Hemoptysis

Hemoptysis is a dreaded condition that arises in approximately 5-10% of people suffering from tuberculosis. Read and find out all about the causes, symptoms, diagnosis and treatment of this disease.

Hemoptysis Definition

Hemoptysis refers to the coughing up (expectoration) of blood or bloody sputum from the respiratory tract. It can occur due to underlying conditions like respiratory infections, tuberculosis, bronchitis and various lung conditions.

The word “hemoptysis” is derived from the Greek terms “haima,” standing for “blood,” and “ptysis,” meaning “a spitting”.

Hemoptysis ICD-9 Code

The ICD-9 Code for this disease is 786.3.

Hemoptysis Pronunciation

The condition is pronounced as “he-MOP-tis-is.”

Hemoptysis Symptoms

Some of the main symptoms of this condition include:

• Unexplained loss of weight
• Dyspnea (respiratory shortness, even without exercise)
• Tachypnea (rapid breathing)
• Nausea
• Vomiting
• Fever
• Chest pain

Patients may cough up blood. The sight of blood in sputum can be very unpleasant and frightening for patients and make them suffer from anxiety. Suffering individuals are advised to spit into a partially-enclosed bowl or cover the mouth with a clean handkerchief while coughing. This will help them avoid spreading the disease to people close to them.

Hemoptysis Causes

Aproximately 80-90% cases of Hemoptysis occur due to inflammatory airway conditions, such as Bronchitis, Laryngitis and Bronchiectasis. Around 20% cases arise due to primary tumors of the lungs (particularly Carcinoma). Such tumors mostly arise in patients who smoke and are over 40 years of age. In rare cases, the condition may also occur due to metastatic lung cancers.

Picture 1 – Hemoptysis

Other causes of this condition include:

• Tuberculosis
• Pulmonary emboli
• Cystic fibrosis

In some cases, the condition may arise due to lung trauma, particularly after medical procedures like pulmonary artery catheterization, lung biopsy or bronchoscopy have been conducted. In 30-40% cases, the exact underlying cause of this condition cannot be found.

Hemoptysis Diagnosis

Patients should immediately inform doctors if they cough up blood. Doctors typically conduct a thorough physical examination and check whether any medications used by the patient are causing bleeding. Based on the underlying cause, physical examination may disclose problems like:

• Nasal inflammation
• Swelling of the throat
• Reduced sounds of breath
• Unusual sounds from the lungs, such as crackles or wheezes
• Additional cardiac sounds
• Distention of the neck veins
• Generalized inflammation of the extremities

Further diagnosis typically involves

• Chest x-rays
• CAT scan
• Laboratory examinations

Chest x-ray (radiograph) is usually the first medical procedure that is used to test the possibility of a lung disorder. Sputum of patients may be collected and analyzed to detect:

• Bacterial infection
• Tuberculosis
• Malignancy

In some cases, a Bronchial arteriography may also be conducted to detect the source of bleeding. The process can help doctors see the airways of the lungs and obtain cultures and biopsies. Doctors may also perform Coagulation studies, serologic studies and BUN/creatinine examinations. Magnetic Resonance Imaging (MRI) or CT scans may help detect abnormal lumps or lesions in the lungs or in any other parts of the body.

Hemoptysis Differential Diagnosis

The differential diagnosis of Hemoptysis involves telling its symptoms apart from those of other similar conditions, such as:

• Aspergilloma
• Bronchitis
• Bronchiectasis
• Bleeding disorders
• Foreign body aspiration
• Goodpasture’s Syndrome
• Lung cancer (that involves both big and small cell lung carcinoma)
• Sarcoidosis
• Tuberculosis
• Histoplasmosis
• Hughes-Stovin Syndrome
• Lung abscess
• Mitral stenosis
• Pneumonia
• Pulmonary embolism
• Trauma
• Tropical eosinophilia
• Variants of Behçet’s disease
• Wegener’s granulomatosis

Hemoptysis Treatment

Effective treatment of this condition depends on the underlying cause. Medical therapy should concentrate on:

• Stopping loss of blood
• Controlling cough
• Preventing any spread of infection
• Providing relief from fear and apprehension (due to the sight of bloody sputum)

While mild loss of blood often stops in a spontaneous manner, massive or constant bleeding (higher than 400 – 600 cc) within a day can be threatening to life. It may require immediate medical intervention. Bronchial artery embolization is an intervention that helps control massive bleeding from the lungs. In people with massive hemoptysis, bleeding can be checked by Laser therapy. In individuals suffering from massive bleeding and having an identifiable lung lesion, surgical intervention (Thoracotomy) may be considered.

Medications and respiratory therapy can be effective in the treatment of cough. These help decrease swelling or treat an infection. Narcotics and Sedatives can depress respiration. Naturally, they should be avoided.

Other treatment methods involve:

• Selective bronchial intubation – It can be used for collapsing a lung where hemorrhage is occurring. Endobronchial tamponade can also be used to cure the process.
• Laser photocoagulation – It can be used to stop the loss of blood during Bronchoscopy.
• Drugs – Medications may be used to cure underlying infections like Bronchitis, Pneumonia or Tuberculosis. Topical vasoconstrictors, such as vasopressin or adrenalin, and iced saline may also be used for treatment of Hemoptysis. Gefitinib or Erlotinib may be used as a remedy for Non–Small-Cell Lung Cancers.

In acute cases, where Hemoptysis does not show any improvement, physicians may consider use of:

• Therapeutic Bronchoscopy (to prevent more bleeding)
• Endobronchial balloon catheters (for occlusion of the bronchus)
• Placing coils into the artery that caters to the site of bleeding

In cases where all other treatment options fail, surgical procedures (such as Pneumonectomy or Lobectomy) may be used as a last resort. Surgery may be conducted to remove the site of bleeding.

Massive Hemoptysis

It refers to a severe form of Hemoptysis that is characterized by interruption of breathing due to high amounts of blood (usually about 1 cup or 200-240 mL, within a 24-hour span). This is a medical emergency and can have a mortality rate, as high as 75%, for sufferers. Most people dying from this condition suffer from an oxygen deficiency (asphyxiation) due to presence of high amounts of blood in the air passages. The condition, once diagnosed, needs immediate medical attention.

Picture 2 – Massive Hemoptysis

Mild Hemoptysis

It refers to a condition where there is only a small percentage of blood in the sputum of patients. In 60-70% patients of this disorder, the underlying condition is benign and goes away on its own without leading to permanent damage or any serious problems. Depending on the underlying cause for bleeding, Mild Hemoptysis can cause critical respiratory problems. The condition has a tendency to arise and recur intermittently. Due to this, it is impossible to predict whether patients suffering from mild hemoptysis are at risk of suffering from Massive Hemoptysis. It is important to carry out a proper diagnosis to avoid a more acute condition.

Hemoptysis Management

The management of Hemoptysis depends on the form of the condition that a person is suffering from. Management tends to vary based on whether a person is having mild or massive Hemoptysis.

Mild Hemoptysis Management

Management of mild forms of Hemoptysis aims at stopping bleeding, preventing aspiration and curing the underlying cause of the disorder. Management in the initial stages, similar to any potentially serious ailment, depends on evaluating the airway, breathing, and circulation of patients. When physicians suspect malignancy, and when bronchoscopy and sputum analysis are not effective in detecting any cause, high-resolution CT can be conducted. It can also be used when chest radiography reveals any parenchymal or peripheral disease.

Massive Hemoptysis Management

The death rate associated with massive forms of the condition depends on the underlying cause as well as the bleeding rate. If there is presence of malignancy, and the amount of blood lost every day is higher than 1,000 mL, the rate of mortality is approximately 80 percent. Massive forms of this disorder require a more aggressive treatment approach. Patients of this condition need early consultation with a pulmonologist (physicians specializing in disorders of the respiratory tract and lungs) as well as intensive care. This is a life-threatening syndrome and requires diagnosis as well as treatment to be conducted simultaneously. It is essential to maintain airways due to the fact that asphyxiation is main mechanism of death in this disorder. It is important to use fluid resuscitation and Supplemental oxygen to safeguard the health of patients. Surgical intervention may be required on an emergency basis. Due to this reason, it is necessary to seek the assistance of a cardiothoracic surgeon.

Hemoptysis in Children

Foreign body aspiration and lower respiratory tract infection are the two major causes of Hemoptysis in children. In children, Foreign body aspiration is the second most prominent cause of this disorder. Most cases of aspiration occur in kids who are less than four years old. Bronchiectasis and Cystic Fibrosis are found to be other important causes. Primary pulmonary tuberculosis is found to be a rare cause that accounts for less than 1% cases. The condition may also arise in kids due to injuries (blunt-force trauma) and bleeding caused by accidental or deliberate suffocation.

Pseudohemoptysis

Hemoptysis specifically refers to the blood that comes out of the respiratory tract. Blood may also come out of the back of the throat, part of the gastrointestinal tract or the nose. Pseudohemoptysis is referred to a condition where blood springs up from outside the respiratory tract. Hematemesis, which is a type of Pseudohemoptysis, is the medical name for vomiting up blood.

Catamenial Hemoptysis

It is a condition that rarely occurs due to Thoracic Endometriosis. It is characterized by bleeding from the lungs and the bronchial tree which occurs at the same as that of the female menstrual cycle. It is much rarer than catamenial pneumothorax. Due to this reason, no individual series of this condition has been reported. Only anecdotal case reports exist in medical literatures. The treatment options for this condition are the subject of controversy. Both pulmonary resection and hormone therapy have been used for its treatment. Treatment methods for this disease aim at suppressing the endometrial tissue with the aid of hormones.

Hemoptysis in Tuberculosis

Tuberculosis is a dreaded infection that is transmitted by ingestion or inhalation of tubercle bacilli. It gives rise to fever and tiny lesions. The lesions generally arise in the lungs. In acute stages, however, these may also develop in many other parts of the human body. Tuberculosis is a main cause of Hemoptysis around the world. Approximately 2 billion individuals are reported to be infected with tuberculosis. Around 5 to 10% of all tuberculosis sufferers are likely to develop Hemoptysis.

Hemoptysis Prognosis

The prognosis of this syndrome is usually good, based on its underlying cause. Most individuals affected with this disease are found to survive. However, patients with bleeding disorders generally suffer from a higher amount of bleeding. It is difficult to stop the bleeding. Naturally, the mortality rate is found to be higher. Only around 1.5% of all Hemoptysis cases are regarded as massive or extremely severe. If underlying conditions are found to be malignant in nature, the mortality rate can be quite high. This frequently occurs due to the complications arising from infection rather than the bleeding in the initial stages.

Prognosis of surgically treated cases and those of bronchial artery embolization are based on the degree of treatment of the underlying syndrome.

Hemoptysis Complications

Massive loss of blood may lead to anemia, shock and a deficiency of oxygen (Asphyxia). Complications arising due to respiratory failure, bleeding and infection may result in death.

Hemoptysis Risk Factors

The risk factors for this condition include:

• Being male
• Being more than 40 years of age
• Smoking

Smoking in excessive amounts may contribute to the development of underlying conditions that result in Hemoptysis. Travelling to areas having an infectious agent (fungus, bacteria, virus or parasites) that cause the disease may also lead to Hemoptysis.

If diagnosed and treated in time, Hemoptysis (even in its massive form) can be cured properly. The prognosis can be quite positive and patients can show a good rate of recovery. If you have any family member who is showing symptoms of Hemoptysis, seek medical care on an immediate basis. Timely treatment can prevent any complications, even life-threatening ones, and safeguard the health of the sufferer.

References:

http://www.ncbi.nlm.nih.gov/books/NBK360/

http://www.mdguidelines.com/hemoptysis

http://www.mayoclinic.com/health/coughing-up-blood/MY01064

http://www.healthcommunities.com/hemoptysis/hemoptysis-definition.shtml