
Goodpasture's syndrome
Goodpasture syndrome (GPS), also known as anti–glomerular basement membrane disease, is a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs, glomerulonephritis, ...
, and
granulomatosis with polyangiitis
Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis (WG), is a rare long-term systemic disorder that involves the formation of granulomas and inflammation of blood vessels (vasculitis). It is a form of vasculitis ...
. A rare cause of hemoptysis in women is
endometriosis
Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, fa ...
, which leads to intermittent hemoptysis coinciding with menstrual periods in 7% of women with thoracic endometriosis syndrome.
Hemoptysis may be exacerbated or even caused by overtreatment with
anticoagulant
Anticoagulants, commonly known as blood thinners, are chemical substances that prevent or reduce coagulation of blood, prolonging the clotting time. Some of them occur naturally in blood-eating animals such as leeches and mosquitoes, where t ...
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
Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, ...
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.
*
Lung cancer
Lung cancer, also known as lung carcinoma (since about 98–99% of all lung cancers are carcinomas), is a malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Lung carcinomas derive from transformed, mali ...
, including both non-small cell lung carcinoma and small cell lung carcinoma.
*
Sarcoidosis
Sarcoidosis (also known as ''Besnier-Boeck-Schaumann disease'') is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph nodes. Less commonly af ...
*
Aspergilloma
*
Tuberculosis
Tuberculosis (TB) is an infectious disease usually caused by '' Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can also affect other parts of the body. Most infections show no symptoms, ...
*
Histoplasmosis
*
Pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severit ...
*
Pulmonary edema
Pulmonary edema, also known as pulmonary congestion, is excessive liquid accumulation in the tissue and air spaces (usually alveoli) of the lungs. It leads to impaired gas exchange and may cause hypoxemia and respiratory failure. It is due ...
*
Endometriosis
Endometriosis is a disease of the female reproductive system in which cells similar to those in the endometrium, the layer of tissue that normally covers the inside of the uterus, grow outside the uterus. Most often this is on the ovaries, fa ...
and
thoracic endometriosis syndrome
*
Foreign body aspiration and
aspiration pneumonia
*
Goodpasture's syndrome
Goodpasture syndrome (GPS), also known as anti–glomerular basement membrane disease, is a rare autoimmune disease in which antibodies attack the basement membrane in lungs and kidneys, leading to bleeding from the lungs, glomerulonephritis, ...
*
Microscopic polyangiitis
*
Granulomatosis with polyangiitis
Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis (WG), is a rare long-term systemic disorder that involves the formation of granulomas and inflammation of blood vessels (vasculitis). It is a form of vasculitis ...
*
Eosinophilic granulomatosis with polyangiitis
*
Bronchitis
*
Bronchiectasis
Bronchiectasis is a disease in which there is permanent enlargement of parts of the airways of the lung. Symptoms typically include a chronic cough with mucus production. Other symptoms include shortness of breath, coughing up blood, and chest ...
*
Pulmonary embolism
*
Anticoagulant use
*
Trauma
Trauma most often refers to:
*Major trauma, in physical medicine, severe physical injury caused by an external source
*Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event
*Traumatic inju ...
*
Lung abscess
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.
This pus-filled cavity is often caused by aspiration, which may ...
*
Mitral stenosis
*
Tropical pulmonary eosinophilia
*
Bleeding disorders
Coagulopathy (also called a bleeding disorder) is a condition in which the blood's ability to coagulate (form clots) is impaired. This condition can cause a tendency toward prolonged or excessive bleeding (bleeding diathesis), which may occur spo ...
*
Hughes-Stovin syndrome and other variants of
Behçet's disease
* Pulmonary
arteriovenous malformations
Massive hemoptysis and mortality
Although there are reports that the fatality rate is as high as 80%, the in-hospital mortality rate for hospitalized hemoptysis patients is 2669/28539=9.4%, calculated from the data in the article by Kinoshita et al.
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, 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
Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles. The process is the opposite of vasodilation, the widening of blood vessel ...
such as
adrenalin or
vasopressin.
Tranexamic acid
Tranexamic acid (TXA) is a medication used to treat or prevent excessive blood loss from major trauma, postpartum bleeding, surgery, tooth removal, nosebleeds, and heavy menstruation. It is also used for hereditary angioedema. It is taken ei ...
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.
Laser photocoagulation can be used to stop bleeding during
bronchoscopy.
Angiography of
bronchial arteries
In human anatomy, the bronchial arteries supply the lungs with nutrition and oxygenated blood. Although there is much variation, there are usually two bronchial arteries that run to the left lung, and one to the right lung and are a vital part ...
can be performed to locate the bleeding, and it can often be
embolized
An embolism is the lodging of an embolus, a blockage-causing piece of material, inside a blood vessel. The embolus may be a blood clot (thrombus), a fat globule ( fat embolism), a bubble of air or other gas ( gas embolism), amniotic fluid (amni ...
.
Bronchial artery embolization
Bronchial artery embolization is a treatment for hemoptysis, abbreviated as BAE. It is a kind of catheter intervention to control hemoptysis (airway bleeding) by embolizing the bronchial artery, which is a bleeding source. Embolic agents are parti ...
(BAE) is the first line treatment nowadays.
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.
References
Further reading
*
External links
{{Authority control
Bleeding
Respiratory diseases
Symptoms and signs: Respiratory system