Coughing up blood (blood in phlegm)

Coughing Up Blood (Hemoptysis)

Introduction

Hemoptysis is defined as coughing up blood or blood-stained sputum originating from the lungs or bronchi. It must be distinguished from:

Hematemesis: Vomiting blood from the gastrointestinal tract.
Epistaxis/postnasal bleed: Blood trickling from the nose into the throat.

Hemoptysis is classified as:

Mild: <30 mL/day, usually self-limiting.
Moderate: 30–200 mL/day.
Massive: >200–600 mL/day — life-threatening due to airway compromise and blood loss.

Pathophysiology

Most cases arise from bleeding of the bronchial arteries (systemic circulation, high pressure), less often from pulmonary arteries. Causes include:

Inflammation/infection → vessel erosion.
Neoplasm → friable tumor vessels.
Vascular malformations.
Pulmonary infarction from embolism.

Causes of Hemoptysis

1. Respiratory Infections

Acute bronchitis.
Pneumonia.
Tuberculosis.
Lung abscess.
Bronchiectasis.

2. Malignancy

Bronchogenic carcinoma (lung cancer).
Metastatic tumors to lung.

3. Vascular Causes

Pulmonary embolism with infarction.
Arteriovenous malformations.
Pulmonary hypertension.

4. Cardiac Causes

Mitral stenosis (pulmonary venous hypertension).
Left ventricular failure.

5. Autoimmune/Inflammatory

Wegener’s granulomatosis (Granulomatosis with polyangiitis).
Goodpasture’s syndrome.
Systemic lupus erythematosus.

6. Trauma and Iatrogenic

Airway trauma (intubation, bronchoscopy).
Chest injury.
Anticoagulant therapy (warfarin, heparin, DOACs).

7. Miscellaneous

Fungal infections (aspergilloma).
Coagulopathies.
Idiopathic hemoptysis.

Clinical Features

Hemoptysis: Bright red, frothy, alkaline pH, mixed with sputum.
Associated symptoms depend on cause:
- Fever, cough, sputum (pneumonia, TB).
- Chronic cough, weight loss, night sweats (TB, cancer).
- Dyspnea, chest pain (PE, pneumonia).
- Wheeze, recurrent infection (bronchiectasis).
- Orthopnea, palpitations (mitral stenosis, heart failure).

Differential Diagnosis (Mimics)

Hematemesis (GI bleed): dark, coffee-ground, acidic, nausea.
Epistaxis/postnasal bleed: blood without cough.

Diagnostic Approach

1. History

Quantity, duration of bleeding.
Associated systemic symptoms (fever, weight loss, chest pain).
Past TB, smoking history, malignancy risk.
Medications (anticoagulants, antiplatelets).

2. Examination

Vitals: hemodynamic stability, hypoxia.
Chest exam: crackles, bronchial breathing, wheezes.
Signs of heart disease (murmurs, edema).
ENT exam to rule out upper airway source.

3. Investigations

Bedside

Pulse oximetry.
Arterial blood gases if severe.

Laboratory

CBC: anemia, leukocytosis.
Coagulation profile (INR, aPTT).
Renal and liver function tests.
Sputum: AFB (TB), cytology (cancer).

Imaging

Chest X-ray: Infiltrates, cavitation, mass, effusion.
CT chest with contrast: Better for tumors, bronchiectasis, embolism.
Bronchoscopy: Localize bleeding site, therapeutic interventions.
Echocardiogram: Cardiac causes (mitral stenosis, LV failure).

Management and Treatment

A. General Principles

Assess severity (mild vs massive).
Maintain airway and oxygenation.
Position bleeding lung downwards (lateral decubitus) to protect contralateral lung.
IV access, resuscitation, transfusion if needed.

B. Medical Management

1. Supportive Therapy

Oxygen: Nasal cannula 2–6 L/min or mask.
IV fluids: To maintain perfusion.
Blood transfusion if significant anemia/bleeding.

2. Specific Therapy Based on Cause

Infections:
- Community-acquired pneumonia:
  - Amoxicillin 1 g orally three times daily for 5–7 days, or
  - Ceftriaxone 1–2 g IV daily + Azithromycin 500 mg daily for hospitalized cases.
- Tuberculosis:
  - Isoniazid 5 mg/kg (max 300 mg) daily,
  - Rifampicin 10 mg/kg (max 600 mg) daily,
  - Pyrazinamide 25 mg/kg daily,
  - Ethambutol 15 mg/kg daily (6-month regimen under DOTS).
- Lung abscess: Clindamycin 600 mg IV every 8 h, then 300 mg orally every 6 h × 4–6 weeks.
Bronchiectasis:
- Chest physiotherapy, airway clearance.
- Amoxicillin–clavulanate 875/125 mg orally twice daily for 10–14 days in acute infection.
- Long-term macrolide (azithromycin 250 mg three times weekly) for recurrent cases.
Pulmonary embolism:
- Enoxaparin 1 mg/kg SC every 12 h or Apixaban 10 mg orally twice daily × 7 days then 5 mg BID.
Heart failure / Mitral stenosis:
- Furosemide 20–40 mg IV, titrate to effect.
- Treat underlying valve disease (surgery if indicated).
Autoimmune (Goodpasture’s, vasculitis):
- High-dose corticosteroids (Prednisone 1 mg/kg/day orally).
- Immunosuppressants (Cyclophosphamide 2 mg/kg/day orally).
- Plasmapheresis if severe alveolar hemorrhage.
Coagulopathy / Anticoagulant overdose:
- Stop anticoagulant.
- Vitamin K 5–10 mg IV slowly.
- Protamine sulfate 1 mg per 100 units of heparin (for heparin reversal).
- Prothrombin complex concentrate or FFP for warfarin reversal.

C. Interventional and Surgical Treatment

Bronchoscopy:
- Localize bleeding site.
- Ice saline lavage, adrenaline instillation, argon plasma coagulation.
Bronchial artery embolization (BAE):
- Endovascular procedure, first-line for massive or recurrent hemoptysis.
Surgery:
- Lobectomy or pneumonectomy for localized, uncontrolled bleeding (e.g., destroyed lung from TB, localized cancer).

Complications

Airway obstruction → asphyxiation.
Hemorrhagic shock.
Aspiration of blood into unaffected lung → secondary pneumonia.
Chronic anemia in recurrent small-volume hemoptysis.
Death if massive bleeding untreated.

Prognosis

Mild hemoptysis: Usually benign, resolves with treatment of infection.
Chronic lung disease (bronchiectasis, TB, cancer): Risk of recurrence.
Massive hemoptysis: High mortality if not treated promptly, but survival improves with bronchial artery embolization and surgery.

Patient Education

Report any new or recurrent blood in sputum immediately.
Adhere to treatment for infections (complete antibiotics/TB regimen).
Quit smoking — reduces risk of lung cancer and COPD.
Vaccination: influenza and pneumococcal vaccines to prevent pneumonia.
Avoid self-medicating with aspirin/NSAIDs if prone to bleeding.

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