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Saturday, August 23, 2025

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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