What is Hemoptysis (Coughing up Blood) - Causes, and Signs of an Emergency

Coughing up blood is called hemoptysis (pronounced "he-MOP-tih-sis"). Imagine coughing out blood every now and then- even the thought of it is scary. But if and when it happens, it is a concerning symptom that should not be ignored. It is important to understand what might be causing it, what to do if it happens, and what treatments are available. 

Introduction

Coughing up blood, or hemoptysis, is an alarming symptom that should not be ignored. It involves spitting up blood or bloody mucus from the lower respiratory tract, which includes the lungs and the throat. It may be a sign of an underlying condition and should be evaluated by a doctor. Hemoptysis often can be a 'lucky' symptom, allowing diagnosis of a small lung cancer or bronchial adenoma. Many patients present to us in our clinic with this complaint. Typically, it starts with just a "streak or tinge of red" in the sputum, wherein it's more phlegm and less blood. Gradually, the quantity of blood starts increasing to maybe a teaspoon or tablespoon. Often, patients cough up massive amounts of blood (100-200ml ) with every bout of cough. The frequency of such episodes may also increase with time.

What causes blood in the cough?

While hemoptysis is a tell-tale sign of lung cancer, it is more often due to a benign cause. It can be caused by a number of conditions, including infections and lung diseases like emphysema and bronchiectasis. It can also be caused by trauma to the lungs, such as a blunt force injury or a foreign object lodged in the lungs.

Infections are the most common cause of hemoptysis. These include bacterial, viral, parasitic (hydatid cysts), and fungal infections. A special kind of fungal infection called 'Aspergilloma' is often seen in the Indian scenario- a fungal ball may be found inside a cavity in the lung. 

Tuberculosis and pneumonia are the most common causes of infectious hemoptysis. Even after tuberculosis has been treated and cured, it may still leave behind its sequelae in the lungs. These can cause blood in cough many days, months, or even years after the completion of the treatment of tuberculosis.

Other causes of hemoptysis include heart failure, lung cancer, pulmonary embolism, and pulmonary hypertension.

Read more- Hemoptysis: Know the Underlying Causes of Coughing up Blood

What to do if you notice blood in your cough?

Although just the presence of blood in a cough is a reason enough to see a doctor, coughing out massive amounts of blood is an emergency and should not be ignored at any cost. Losing too much blood at once may be life-threatening not only because of loss of blood from the body but also because of the risk of drowning in your own blood when it fills up your airways, leading to suffocation. You need to visit an ER immediately if you're coughing up large amounts of blood.

In the meantime, there are certain measures that you can take to help relieve the symptoms. If you cough up a lot of blood, it is important to remain calm and minimize the amount of coughing. You should avoid activities that could cause further coughing, such as strenuous activity or smoking. Additionally, take deep, slow breaths to help increase oxygen levels in your lungs.

Diagnostic tests for hemoptysis

Your doctor will try to ascertain the exact reason as to why there is blood in your cough, because there can be many reasons for this. They will order a series of tests to determine the underlying cause. These tests include a chest X-ray, a sputum culture, a bronchoscopy, and a CT scan. 

• A chest X-ray can help your doctor evaluate the size and shape of your lungs and detect any abnormalities. 
• A sputum culture is a test to check for bacteria or fungi in your sputum, which can indicate an infection. 
• Bronchoscopy is a procedure where a small camera is inserted into your airways to evaluate for abnormalities. 
• A CT scan can helps doctors detect tumours, fungal balls or other gross abnormalities in your lungs.

Treatment options for coughing up blood

The treatment for hemoptysis will depend on the underlying cause. But while the doctors look for the cause, they may start some treatment for blood loss related to coughing up blood, which may include:

1. Medicines- They are used to stop bleeding related to severe blood loss (like tranexamic acid).

2. Bronchoscopy- To remove clots in your airways. They may use one of these methods or a combination to see if they can control the bleeding bronchoscopically:

• Cold saline lavage
• Topical vasoconstrictor agents
• Balloon tamponade
• Laser photocoagulation
• Argon plasma coagulation
• Electrocautery 

3. Bronchial Artery Embolization (BAE)- This is used to stop blood flow in blood vessels causing the bleeding. BAE is a procedure done by intervention radiologists where they block the culprit blood vessels (bronchial arteries) feeding the area of the lung, which is the source of bleeding. If BAE is successful, you may get rid of the bleeding temporarily.

4. Blood transfusion- To replace the lost blood if it is a lot and has caused a drop in haemoglobin. Once a cause is found, your doctor will address it. Treatments may include:

• Antibiotics: If pneumonia or tuberculosis is the culprit.
• Steroids: If inflammation is causing your condition.
• Surgery: If a malignant (cancerous) tumor or a gross lung cavity is causing your condition. Sometimes, you may not respond to medicines and repeated BAEs may also fail. In such situation also you may be referred for a surgery. The cause here is usually structural damage in some part of the lung or some other parenchymal abnormality, which is the source of the recurrent bleeding. The goal here is source control, which means removing the damaged part of the lung. This is where a thoracic (chest) surgeon gets involved. They will evaluate your CT scans, identify the damaged portion of the lung, and advise surgical removal of that part.

Surgery for Coughing Up Blood

In some cases, surgery may be necessary to treat hemoptysis. Surgery is reserved for cases of persistent or recurrent hemoptysis that cannot be controlled by non-surgical treatment and in whom the lesions could be anatomically localized and confirmed by CT or bronchoscopy.

Surgery can involve the removal of the tumour or other affected tissue, or it may involve using a stent or other device to help keep the airways open.

Depending on the size and damage on the tumour, the following types of surgeries may be offered:

• Wedge Resection – It is a non-anatomical resection of a small part of the lung
• Segmentectomy– Removal of one or a combination of broncho-pulmonary segments
• Lobectomy – Resection of one out of the three lobes on the right side or one out of the two lobes on the left side
• Bilobectomy– It is the removal of two lobes together
• Pneumonectomy– Complete removal of one lung