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Saturday, August 23, 2025

Blood in phlegm


Blood in Phlegm (Hemoptysis)

Introduction

Hemoptysis is the expectoration (coughing up) of blood originating from the lower respiratory tract (lungs, bronchi, trachea).

  • Mild cases: small streaks of blood with phlegm during infection.

  • Severe cases: massive hemoptysis (>200–600 mL in 24 h), a life-threatening emergency due to risk of asphyxiation and shock.

Pathophysiology

  • The lungs receive blood supply from the pulmonary arteries (low pressure) and the bronchial arteries (high pressure).

  • Most significant hemoptysis arises from bronchial arteries due to their higher pressure.

  • Causes include:

    • Infection/inflammation damaging mucosa.

    • Neoplasm eroding blood vessels.

    • Vascular malformations.

Causes of Blood in Phlegm

1. Infectious Causes

  • Acute bronchitis.

  • Pneumonia.

  • Tuberculosis (TB).

  • Lung abscess.

  • Fungal infections (Aspergillosis).

2. Neoplastic Causes

  • Lung cancer (bronchogenic carcinoma).

  • Bronchial adenomas.

  • Metastatic lung tumors.

3. Vascular Causes

  • Pulmonary embolism (PE).

  • Pulmonary hypertension.

  • Arteriovenous malformations.

  • Mitral stenosis (raised pulmonary venous pressure).

4. Airway / Trauma Causes

  • Iatrogenic (bronchoscopy, biopsy).

  • Foreign body aspiration.

  • Chest trauma.

5. Other Causes

  • Autoimmune: Granulomatosis with polyangiitis (Wegener’s), Goodpasture’s syndrome.

  • Coagulopathies, anticoagulant therapy.

  • Idiopathic (no cause found).

Clinical Features

  • Cough with blood-streaked sputum or pure blood.

  • May be bright red (fresh) or rust-colored (old blood).

  • Associated symptoms depend on cause:

    • Fever, productive cough, chest pain → infection.

    • Weight loss, chronic cough, smoker → lung cancer.

    • Night sweats, weight loss, chronic cough → TB.

    • Sudden chest pain, dyspnea, hemoptysis → pulmonary embolism.

    • Hematuria, systemic features → vasculitis, autoimmune disease.

 Important to distinguish hemoptysis from:

  • Hematemesis (vomiting blood from GI tract).

  • Epistaxis (nosebleed dripping into throat).

Diagnostic Approach

1. History

  • Onset, volume, duration.

  • Associated symptoms: fever, weight loss, chest pain, dyspnea.

  • Past medical history: TB, cancer, heart disease.

  • Smoking, occupational exposures.

  • Drug history: anticoagulants.

2. Examination

  • General: vitals, anemia, clubbing, cyanosis.

  • Chest: crackles, wheezes, bronchial breathing.

  • Cardiac: murmurs (mitral stenosis).

3. Investigations

  • Blood tests: CBC (anemia, infection), coagulation profile, renal/liver function.

  • Sputum tests: Culture, AFB smear/culture (for TB), cytology (cancer).

  • Chest X-ray: Pneumonia, TB, mass, abscess.

  • CT chest (HRCT): More detailed lung pathology.

  • Bronchoscopy: Identify and control bleeding source, biopsy if tumor suspected.

  • Echocardiogram: Cardiac causes (mitral stenosis, heart failure).

  • Autoimmune tests: ANA, ANCA, anti-GBM antibodies if vasculitis suspected.

Management and Treatment

Treatment depends on volume of bleeding and underlying cause.

A. Emergency Management (Massive Hemoptysis)

  • Airway protection: Position patient with bleeding lung downwards.

  • Oxygen therapy, possible intubation.

  • IV access, fluid resuscitation, blood transfusion if needed.

  • Urgent bronchoscopy for localization and hemostasis.

  • Interventional radiology: bronchial artery embolization.

  • Surgery (lobectomy/pneumonectomy) in refractory cases.

B. Medical Treatment by Cause

1. Infections

  • Bronchitis: Supportive, antibiotics if bacterial.

    • Amoxicillin 500 mg orally every 8 h × 7 days.

  • Pneumonia:

    • Amoxicillin 1 g orally three times daily × 5–7 days.

    • Severe: Ceftriaxone 1–2 g IV daily + Azithromycin 500 mg daily.

  • Tuberculosis:

    • Standard 6-month regimen: Isoniazid + Rifampicin + Pyrazinamide + Ethambutol for 2 months, then Isoniazid + Rifampicin for 4 months.

  • Lung abscess:

    • Clindamycin 600 mg IV every 8 h, then 300 mg orally every 6 h × 3–6 weeks.

2. Malignancy

  • Surgery, chemotherapy, or radiotherapy depending on stage.

  • Endobronchial therapies (laser, stenting) for bleeding tumors.

3. Pulmonary Embolism

  • Oxygen, analgesia.

  • Anticoagulation: Enoxaparin 1 mg/kg SC every 12 h, then switch to Warfarin or Apixaban.

  • Thrombolysis (Alteplase) if massive PE with shock.

4. Autoimmune Vasculitis / Goodpasture’s

  • High-dose corticosteroids (Prednisone 1 mg/kg/day).

  • Cyclophosphamide 1–2 mg/kg/day orally.

  • Plasmapheresis in Goodpasture’s.

5. Anticoagulant-Related Bleeding

  • Stop anticoagulant.

  • Reversal: Vitamin K 5–10 mg IV (for warfarin).

  • Protamine sulfate (for heparin).

  • Idarucizumab (for dabigatran).

Complications

  • Aspiration and asphyxiation.

  • Severe anemia, hypovolemic shock.

  • Recurrent infections.

  • Missed underlying cancer or TB → delayed treatment.

Prognosis

  • Mild, infection-related cases: Good prognosis.

  • Chronic diseases (TB, cancer, autoimmune): Depends on early detection and treatment.

  • Massive hemoptysis: High mortality unless managed urgently.

Patient Education

  • Any new, recurrent, or large-volume blood in sputum requires urgent medical review.

  • Stop smoking to reduce risk of lung cancer and chronic bronchitis.

  • Complete antibiotics for infections.

  • Regular follow-up for chronic lung conditions.

  • Seek immediate help if hemoptysis is massive, associated with chest pain, shortness of breath, or weight loss.




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