Hemoptysis

What Causes Hemoptysis?

Hemoptysis causes can be described based on the source of origin of bleeding. Blood in sputum essentially arises from the respiratory tract. This can be further sub-classified as Upper respiratory tract and Lower Respiratory. The upper respiratory tract includes the nose, pharynx, and larynx. The lower respiratory tract consists of the trachea (windpipe), bronchial tree (the air passages), and lungs. On the basis of the source, the causes for blood in cough can be categorised as below:

It is clear from the list above that hemoptysis is a very non-specific symptom that can be caused by a multitude of diseases. In India and other developing countries Tuberculosis and its sequelae (bronchiectasis, aspergilloma) are the most common cause for hemoptysis. This is good in a way because, in most cases, Tuberculosis is a benign infection that is treatable by antitubercular treatment. But it also leads to big problems for us because of the second most common cause of hemoptysis, which is Lung Cancer. It’s a deadly cancer that kills close to 70,000 in India and is the leading cause of cancer-related deaths worldwide. The endemicity of tuberculosis and its widespread prevalence leads to misdiagnosis of tuberculosis in patients with hemoptysis due to lung cancer. This leads to a delay in diagnosis of lung cancer and we all know that the only thing that can reduce the mortality of Lung cancer is early diagnosis. Awareness regarding lung cancer is a must to avoid misdiagnosis.

What are the Symptoms of Hemoptysis ?

• Coughing Up Blood: The primary symptom of hemoptysis is coughing up blood, which can vary from a few streaks of blood in sputum to more severe bleeding episodes.
• Chest Pain: Some individuals may experience chest pain, particularly if the bleeding is associated with trauma or pulmonary embolism.
• Shortness of Breath: Hemoptysis related to conditions like pulmonary embolism or lung cancer may be accompanied by shortness of breath, especially with exertion.
• Other Associated Symptoms: Depending on the underlying cause, hemoptysis may be accompanied by additional symptoms such as fever, fatigue, weight loss, or persistent cough.

Evaluation of a patient with Hemoptysis (Blood in cough)

It requires a very systematic evaluation to diagnose the underlying cause accurately and plan appropriate treatment. Let us look at how we evaluate coughing up blood step-by-step:

• 1. Medical History
  The first step in evaluating hemoptysis is obtaining a detailed medical history. This includes inquiring about the onset and duration of symptoms, frequency and severity of bleeding episodes, associated symptoms such as cough, chest pain, or shortness of breath, and any relevant past medical history, including chronic lung conditions, smoking history, or recent illnesses.
• 2. Physical Examination
  A thorough physical examination by a doctor is essential to assess the patient's overall health and identify any signs that may provide clues to the underlying cause of hemoptysis.
• 3. Diagnostic Tests
  Following the initial assessment, various diagnostic tests may be ordered to evaluate the cause of hemoptysis further:
  • Imaging Studies: Chest X-ray is typically the initial imaging modality used to assess for any obvious abnormalities such as lung masses, infiltrates, or signs of pulmonary edema. Computed tomography (CT) scan of the chest with IV contrast provides more detailed information. It is usually performed as soon as possible to evaluate for structural abnormalities and assess the blood vessels that may be causing hemoptysis.
  • Sputum Culture and Analysis: Collecting and analysing a sputum sample can help identify any infectious organisms, such as bacteria or fungi, contributing to respiratory symptoms.
  • Bronchoscopy: Bronchoscopy is a valuable diagnostic tool that allows direct visualisation of the airways and collection of samples for biopsy or culture. It can help identify sources of bleeding, such as tumours, inflammation, or vascular abnormalities, and guide further management. It also will tell us where which part of the respiratory system is the bleeding coming from.
• 4. Specialized Testing
  Depending on the clinical presentation and initial test results, additional specialized testing may be warranted, such as:
  • Lung Biopsy: A biopsy of lung tissue may be performed, either via bronchoscopy or surgical intervention, to obtain a definitive diagnosis in cases of suspected malignancy or interstitial lung disease.
  • Vascular Imaging: If vascular abnormalities are suspected, such as arteriovenous malformations (AVMs) or pulmonary hypertension, specialized imaging studies like pulmonary angiography or magnetic resonance angiography (MRA) may be indicated to evaluate the vascular anatomy and guide treatment decisions.
• 5. Treatment Planning
  Treatment of Hemoptysis is two staged and depends on the severity of hemoptyis. Hemoptysis is classified as mild ( < 30 ml), moderate 31-100 ml, severe (100-600 ml), and massive. Massive hemoptysis defined by a number of criteria, often ranging from 100 ml to more than 600 ml over 24 h with respiratory or hemodynamic compromise.
  In case of Moderate to severe or massive Hemoptysis treatment is directed towards controlling the bleeding and protecting the airways from getting drowned in blood and saving life. This may require
  • Initial Resuscitation and Protection of airways – Patient
  • Control of Bleeding by Bronchial artery embolization
  • Bronchoscopic Procedures to control bleeding
  • Emergent Surgery in cases not responding to treatment.

The aim of the treatment is to stabilise the patient and control the bleeding. Once acute control and stabilisation is achieved –The treatment can be tailored to address the underlying cause of hemoptysis. This may include:

• Antibiotics for respiratory infections
• Anticoagulation therapy for pulmonary embolism
• Chemotherapy, radiation therapy, or surgery for lung cancer
• Bronchial artery embolization or surgical intervention for vascular abnormalities
• Symptomatic management to alleviate cough, pain, or respiratory distress

In the initial treatment of hemoptysis, the primary goal is to control the emergency bleeding rather than addressing its underlying cause. At this stage, understanding the role of bronchial artery embolization (BAE) is crucial for effective management. The expertise of the Best Thoracic Surgeon in India can make a significant difference in achieving optimal outcomes.

Bronchial Artery Embolisation in Hemoptysis

Bronchial Artery Embolisation is a procedure wherein the arteries (blood vessels) that are the source of blood in cough are identified by the means of angiography. The bleeding vessels are then blocked from inside by using various materials so that the bleeding stops.

This is a very useful procedure that helps control bleeding, as bronchial arteries are the source of bleeding in 90-95% of cases. It helps convert an emergency situation into a controlled elective situation, which allows time for proper evaluation and institution of tailor-made treatment. Unfortunately, many patients, particularly those with structural lung lesions secondary to Tuberculosis sequelae like bronchiectasis and Aspergilloma (fungus ball in lungs) have a temporary control and hemoptysis usually recurs in them at a later stage. It is, therefore, imperative that the patient be evaluated by a good Thoracic Surgery team with experience in handling such cases so that surgery, if indicated, can be offered as a definitive cure. This is also important for patients with Lung Cancer, who also need evaluation and staging so that early treatment can be initiated.

Surgery for hemoptysis usually involves the removal of the portion of the lung that is the source of bleeding. This may require a segmentectomy, Lobectomy or removal of the entire lung in some cases. Advancement in thoracic surgery allows us to perform many of these procedures by minimally invasive techniques like video-assisted thoracic surgery (VATS) and robotic lung surgery, which allows the removal of the lung portion without the need for open surgery. This allows for faster recovery, less pain, less blood loss and shorter hospital stay.