Hemoptysis (hemoptysis) is a respiratory symptom characterized by coughing up streaks or blood clots. May indicate infections and tumors of the respiratory tract, thoracic injuries, vascular lesions, systemic diseases, coagulopathy. Hemoptysis is a potentially dangerous condition, because. can develop into fatal pulmonary hemorrhage, therefore, it always requires immediate and thorough diagnosis. Topical determination of the source of bleeding includes fibrobronchoscopy, X-ray and CT of the lungs. Before the arrival of the ambulance, it is necessary to remain calm, lie with a raised headboard, you can take antihypertensive and antitussive drugs.
General characteristics of hemoptysis
The causes and mechanisms of the development of hemoptysis (hemoptysis) are generally similar to the etiology and pathogenesis of pulmonary hemorrhage (hemoptoea). The difference between these conditions is mainly quantitative: when coughing up a small amount of blood (less than 5 ml per day), it is customary to talk about hemoptysis, when a larger amount is coughed up - about bleeding.
The occurrence of hemoptysis may be preceded by persistent cough, hypertensive crisis, intercurrent diseases. This symptom can be provoked by active physical activity, thermal and water procedures, for example, soaring in a bath, paraffin therapy, general baths and healing showers. Also, meteorological factors often contribute to the onset of hemoptysis: an increase in atmospheric pressure, cold or hot weather.
Usually hemoptysis begins suddenly. During the next coughing up of sputum, the patient notices traces of blood in it. Some patients note the harbingers of hemoptysis: perspiration (tickling) and gurgling (gurgling) in the throat, retrosternal pain, sometimes - unpleasant warmth spreading through the chest. Against the background of shortness of breath, a cough occurs with the release of blood. At the same time, there is a salty taste of blood in the mouth and its specific smell.
Blood with hemoptysis is released periodically, not with every cough attack. In some cases, hemoptysis has the form of streaks in saliva or sputum, in others - individual spitting of scarlet (fresh) or dark (old) blood. If the release of scarlet blood is repeated systematically when coughing, it is considered that the patient has begun pulmonary bleeding. During an episode of hemoptysis, the patient turns pale, looks frightened, feels weakness throughout the body, dizziness. Chronic and recurrent attacks of hemoptysis lead to anemia.
Causes of hemoptysis
Tumors of the lungs and bronchi
Hemoptysis is often observed in various tumor processes of the respiratory tract, although it is not an obligatory symptom of bronchopulmonary neoplasia. Hemoptysis can be caused by the germination of the bronchial wall vessels by the tumor, compression and usuration of large arterial trunks by a rapidly growing neoplasm, the decay of the tumor mass containing the newly formed vessels. A third of patients with tumor diseases first visit a doctor precisely because of recurrent hemoptysis. This symptom may indicate the following neoplastic processes:
- Bronchogenic cancer. Coughing up blood, as a rule, appears against the background of other symptoms and is of a moderate nature. More often occurs with central (exophytic), less often with peripheral lung cancer. Hemoptysis is preceded by a painful cough of reflex origin, against the background of which scarlet blood is found in the bronchial secretion in the form of individual blood threads (veins) or clots. Sometimes bloody sputum resembles "raspberry jelly". Episodes of hemoptysis are repeated repeatedly. Associated symptoms are shortness of breath, chest pain, hacking cough, weight loss. The clinic of obstructive pneumonia can develop. Fulminant terminal bleeding occurs in 5-8% of patients and is associated with ulceration of the branches of the pulmonary artery.
- bronchial adenoma. Bronchoadenoma has abundant vascularization, often grows into the lumen of the bronchi, causing a persistent dry cough with wheezing. Recurrent hemoptysis is an early and persistent symptom of adenoma (occurs in 80% of patients). The diagnosis of bronchoadenoma is likely in young women with recurrent segmental and lobar pneumonia, cough paroxysms, and hemoptysis.
- Lung hemangioma . Very dangerous is hemoptysis in hemangiomas of the lung. These vascular tumors may be asymptomatic or accompanied by thoracalgia, shortness of breath. Hemoptysis occurs for no reason or against the background of physical effort, coughing, insolation. Blood spit is scarlet in color, sputum, as a rule, is not excreted. Hemoptysis recurs repeatedly. Ulceration and rupture of a large hemangioma can be complicated by fatal bleeding. Angiomatosis of the internal organs is indirectly indicated by the presence of multiple telangiectasias on the patient's body.
- Other lung tumors . More rare causes of hemoptysis are plasmacytoma, lung sarcoma, bronchioloalveolar cancer. Perhaps the development of hemoptysis with metastatic lung disease, germination of pleural mesothelioma. Along with malignant neoplasms, pulmonary hamartomas, mediastinal teratomas, etc. can be complicated by hemoptysis. The clinic is nonspecific - cough with bloody sputum. The exception is bronchial alveolar cancer, in which a large volume (about 1 liter per day) of watery mucous sputum with blood impurities is released with a cough.
Hemoptysis is considered a pathognomonic sign of tuberculosis infection and occurs in almost 80% of TB patients. More than half of the cases of hemoptysis of tuberculous etiology are due to fibrous-cavernous and cirrhotic pulmonary tuberculosis, from 15 to 25% - to disseminated, about 10% - to the infiltrative-pneumonic variant, about 5% - to tuberculomas. In elderly patients, hemoptysis occurs twice as often as in young patients.
With hemoptysis, a tuberculous patient coughs up mucopurulent sputum with bright red blood inclusions or separate spitting of pure blood. With a long stay of blood in the cavity of the cavity, its color becomes dark brown or rusty. During coughing, patients feel a burning sensation in the chest and can accurately indicate the affected side and the source of hemoptysis. The onset of pulmonary bleeding is signaled by profuse coughing up of scarlet foaming blood or blood clots.
Hemoptysis of tuberculous etiology is usually chronic or recurrent, recurring throughout the entire period of the disease and even after treatment (with residual changes in the lungs - post-tuberculous pneumosclerosis, bronchiectasis). To refer to such forms of tubinfection in phthisiology, the term "hemoptotic consumption" is used. In addition to hemoptysis, the tuberculosis clinic is characterized by persistent cough, fever, night sweats, and weight loss.
Various morphological (lobar, hemorrhagic, atypical) and etiological forms of pneumonia (pneumococcal, Klebsiella, staphylococcal) occur with hemoptysis. Initially, the patient is concerned about general symptoms - weakness, febrile intoxication syndrome, chills, shortness of breath. Cough with hemoptysis joins already in the expanded phase of pneumonia. With various types of pneumonia, hemoptysis has its own differences:
- Croupous pneumonia . With lobar pneumococcal pleuropneumonia, hemoptysis is observed in 40% of patients. It is not abundant, occurs 2-3 days from the onset of the disease, which corresponds to the stage of red hepatization in the lungs (sweating of red blood cells into alveolar exudate). The admixture of blood gives the sputum a brownish, brown tint - to indicate the nature of the discharge from the bronchial tree with lobar pneumonia, the term "rusty sputum" is used.
- Friedlander 's pneumonia . The course of the disease is acute and extremely severe: severe fever, intoxication, pain in the side on inspiration, the presence of hemorrhages on the skin and mucous membranes are typical. For Friedländer's pneumonia, an obsessive cough with viscous muco-bloody sputum, which has an unpleasant smell of burnt meat, is pathognomonic. Hemorrhagic inclusions give sputum a look resembling "currant jelly". Isolation of abundant bloody sputum is associated with the formation of multiple cavities of destruction in the lung tissue filled with exudate.
- Hemorrhagic pneumonia . More often it has an influenza etiology, it is also found in measles, smallpox, pulmonary forms of anthrax and plague. The appearance of blood in the sputum in these nosologies is a consequence of infectious-toxic damage to the walls of the capillary network. With hemorrhagic pneumonia, a copious frothy secret, colored bright red, is coughed up. Other typical signs are cyanosis, severe respiratory failure, hypotension, and other hemorrhagic manifestations.
- Suppurative diseases of the lungs . Bacterial destruction of the lungs is often the outcome of pneumonia. With an abscess or gangrene of the lung, hemoptysis is a consequence of damage to blood vessels during a breakthrough of pus from the pathological focus into the draining bronchus. At the same time, purulent sputum with a bloody admixture is coughed up with a full mouth, and has a fetid odor. Pain in the chest, febrile syndrome, intoxication, shortness of breath are expressed. When the bronchial arteries are melted, hemoptysis has a high risk of transition to profuse pulmonary hemorrhage.
"Bloody sputum" also occurs in a number of other pneumonias. So, a paroxysmal excruciating cough with a rusty-brown sputum is noted with gasoline pneumonia. An admixture of blood in the mucopurulent secret can be detected with pulmonary inflammation of ornithosis and mycoplasma etiology. Hemorrhagic complications in the form of hemoptysis, gastric bleeding, hematuria are characteristic of legionella pneumonia. In general, hemoptysis is not a specific sign of pneumonia, therefore, with its abundant or persistent nature, it is necessary to look for other causes, primarily tuberculosis and lung cancer.
Cough of any etiology is one of the most common factors provoking hemoptysis. Cough paroxysms accompany various diseases of the lungs and cardiovascular system, but above all, it is associated with the pathology of the tracheobronchial tree. It has been established that about 60-70% of cases of hemoptysis are caused by one or another lesion of the bronchi:
- Bronchitis . In the structure of the causes of hemoptysis, they make up 15%. Hemoptysis complicates both acute and chronic bronchitis in the acute phase. The rupture of small vessels contributes to a hacking strong cough. Bloody impurities are usually minimal, have the character of individual veins. Cough bothers mainly in the morning, typically discharge of viscous sputum of a mucopurulent or purulent nature.
- Bronchiectasis. Cause more than 30% of cases of hemoptysis, being the outcome of chronic pneumonia and bronchitis, lung abscess, cavernous tuberculosis. The source of hemoptysis in bronchiectasis is the bronchial arteries (often the middle lobe artery). Hemoptysis occurs during the period of exacerbation of inflammatory phenomena (usually in autumn and spring) against the background of abundant expectoration of purulent sputum. It often looks like bloody streaks, but cases of massive pulmonary bleeding are described.
- Foreign bodies of the respiratory tract . Aspiration of foreign bodies is a common cause of hemoptysis in the pediatric population. In this regard, the most dangerous are small pointed objects that are fixed in the bronchi. They cause permanent trauma to the mucosa, the formation of bedsores, recurrent inflammation of the bronchi. Foreign bodies of the bronchi are manifested by bouts of whooping cough with hemoptysis, stridor breathing, shortness of breath.
- Broncholithiasis . Refers to cases of foreign bodies of the bronchi of endogenous origin. The formation of bronchial stones - broncholiths - can cause persistent, often recurring episodes of hemoptysis. With broncholithiasis, a crumbly white mass can be found in the coughed up blood secretion, which is fragments of calcareous broncholitis.
- Bronchial fistulas . Hemoptysis often complicates bronchoesophageal fistulas. This pathology is indicated by a cough that occurs during meals, coughing up particles of food that has just been eaten, accompanied by suffocation and cyanosis. Along with hemoptysis, vomiting with an admixture of blood is possible.
Fungal and parasitic infestations
Pulmonary forms of various helminthiases are complicated by hemoptysis. In such cases, the development of hemorrhagic syndrome may be due to the migration of parasites through the lungs (schistosomiasis, ascariasis, strongyloidiasis), the formation of cysts and foci of destruction (paragonimiasis, echinococcosis). Cough occurs paroxysmal, often accompanied by bronchospasm, shortness of breath. Sputum is mucous or mucopurulent with splashes of blood. At microscopy in a secret of bronchial larvae of helminths can be defined. As the parasitic focus in the lungs progresses, hemoptysis intensifies up to hemoptoea.
With the phenomena of hemoptysis, some fungal invasions occur: actinomycosis, candidiasis, aspergillosis of the respiratory system. The development of hemorrhagic symptoms is facilitated by the germination of mycelium, the release of proteolytic enzymes by fungi that melt the lung tissue. Hemoptysis is often mild, episodic, in the form of blood inclusions in the coughed up secret. The clinical picture is complemented by a hacking cough, fever, shortness of breath. Verification of the diagnosis and type of pneumomycosis is facilitated by the detection of the fungus in the secret and bronchial washings.
Endometriosis of the lungs
For the pulmonary form of endometriosis, hemoptysis is typical, which is repeated during menstruation. The volume of hemoptysis varies from small to large, leading to anemia, and is independent of menstrual blood loss. Sputum may contain fragments of endometrial tissue. Hemoptysis does not recur every menstruation, and its severity also varies from cycle to cycle.
During pregnancy, hemoptysis stops, but after a medical abortion, coughing up bloody sputum may become more regular and abundant. In addition to coughing and hemoptysis, endometriosis of the lungs is accompanied by aching or stabbing pains in the chest. All manifestations are typical for women of reproductive age.
Bronchial and lung injuries
Coughing up blood can be associated with direct mechanical damage to the respiratory tract, in which the integrity of the bronchial and pulmonary arteries is violated, and the parenchyma of the lungs is impregnated with blood. At the same time, in the genesis of hemoptysis, there is always a clear connection with the impact of a traumatic factor. Hemoptysis may occur immediately after injury or be delayed, be single or persist for several days.
- Endobronchial manipulation . Potentially possible iatrogenic causes of hemoptysis are trauma to the bronchial mucosa with a rigid tube of a bronchoscope, biopsy forceps, or a needle when taking tissue samples. In all these cases, fresh blood is coughed up immediately after the procedure. Usually, hemoptysis is mild or moderate, disappears on its own or is quickly stopped by hemostatic therapy, and does not develop again.
- Lung tissue damage . Hemoptysis is complicated by fractures of the ribs, stab and gunshot wounds, ruptures of the bronchus, crushing of the lung. At the same time, chest pains and other signs of thoracic injury (subcutaneous emphysema, severe shortness of breath, pleuropulmonary shock) come to the fore, and hemoptysis complements the clinical picture in only a third of patients. Depending on the nature of the injury, conservative measures or diagnostic thoracotomy are performed.
Cardiovascular diseases associated with pulmonary hypertension (PH) and left ventricular failure are most often complicated by hemoptysis. In the first case, the mechanism of hemoptysis is associated with rupture of arteriovenous bronchopulmonary anastomoses and small sclerotic alveolar vessels; in the second - with congestion in the pulmonary circulation system, the release of transudate and erythrocytes into the alveoli.
- Pulmonary hypertension . Hemoptysis is characteristic of all diseases accompanied by PH: mitral stenosis, congenital heart defects (septal defects, PDA, Eisenmenger complex and a number of others), left atrial myxoma. In the clinic of pulmonary hypertension, pain behind the sternum, shortness of breath, cyanosis, and swelling of the extremities predominate. Hemoptysis (mild or moderate) develops against the background of an unproductive cough.
- TELA . Hemoptysis accompanies 20-30% of cases of LA thromboembolism occurring with the development of pulmonary infarction. A typical clinical variant of myocardial pneumonia is characterized by shortness of breath, more pronounced in an upright position, stabbing pain in the lateral parts of the chest, and fever. Hemoptysis in PE has the character of blood blotches or clots on the surface of poorly coughed up sputum.
- Pulmonary edema . Cardiogenic pulmonary edema can occur in acute myocardial infarction, myocarditis, arrhythmias. In the expanded stage, frothy sputum is secreted, stained with blood in a pinkish color. Pulmonary edema is accompanied by severe suffocation, coughing fits. Cyanosis is rapidly growing, the face becomes puffy. The patient experiences a terrible fear of death, greedily catches air with his mouth. In the distance, his gurgling breath can be heard.
- Aneurysm LA . A ruptured pulmonary aneurysm leads to fatal bleeding. However, a harbinger of this formidable complication is often hemoptysis, which gradually increases over several weeks or days. It can occur either for no reason, or due to physical exertion or increased coughing.
Hereditary and congenital diseases
Genetic and congenital defects do not play a leading role in the structure of etiofactors of hemoptysis. As a rule, pulmonary hemorrhagic manifestations develop secondarily, against the background of morphological and functional changes in the lungs. Less commonly, for example, with angiodysplasia, the cause of hemoptysis is the primary inferiority of the walls of the vessels of the lungs.
- Cystic fibrosis . The respiratory form of cystic fibrosis occurs with the phenomena of chronic pneumonia, against which bronchiectasis, pneumosclerosis, cor pulmonale are formed. These factors become decisive in the pathomechanism of hemoptysis. The disease is accompanied by a persistent cough with thick sputum, shortness of breath, deformity of the chest and phalanges of the fingers. Pulmonary bleeding occurs rarely.
- Hereditary telangiectasia . Hemorrhagic syndrome is a typical manifestation of the Rendu-Weber-Osler syndrome. Hemoptysis occurs spontaneously, for no apparent reason. In addition to hemoptysis, nasal and gastric bleeding, bleeding of angiomas and telangiectasias on the mucosa of the lips, oral cavity and various parts of the skin are typical.
- Malformations of the lungs . Hypoplasia, sequestration, cysts are complicated by hemoptysis due to the development of inflammation or abscess formation. Bloody inclusions appear during periods of exacerbation against the background of coughing up purulent bronchial secretions, intoxication, and febrile condition. With a breakthrough of a pulmonary cyst in the bronchus, there is a threat of pulmonary hemorrhage, aspiration pneumonia and asphyxia.
Hemoptysis syndrome can accompany the clinic of vasculitis occurring with damage to the pulmonary vessels: Goodpasture's syndrome, Wegener's granulomatosis, allergic purpura (Schonlein-Genoch disease). Systemic vasculitis is characterized by multiple organ lesions (skin, articular, renal, pulmonary, and other syndromes), a tendency to hemorrhages. Hemoptysis is recurrent, may progress to pulmonary hemorrhage. Sometimes hemoptysis accompanies sarcoidosis, Behçet's disease, polyarteritis nodosa, and other autoimmune pathologies.
The immunocomplex mechanism presumably underlies idiopathic pulmonary hemosiderosis, characterized by recurrent alveolar hemorrhages. This factor determines the clinic of the disease - a constant dry cough, during which spitting of blood without impurities is coughed up, shortness of breath. With prolonged hemoptysis, an anemic syndrome develops (dizziness, weakness, flies before the eyes). The disease manifests itself in childhood.
Hematological disorders as causes of hemoptysis are relatively rare. In these cases, hemoptysis is caused either by the pathology of various parts of hemostasis, or by iatrogenic factors - improper prescription and use of blood-thinning drugs. Among the conditions complicated by hemoptysis, the following are considered:
- Coagulopathy. Hemoptysis can be a symptom of hemophilia, von Willebrand disease, thrombocytopenia, and more. etc. At the same time, spontaneous bleeding of various localizations (gingival, nasal, gastrointestinal, uterine), permanent bruises on the skin, hemarthroses are noted. Hemoptysis has a recurrent spontaneous course, hemoptysis often occurs.
- Leukemia . Leukemic infiltration leads to multiple hemorrhages in the lung tissue, causing the development of hemoptysis. At the same time, the clinical picture is very similar to focal pneumonia, an admixture of blood is noted in the sputum, and intense staining of the bronchial secretion with blood is less often observed. For the clinic of acute leukemia, other bleeding, fever, severe weakness, body pain, and lymphadenopathy are pathognomonic.
- Complications of anticoagulant therapy . Hemorrhagic complications are observed with an overdose of indirect and direct anticoagulants: phenidion, heparins, warfarin, rivaroxaban, etc. Microhemorrhagic manifestations include the presence of blood streaks in the sputum, the admixture of erythrocytes in the urine (hematuria), short-term nosebleeds, subconjunctival hemorrhages.
The variety of causes of hemoptysis poses serious diagnostic problems for medical specialists, which must be solved as soon as possible. Presumably, a careful study of the anamnesis, an assessment of the data of an external examination and auscultatory examination helps to determine the leading etiological factors. Primary diagnosis is carried out by therapists and pulmonologists, in the future, taking into account the cause of hemoptysis, the patient can be cured by a phthisiatrician, rheumatologist, and oncologist. To obtain objective data for hemoptysis, the following are used:
- X-ray OGK . Polypositional radiography of the lungs can detect the cause of hemoptysis in a third of cases. In this case, tuberculous infiltrates or cavities, inflammatory foci in pneumonia, focal changes in lung tumors, cysts in parasitic invasions, etc. can be detected. X-ray contrast techniques - bronchography, angiopulmonography (APG), bronchial arteriography - help to detail the nature of changes in the vascular and bronchopulmonary pattern.
- Computed tomography . CT of the lungs has a higher diagnostic accuracy compared to Rg of the chest - the source of bleeding is detected in 77% of cases (including small neoplasms, segmental atelectasis, bronchiectasis, abnormal development of the lungs). Conducting MSCT of the lungs with bolus intravenous contrasting makes it possible to additionally assess the condition of the bronchial arteries and vessels of the small circle.
- Fibrobronchoscopy . Informative for the detection of endobronchial pathology as a source of hemoptysis. Bronchoscopy allows you to simultaneously perform a number of diagnostic and therapeutic tasks: biopsy, sputum sampling, removal of a foreign body, removal of an endobronchial tumor, cauterization of a bleeding vessel.
- Blood study . To assess the degree of blood loss and the level of anemia, a general blood test is recommended to determine the level of hemoglobin and red blood cells. If infectious processes are suspected, oncohematological diseases, the study of the leukocyte formula is informative. In order to detect blood coagulation disorders, coagulogram parameters (PTI, APTT, fibrinogen), platelet count are studied. With pronounced signs of respiratory failure, the indicators of acid-base balance, the gas composition of arterial blood are determined.
- The study of bronchial secretions . Microscopically, sputum with blood impurities is examined for the presence of atypical cells, Mycobacterium tuberculosis, parasite larvae, and fungi. To identify the infectious agent, cultures of freely coughed up bronchial secretions or lavage fluids obtained during bronchoscopy are performed on nutrient media.
- Diagnostic Operations . Thoracoscopy or exploratory thoracotomy is performed in cases where the source of hemoptysis cannot be identified by any of the above methods, there is a history of lung injury, or there is a tendency to increase hemoptysis. The purpose of the intervention is intraoperative revision, identification of the source of bleeding and its elimination.
- Heart study. With the help of echocardiography, cardiac defects and secondary changes in the myocardium are detected in pulmonary hypertension. An ECG recording is necessary to confirm PE (signs of acute cor pulmonale are recorded - overload of the right ventricle).
Hemoptysis in the process of diagnosis is differentiated from bleeding from varicose veins of the esophagus, stomach. With hemoptysis, blood is coughed up with sputum, more often it has a scarlet color, an alkaline reaction. The duration of hemoptysis is from several hours to several days. Hemoptysis never happens in a dream, without expectoration, the release of blood from the respiratory tract to the outside is impossible.
When bleeding from the gastrointestinal tract, blood is released with vomit (“coffee grounds”), vomiting is profuse and short-term, the reaction of the blood is acidic, tar-like stools are characteristic. Esophageal bleeding is accompanied by belching, the secreted blood has a brown color, clots, and an unpleasant sour smell. Sometimes bleeding from the nose or gums is mistaken for hemoptysis.
Bronchoscopy for hemoptysis
Primary therapeutic measures are aimed at stopping hemoptysis and preventing its progression to pulmonary hemorrhage. If hemoptysis started at home, it is necessary to call the SMP team and not leave the patient alone until the doctors arrive. It is necessary to put the patient in bed, give him a semi-sitting position or raise the head end. It is necessary to try to calm the patient, convince him to breathe calmly, not to talk, not to force a cough. To ensure adequate access to oxygen, unbutton clothing, remove dentures, open a window, or give oxygen through a nasal catheter.
It is allowed to put an ice pack on the patient's chest or offer to swallow pieces of ice with an interval of 15-2 minutes. Of the drugs, it is acceptable to take mild tranquilizers with excessive excitement, antitussive drugs for persistent cough, antihypertensive drugs for high blood pressure, peripheral vasodilators (nitrosorbide) under the tongue. Symptomatic therapy for hemoptysis at the prehospital stage includes the introduction of a solution of aminocaproic acid, calcium chloride, tranexamic acid intravenously for hemostatic purposes, intramuscular injections of vikasol.
Until the cessation of hemoptysis is strictly prohibited:
- any physical activity
- hot drink, any meal
- drinking alcohol, smoking
- inhalations and thermal treatments
- taking expectorant and blood-thinning drugs.
Attention (this is important)!
It should be remembered that even a small single or recurring hemoptysis can be a harbinger of massive pulmonary hemorrhage. Aspiration or ingestion by the patient of part of the blood released from various parts of the respiratory tract often makes it difficult to assess the true extent of blood loss. Even a single episode of hemoptysis is a reason for immediate medical attention and a thorough comprehensive examination.