Hemoptysis
Frightening to the patient and commonly ominous, hemoptysis is the expectoration of blood or bloody sputum from the lungs or tracheobronchial tree. It’s sometimes confused with bleeding from the mouth, throat, nasopharynx, or GI tract. (See Identifying hemoptysis.) Expectoration of 200 ml of blood in a single episode suggests severe bleeding, whereas expectoration of 400 ml in 3 hours or more than 600 ml in 16 hours signals a life-threatening crisis.
Hemoptysis usually results from chronic bronchitis, lung cancer, or bronchiectasis. However, it may also result from inflammatory, infectious, cardiovascular, or coagulation disorders and, rarely, from a ruptured aortic aneurysm. In up to 15% of patients, the cause is unknown. The most common causes of massive hemoptysis are lung cancer, bronchiectasis, active tuberculosis (TB), and cavitary pulmonary disease from necrotic infections or TB.
Several pathophysiologic processes can cause hemoptysis. (See What happens in hemoptysis.)
Emergency interventions
If the patient coughs up copious amounts of blood, endotracheal intubation may be required. Suction frequently to remove blood. Lavage may be necessary to loosen tenacious secretions or clots. Massive hemoptysiscan cause airway obstruction and asphyxiation. Insert an I
V. line to allow fluid replacement, drug administration, and blood transfusions, if needed. An emergency bronchoscopy should be performed to identify the bleeding site. Monitor the patient’s blood pressure and pulse to detect hypotension and tachycardia, and draw an arterial blood sample for laboratory analysis to monitor respiratory status.
History and physical examination
If the hemoptysis is mild, ask the patient when it began. Has he ever coughed up blood before? About how much blood is he coughing up now and about how often? Ask about a history of cardiac, pulmonary, or bleeding disorders. If he’s receiving anticoagulant therapy, find out the drug, its dosage and schedule, and the duration of therapy. Is he taking other prescription drugs? Does he smoke? Ask the patient if he has had a recent infection. Has he been exposed to TB? When was his last tine test and what were the results?
Take the patient’s vital signs and examine his nose, mouth, and pharynx for sources of bleeding. Inspect the configuration of his chest and look for abnormal movement during breathing, the use of accessory muscles, and retractions. Observe his respiratory rate, depth, and rhythm. Finally, examine his skin for lesions.
Next, palpate the patient’s chest for diaphragm level and for tenderness, respiratory excursion, fremitus, and abnormal pulsations; then percuss for flatness, dullness, resonance, hyperresonance, and tympany. Finally, auscultate the lungs, noting especially the quality and intensity of breath sounds. Also auscultate for heart murmurs, bruits, and pleural friction rubs.
Obtain a sputum sample and examine it for overall quantity, for the amount of blood it contains, and for its color, odor, and consistency.
Medical causes
Bronchial adenoma
Bronchial adenoma is an insidious disorder that causes recurring hemoptysis in up to 30% of patients, along with a chronic cough and local wheezing.
Bronchiectasis
Inflamed bronchial surfaces and eroded bronchial blood vessels cause hemoptysis, which can vary from blood-tinged sputum to blood (in about 20% of cases) The patient’s sputum may also be copious, foul-smelling, and purulent
He may exhibit a chronic cough, coarse crackles, clubbing (a late sign), a fever, weight loss, fatigue, weakness, malaise, and dyspnea on exertion.
Bronchitis (chronic)
The first sign of chronic bronchitis is typically a productive cough that lasts at least 3 months Eventually this leads to the production of blood-streaked sputum; massive hemorrhage is unusual
Other respiratory effects include dyspnea, prolonged expirations, wheezing, scattered rhonchi, accessory muscle use, barrel chest, tachypnea, and clubbing (a late sign).
Coagulation disorders
Such disorders as thrombocytopenia and disseminated intravascular coagulation can cause hemoptysis Besides their specific related findings, these disorders may share such general signs as multisystem hemorrhaging (for example, GI bleeding or epistaxis) and purpuric lesions.
Lung abscess
In about 50% of patients, lung abscess produces blood-streaked sputum resulting from bronchial ulceration, necrosis, and granulation tissue Common associated findings include a cough with large amounts of purulent, foul-smelling sputum; a fever with chills; diaphoresis; anorexia; weight loss; a headache; weakness; dyspnea; pleuritic or dull chest pain; and clubbing
Auscultation reveals tubular or cavernous breath sounds and crackles. Percussion reveals dullness on the affected side.
Lung cancer
Ulceration of the bronchus commonly causes recurring hemoptysis (an early sign), which can vary from blood-streaked sputum to blood Related findings include a productive cough, dyspnea, a fever, anorexia, weight loss, wheezing, and chest pain (a late symptom).
Plague (Yersinia pestis)
The pneumonic form of this acute bacterial infection can produce hemoptysis, a productive cough, chest pain, tachypnea, dyspnea, increasing respiratory distress, and cardiopulmonary insufficiency, along with the sudden onset of chills, a fever, a headache, and myalgia.
Pneumonia
In up to 50% of cases, Klebsiella pneumonia produces dark brown or red (currant jelly) sputum, which is so tenacious that the patient has difficulty expelling it from his mouth This type of pneumonia begins abruptly with chills, a fever, dyspnea, a productive cough, and severe pleuritic chest pain
Associated findings may include cyanosis, prostration, tachycardia, decreased breath sounds, and crackles.
Pneumococcal pneumonia causes pinkish or rusty mucoid sputum. It begins with sudden, shaking chills; a rapidly rising temperature; and, in over 80% of cases, tachycardia and tachypnea. Within a few hours, the patient typically experiences a productive cough along with severe, stabbing, pleuritic pain. The agonizing chest pain leads to rapid, shallow, grunting respirations with splinting. Examination reveals respiratory distress with dyspnea and accessory muscle use, crackles, and dullness on percussion over the affected lung. Malaise, weakness, myalgia, and prostration accompany a high fever.
Pulmonary edema
Severe cardiogenic or noncardiogenic pulmonary edema commonly causes frothy, blood-tinged pink sputum, which accompanies severe dyspnea, orthopnea, gasping, anxiety, cyanosis, diffuse crackles, a ventricular gallop, and cold, clammy skin This life-threatening condition may also cause tachycardia, lethargy, cardiac arrhythmias, tachypnea, hypotension, and a thready pulse.
Pulmonary embolism with infarction
Hemoptysis is a common finding in pulmonary embolism with infarction, a life-threatening disorder, although massive hemoptysis is infrequent Typical initial symptoms are dyspnea and anginal or pleuritic chest pain
Other common clinical features include tachycardia, tachypnea, a low-grade fever, and diaphoresis. Less commonly, splinting of the chest, leg edema, and — with a large embolus — cyanosis, syncope, and jugular vein distention may occur. Examination reveals decreased breath sounds, a pleural friction rub, crackles, diffuse wheezing, dullness on percussion, and signs of circulatory collapse (a weak, rapid pulse; hypotension), cerebral ischemia (transient loss of consciousness, convulsions), and hypoxemia (restlessness and, particularly in elderly patients, hemiplegia and other focal neurologic deficits).
Pulmonary hypertension (primary)
Features generally develop late Hemoptysis, exertional dyspnea, and fatigue are common
Angina-like pain usually occurs with exertion and may radiate to the neck but not to the arms. Other findings include arrhythmias, syncope, a cough, and hoarseness.
Pulmonary TB
Blood-streaked or blood-tinged sputum commonly occurs in pulmonary TB; massive hemoptysis may occur in advanced cavitary TB
Accompanying respiratory findings include a chronic productive cough, fine crackles after coughing, dyspnea, dullness on percussion, increased tactile fremitus, and possible amphoric breath sounds. The patient may also develop night sweats, malaise, fatigue, a fever, anorexia, weight loss, and pleuritic chest pain.
Systemic lupus erythematosus (SLE)
In 50% of patients with SLE, pleuritis and pneumonitis cause hemoptysis, a cough, dyspnea, pleuritic chest pain, and crackles
Related findings are a butterfly rash in the acute phase, nondeforming joint pain and stiffness, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, anorexia with weight loss, and lymphadenopathy.
Tracheal trauma
Torn tracheal mucosa may cause hemoptysis, hoarseness, dysphagia, neck pain, airway occlusion, and respiratory distress.
Other causes
Diagnostic tests
Lung or airway injury from bronchoscopy, laryngoscopy, mediastinoscopy, or lung biopsy can cause bleeding and hemoptysis.
Special considerations
Comfort and reassure the patient, who may react to this alarming sign with anxiety and apprehension If necessary, to protect the nonbleeding lung, place him in the lateral decubitus position, with the suspected bleeding lung facing down
Perform this maneuver with caution because hypoxemia may worsen with the healthy lung facing up.
Prepare the patient for diagnostic tests to determine the cause of bleeding. These may include a complete blood count, a sputum culture and smear, chest X-rays, coagulation studies, bronchoscopy, lung biopsy, pulmonary arteriography, and a lung scan.
Pediatric pointers
Hemoptysis in children may stem from Goodpasture’s syndrome, cystic fibrosis, or (rarely) idiopathic primary pulmonary hemosiderosis Sometimes no cause can be found for pulmonary hemorrhage occurring within the first 2 weeks of life; in such cases, the prognosis is poor.
Geriatric pointers
If the patient is receiving anticoagulants, determine any changes that need to be made in his diet or medications (including over-the-counter and natural supplements) because these factors may affect clotting.
Pictures
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Blood-stained phlegm
» Next page: Hemoptysis* (A Pocket Manual of Differential Diagnosis)
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