Introduction

Haemoptysis is the coughing of blood originating from the lungs. The blood can appear as flecks, streaks or can be massive in amount. Haemoptysis can be caused by many things but it is important to make sure that the blood is really from the lungs and not from other structures like the nose or the stomach. There is a big difference in terms of treatment, expected recovery and final outcome. If you ever cough up blood, it is important for you to see a doctor so that they can investigate the possible causes.

Signs and Symptoms of Hemoptysis

Hemoptysis is a symptom of many different underlying disorders, from mild bronchial infection to cancer. In addition to coughing up blood, a patient may notice other symptoms including the following:

• Chest pain when breathing in deeply (pleuritic chest pain)
• Lethargy/tiredness
• Shortness of breath (at rest or doing minimal activity)
• Fever
• Rapid breathing
• Sweating at night
• Loss of appetite
• Unintentional weight loss

Causes Of Haemoptysis

1. Lung infection (pneumonia)
2. Tuberculosis
3. Lung Cancer
4. Chronic bronchitis
5. Bronchiectasis
6. Lung abscess
7. Fungal infection especially mycetoma
8. Pulmonary embolism
9. Pulmonary oedema
10. Congestive cardiac failure
11. Pulmonary hypertension
12. Congenital or acquired systemic coagulopathy eg leukaemia, thrombotic thrombocytopenic purpura
13.  Anticoagulant or thrombolytic agent eg: warfarin, heparin
14. Inhaled Foreign Body
15. Auto immune disease and vasculitis (Wegeners Granulomatosis,  Goodpasture’s syndrome, systemic lupus erythematosis, Henoch-Schonlein purpura)
16. Trauma to the airways / lung contusion
17. Pulmonary arterio-venous malformation
18. Rupture of a blood vessel after vigorous coughing. In about a quarter of cases, even after thorough investigations, the cause of the bleeding is never found.

Investigations

Usual investigations will be laboratory tests including sputum examination, blood investigations and chest x-ray. Depending on the source and nature of the haemoptysis, bronchoscopy and CT scan may be required especially when lung cancer is suspected. Bronchoscopy may also be used to localise the site of bleeding as well as a measure to stop the bleeding locally. Pulmonary angiography is another measure to detect the source of bleeding.

Complications

1. Asphyxia
2. haemodynamic instability
3. Anaemia
4. Lung infection
5. Renal failure

Treatment

Treatment of haemoptysis is divided into:

1. Stop the bleeding
2. To ensure that the patient does not aspirate the blood into the lungs
3. Treat the source of haemoptysis

Treatment of haemoptysis depends on the quantity of blood coughed up and the underlying cause. Mild or minimal haemoptysis does not require specific and immediate treatment. However, the underlying cause needs to be determined and treated. For example, if the cause of haemoptysis is lung infection (pneumonia), antibiotic should be given. If the source of the haemoptysis is from tuberculosis, anti-tuberculosis drugs should be prescribed. It is important to know the type and stage of lung cancer as well as the performance status of the patient to further determine the appropriate treatment. Antifibrinolytic agent (eg: tranexamic acid) is an option to assist in stopping the bleeding.

Major or massive haemoptysis is a medical emergency and needs urgent treatment. Death can result, usually from asphyxiation. First step is to go to the nearest emergency department. The doctor will stabilise the patient and try to identify the source of bleeding. If the bleeding is massive, blocking/compromising the airway, intubation maybe required.

Some methods of controlling bleeding include:

1. Selective bronchial intubation.
   Patient will undergo single lung intubation and ventilation. The breathing tube will be placed in the non-bleeding lung. This will help to prevent the blood from entering the normal lung.
2. Bronchoscopy
   • Adrenaline
   • Cold saline
   • Tamponade method
   • Cauterization
   • Laser photocoagulation
3. Bronchial artery embolization
   • Angiography of bronchial arteries is done to locate the bleeding site, and it can often be embolized
4. Surgery
   • Usually the last option to remove the bleeding site

Prevention

There is no specific prevention of haemoptysis.

1. Healthy life style
2. Quit smoking
3. Exercise
4. Seek early advice if coughing up blood

Literature Review

1. Lordan JL et al. The pulmonary physician in critical care case 7: Assessment and management of massive haemoptysis. Thorax 2003;58:814±819
2. D. Gompelmann et al. Advanced Malignant Lung Disease: What the Specialist Can Offer. Respiration 2011;82:111–123