Blood in Sputum, Hemoptysis, Causes, Investigations and Treatment

HEMOPTYSIS (Blood in Sputum)
The expectoration of blood or blood-stained sputum is known as hemoptysis. The source of blood should be below the vocal cords. The lungs are supplied with dual circulation; pulmonary arteries arise from the right ventricle and supply pulmonary parenchyma while the bronchial arteries arise from the aorta or intercostals arteries and supply airways, blood vessels, hila and visceral pleura. The bronchial circulation is only 1-2% of total pulmonary blood flow but is a more common source of bleeding. Bronchial blood flow dramatically increases in inflammation.
Causes of Hemoptysis (Blood in Sputum)-
1. Blood From airways in>

• Bronchitis
• Bronchiectasis
• Bronchial adenoma
• Bronchogenic carcinoma

2. From pulmonary vasculature

• Mitral stenosis
• Pulmonary infarction
• Left ventricular failure
• A-V malformation

3. From pulmonary parenchyma

• Pneumonia
• Bleeding disorders
• Autoimmune diseases e.g. Goodpasture’s syndrome and Wegner’s syndrome

4. Massive hemoptysis: more than 200-600 ml of blood in 24 hours. Occurs in bronchiectasis, tuberculosis, pulmonary infarction.

What Investigations should be done in a suspected case of hemoptysis

• X-ray chest: for tuberculosis, bronchogenic carcinoma, pulmonary infarction.
• Blood CP & Platelets: to look for haemoglobin level and platelet count; as thrombocytopenia can also cause hemoptysis.
• Bleeding time, clotting time & prothrombin time
• Bronchoscopy: in high-risk persons for carcinoma of the lung such as chronic smokers.
• High-resolution CT: to diagnose bronchiectasis and arterio-venous malformations.

DIAGNOSIS OF HEMOPYTISIS (blood in Sputum)  AND HEMATEMESIS (Blood in vomiting)

Hemoptysis	Hematemesis
Cough precedes haemorrhage	Nausea and vomiting precede haemorrhage
Blood frothy from admixture with air	Generally airless
Sputum bright red in colour and may be stained for days	Blood often altered in colour by admixture with gastric contents, usually dark red or brown
History suggests respiratory disease	Previous history of indigestion
Confirmed by bronchoscopy	Confirmed by gastroscopy

Treatment Of Hemoptysis (blood in Sputum)

1. Treatment of the cause
2. Resuscitation

• The airway must be protected, ventilation ensured.
• Circulation is maintained with blood or plasma expanders.

3. Bronchoscopy:

• uncontrolled bleeding needs flexible or rigid bronchoscopy and surgical consultation.

4. Angiography to localize the site of bleeding and to embolize the source (bronchial artery) that is effective in 85% of cases.
5. Symptomatic management Reassurance
6. Sedation with Tab. Diazepam (Valium) 5mg to reduce fear.
7. Antibiotics to prevent secondary infection Clotting agent e.g. Tranexamic acid (Transamin) - Caps 250mg / 500mg 3-4 times daily Inj. 250mg 2-4 amps daily IV or IM.