Episode 38: An Approach to Hemoptysis

Welcome to MetPod, the audio podcast from the Department of Medicine at AFMC. We have had many topics where we have approached a symptom and then gone on to discuss the various causes and its management. Continuing in the same series today we shall be discussing although not so common but a very important clinical symptom and that is of hemoptysis or blood and sputum. To discuss this we have with us a very eminent respiratory physician from Amin Institute of Cardiothoracic Sciences, Colonel Rahul Diagi who is a DM in pulmonology and critical care from the prestigious Ames New Delhi. Welcome Rahul. Thank you sir. It is an honor to be here sir. So in this podcast we discuss these topics which should benefit our undergraduate students, postgraduate residents, young specialists in practice and the idea is to approach it very simplistically and then go on to discuss subtle nuances of the clinical problem. So today I will be discuss hemoptysis. I want you to define what is hemoptysis? Sir hemoptysis is basically blood which is cuffed out from below the vocal cords. It can be from the bronchi, the main trachea or the lung parankaima. If it is from above the level of the vocal cord then it will be known as spurious hemoptysis and we also have to differentiate it from pseudo hemoptysis which is just presents of a red pigment in the sputum which can occur in cases of infection with seracea. So basically any blood which is coming from below the vocal cord which is coming from the lungs or the airways that is what is actual hemoptysis. Right and in practice we often see that hemoptysis while it is quite obvious at times when it comes out in cough with the sputum. There are situations where a patient swallows his own sputum and may vomit it out. So in such situations it is very important to differentiate it from hematomysis which is blood or altered blood in vomiting. So how do you differentiate? Sir it is a very important question and it is very difficult even at like when you have seen patients for 10-15 years also then sometimes also you can get confused between hemoptysis and hematomysis. But the things which give us a clue are that if a patient has predominantly respiratory symptoms like he is having cough for 2-3 weeks and then he presents with blood for coming from the mouth that is most likely to be hemoptysis while if he has gastric symptoms like he has retching and vomiting then it is more likely to be hematomysis. Also hemoptysis will be bright red in colour while hematomesis due to presence of acid in the stomach is altered blood which will be there. The hemoptysis will have some amount of frothing which will be there due to it coming from the lungs which will not be present in cases of hematomesis. Also if you check in the lab the hemoptysis will be slightly alkaline in pH while hematomesis will be acidic in pH. So these are the general things how we can differentiate. Right so like you mentioned in the beginning that often in some situations at least it may become a problem to differentiate. So the clinical setting would matter and of course we can evaluate the patient further to differentiate. So coming back to hemoptysis what are the common causes of hemoptysis? So when I was in college sir and we were doing a pathology they used to tell us that the three most common causes of hemoptysis in India are tuberculosis, tuberculosis and tuberculosis. From that time things have changed slightly tuberculosis still remains the most important cause of hemoptysis in India but then there are a lot of cases of bronchitis which may be mostly post tuberculosis but due to other causes also which is known to cause. Then cases of community acquired pneumonia or lung abscess are known to cause hemoptysis. Lung cancer is becoming very common cause of hemoptysis. Then there are some uncommon causes like fungal infections causing hemoptysis especially after covid sir we saw a lot of cases of tuber microsus. So there the patient developed a lot of cases had massive hemoptysis also a lot of patient lost their life due to massive hemoptysis. Other than that cases of diffuse alveolar hemorrhage can occur associated with some connective tissue disorders or vasculitis. Proma can be a cause of hemoptysis which will be obvious from the history of the patient if he gives history of trauma. And some drugs also like penicillamine and phenytoin have been indicated in causes of hemoptysis. So commonly these will be the causes sir. Right and of course if there is a cavitary lesion and there is an artery there which leads sometimes it comes with a very massive hemoptysis as well. So there are situations where it's canty or it could be a very large amount of blood. So looking at a patient how does the student make out what is the severity of hemoptysis? So sir severity of hemoptysis as you told can vary from very streaking of sputum with blood to a patient who's coughing out 100-150 ml at fungal. The thing is that any patient who gets admitted even with mild hemoptysis is a candidate to develop massive hemoptysis that is the first thing which everyone who's managing these patients should keep in mind. Massive hemoptysis has been defined variously by various authors ranging from 200 ml per 24 hours to up to 1 liter per 24 hours. But these days the terminology is shifting to more of a life-threatening hemoptysis wherein any hemoptysis which is causing respiratory failure is defined as a life-threatening hemoptysis or a massive hemoptysis because the conductive tubes in our lungs are only 150 ml. So it makes sense that any 150 ml of blood can also block the tubes and lead to asphyxiation of the patient. Usually these patients will not exsanguinate because before that they will go into respiratory failure. So we should be looking more at their oxygenation in terms of when we define whether this is a life-threatening hemoptysis or not because they may maintain their hemodynamics even when they are having a massive hemoptysis. So what I usually consider is that any patient who has had more than 50 ml of bleeding in 24 hours is a candidate who should be evaluated quickly and treated quickly before he has that massive bout which can be life-threatening. Okay so one is of course most important to suspect it and like patients may come with a history and at that time when he comes to you may not be having hemoptysis. Thankfully now we have phones where patients come with images of their sputum and we are able to make out. So once the patient comes like this what is the initial management? So initially we have to understand what is the most likely etiology of hemoptysis like patients who are having post TB bronchitisis or any cause of bronchitisis. If they come with mild hemoptysis it is most likely due to some secondary infections or maybe a relapse of the TB. So we have to work them up on those lines. Any patient who comes with a history of like 2-3 months history of curve followed by some low-grade fever, weight loss, anorexia in India most likely cause will be TB. Now patients who are smoking they come with history of alteration in their curve and presence of mild hemoptysis also may herald lung cancer. So it is not the quantity of hemoptysis which decides the severity of underlying diagnosis because patient may come with massive hemoptysis and have an underlying TB which is both treatable and curable. While a patient with streaky hemoptysis may end up having CLN which is obviously survival is limited when the patient is diagnosed as a lung cancer. So every hemoptysis is to be taken seriously that is why even Achishan says that when a patient comes with cough you have to ask specifically whether the patient is having hemoptysis or not. That negative history has to be taken with all patients who are coming with cough. It is such an important symptom that it has to be always asked even if the patient does not bring it out himself. Right and in fact one of the causes which I can think of now which can turn out to be very sinister is pulmonary embolism. Yes. So minor embolism may cause a expectoration with sputum having blood and then subsequently lead up to a massive embolism. Hemoptysis is in fact one of the three most common symptoms of pulmonary embolism the other two being dyspnea and tachycardia. Okay. So now after having clinically evaluated the patient what is the role of imaging in such? So imaging first of all we will start with the basic chest radiography. In chest radiography usually it will demarcate the side of the lesion but up to 40% of the cases it may not be able to tell us where the lesion is which is causing hemoptysis. So there comes the role of CT scan. So with the CT scan in up to 80% of the patients the lesion can be demarcated. If we combine a CT scan and a bronchoscopy we can diagnose correctly more than 90% of the cases where the bleeding is coming from. But there are still some patients who will not be diagnosed despite all modalities being used. Like we had a patient recently who was having very significant hemoptysis not massive but it was like five ml per episode multiple episodes in a day they showed videos photos also as usually patients come with photos these days. But when we started evaluating her we did an x-ray which was normal a CT which was normal then we did a bronchoscopy for us thinking it might be a delphi lesion which is a bronchial artery which is submucosal which can present with such a representation but that bronchoscopy was also normal. We did a rbc scintygraphy for her also that was also normal. But usually when all the imaging is normal these patients tend to have good prognosis because in this patient also by the time we finished our evaluation she had already improved and the hemoptysis had stopped. So these patients will just require a follow-up to see that they do not recur. So this can happen in 30% of cases who have hemoptysis. Right so what I understand is that if a patient comes with hemoptysis we should try all out to find a lesion and which may be if we are lucky picked up on just an x-ray or CT scan but otherwise we also need to do a bronchoscopy or like you said if nothing is seen then we do a nuclear imaging in form of rbc scintygraphy. So the idea is to pick up that source of bleeding in the in the air base. Now moving on treatment wise of course the first thing would be treatment of the underlying cause but if hemoptysis itself is a problem what are the other treatment modalities? So sir in patients who are having mild to moderate hemoptysis usually IV tranexamic acid or nebulized tranexamic acid will take care of the bleed. The there are studies which have shown that IV and nebulized tranexamic acid have equal efficacy in management of hemoptysis. The other important things which need to be considered and remembered while managing a patient of hemoptysis are firstly we should find out what is the side of the lesion is it the right side lesion or the left side lesion usually that will be made out from the x-ray if we are not able to make it out from the x-ray sometimes the patient will also tell us that they are having a gurgling feeling on the right side or they are having pain on the right side that can give us an indication. So that patient should be nursed on the side of the lesion the side of the lesion should be kept down so that the blood does not flood the other lung so at least one lung is functional. Secondly after nursing him on the side of the lesion we should also give him some cuff suppressants because what will happen is that if the patient keeps on coughing violently it will cause dislodgement of the clot whatever is forming and the hemoptysis suddenly a massive hemoptysis can occur. So make the patient calm reassure him reduce his anxiety give him cuff suppressant nurse him on the side of the lesion. These are the general measures which can be followed in patients who have mild to moderate hemoptysis. If the patient on the other hand is having massive hemoptysis he will require securing his airway we go as per the protocol according to the airway breathing and circulation we have to maintain the airway which becomes very difficult when a patient is having massive hemoptysis. So you need to immediately intubate these patients especially if they are going into respiratory failure due to massive hemoptysis. So you should choose the biggest possible tube which is available preferably more than 8 to 8.5 size tube should be used so that you can suction out the blood also. Then the second thing is that if you know the side of the lesion then selective intubation of the other bronchus should be done so that you can at least ventilate one lung effectively. The other lung we allow the clot to form before we go ahead. If a bronchoscope is available in the ICU do a bronchoscopy check where the bleeding is coming from and do a balloon dilatation proximal to the bleed so that the clot forms distal to that bronchus and which can be removed subsequently by using various methods. So based on what is available these are the various things which need to be done. Also at the same time once the patient is stabilized we need to look at doing a pulmonary angiography for them so that we can assess where the bleed is coming from and if the site of bleed is localized or we find that there are some hypertrophied arteries there are some tortuous arteries or there is a blush which is forming on contrast with there we can do a bronchial artery embolization to stop the bleed. Right so as a respiratory physician you can intervene with bronchoscope and at least prevent further bleeding or at least let the blood not flood the normal lung and an interventional radiologist can embolize and allow the artery to be blocked and so that it doesn't bleed again. So right now what about role of surgery in hemoptysis once if these things don't work? So initially sir the when hemoptysis was managed only conservatively the mortality in hemoptysis used to be around 75 percent that was early 19th century then as the treatment modality is advanced with surgery only the mortality reduced to around 25 percent now with bronchial artery embolization and bronchoscopic techniques the mortality has reduced to around 13 percent. Now the role of surgery is limited only to the patients where the modalities like bronchoscopic modalities are not working because usually these patients can be managed with this but if a patient has a aspergilloma which is localized or a bronchocytosis which is localized which is causing bleeding again and again these are the patients who should undergo surgery. Surgery may not be an option in an emergency situation so we have to pre-empt this that this patient is likely to have massive hemoptysis and refer the patient for surgery at a correct time so that before he goes into that massive hemoptysis stage surgery can be done for a localized disease surgical options for hemoptysis do exist. But I think most of the role of surgeons has been taken away by intervention really also you know that we can embolize these vessels right. So so most important would be to treat the cause and of course if hemoptysis alone is a problem along with treatment of the cause we also need to address the bleeding part which we have discussed. Now if a patient comes with an episode of hemoptysis and we have looked for and managed what is the follow-up recommended in such case? So the follow-up also will depend on what was the underlying etiology we found. So if a patient has tuberculosis then obviously they will receive anti tubercular therapy if it is a case of post tuberculosis bronchocytosis which is the also a very common cause of hemoptysis in India. These patients we will have to inform them that any hemoptysis which occurs even when mild they have to report immediately so that they can be evaluated and appropriate treatment can be started before it turns into a massive problem. If we have found that the patient has aspergilloma then these patients can be referred for surgery at the correct time. If the patient is found to have chronic pulmonary aspergillosis in that case antifungals can be started. So these patients main follow-up will be that we have to inform them that any hemoptysis if it occurs again it is significant and they should immediately come and report in case of any hemoptysis. So hemoptysis like any other situation where there is bleeding in any of body fluids is a very alarming symptom for patients. So I think the students must understand that it has to be taken seriously and patient of course would be panicking but we also understand there are some very minor issues which can cause or something very sinister. So all our approach should be to diagnose these conditions. So what is the message that you want to give to our students about sort of this level of seriousness or steps that the key words that you would require them to remember when they see a patient with hemoptysis or say right an answer for hemoptysis. So sir hemoptysis is one of the most serious emergencies in pulmonary medicine and it can cause severe panic for the patient for the relatives even for the ward staff and the doctors because sometimes the patients will bleed torrentially. So until and unless you are ready mentally and with regular drills to manage that situation, you will be found blinded. So I suggest that everyone forms a mental picture of what they are going to do if a patient comes with massive hemoptysis that is one. Secondly what I will also want to convey is that massive hemoptysis cases although they are very challenging cases to treat they are very rewarding also because recently we had a patient, young male who was diagnosed as putum positive phase TB. He developed massive hemoptysis. He developed respiratory failure due to massive hemoptysis. We had to intubate him and he was on 100% FIO too. Then we asked our IR colleagues, they did a BAE for him and after 48 to 72 hours we were able to take him off. So a young patient now he will survive the day treaty and he will have a full complete life. So this is very common in India because mostly patients with TB will be young and these patients will come with massive hemoptysis. So if you are able to tide over that episode, they are not very difficult to treat and the results will be really rewarding. So do not panic, do prepare first what you want to do once you are clear do what is required to be done and you will be happy with the result which you achieve. Especially when a cause is benign, if the patient does not die just of drowning in his own blood so to speak, I think he have a better future and it can be totally treated and very heartening results. So thank you very much Raul. It was extremely simplistic and I am sure very enlightening for all our students when they listen and in a very short time we have discussed the topic which is so relevant not just for their exams as a short note but also for clinical practice where such patients often land up. So thank you once again for sparing your time and we look forward to having interaction with you again for more such topics. Thank you sir for the opportunity. (upbeat music)