Coughing Up Blood

Coughing up blood is an alarming symptom. Coughing up blood is one of the symptoms of lung cancer but usually it is due to other more common causes like bronchitis and pneumonia. Any cough in the blood warrants thorough evaluation for lung cancer.

Coughing up blood is also known as hemoptysis. The blood in hemoptysis originates from either the lungs or the bronchial tubes (the airway connecting the lungs with the lower end of the trachea). Coughing up blood originating from anywhere else is called pseudohemoptysis and vomiting out blood is known as hematemesis. Usually in a conscious person, vomited blood and coughed up blood can be easily differentiated.

Hemoptysis can range from just a mild red colored staining of the coughed up sputum to coughing up of fresh blood. The coughed up sputum or blood may contain blood clots also. Coughing up more than 200 ml of blood per day is usually considered massive hemoptysis which usually requires urgent medical and/or surgical intervention in an intensive care setting.

The most important causes of coughing up blood in the adults are bronchitis, lung cancer, pneumonia and tuberculosis (rare in developed nations). However, in children, lower respiratory tract infections and aspiration of foreign body are the most common causes. The table given below mentions the most important causes of hemoptysis. There are numerous other rare causes also.

Table 1: Causes of Coughing Up Blood

Cause

Comments

Tumors

Neoplasm in the lung or bronchial tree can cause hemoptysis. Hemoptysis in person's at risk (age > 40 yrs and/or smoker) requires thorough evaluation for presence of lung cancer.

Bronchitis

Both acute and chronic bronchitis (inflammation of the bronchi) can cause hemoptysis. It is one of the most common causes of coughing up blood.

Pneumonia

Inflammation of the lung tissue, often caused by infection. Pneumonia is also a common cause of hemoptysis.

Lung Abscess

Localized collection of pus in the lungs caused by infections is known as lung abscess.

Tuberculosis

Most important cause of hemoptysis in developing countries. In developed countries, tuberculosis is an unlikely cause for coughing up blood unless the person is immunocompromised (AIDS, anti-cancer therapy etc.) or has history of travel to a developing nation.

Lung / Airway Trauma

Injury to lung (lung contusion) or the airways (bronchi, trachea) can cause coughing of blood.

Foreign Body in Airway

Foreign body in trachea or bronchus can cause hemoptysis. This is more common in children.

Bronchiectasis

Destruction of bronchus resulting in localized dilation of bronchial tree is known as bronchiectasis.

Pulmonary Embolism

Sudden blockage of the pulmonary artery or its branch by emboli is known as pulmonary embolism. It is a rare cause of hemoptysis

Arteriovenous Malformations

AV Malformations are abnormal connections between the veins and arteries. AV Malformations in lung tissue can cause hemoptysis.

Pulmonary Aspergilloma

Mycetoma or Pulmonary Aspergilloma is a fungal infection (Aspergillus species) that grows in a lung cavity. Rare cause of hemoptysis

Idiopathic

Many times no cause for the hemoptysis is found even after thorough evaluation. Such cases are referred to as idiopathic.

General Approach to Management

Stopping the coughing up of blood and prevention of aspiration is the immediate goal of management. Further treatment is focused on the cause of the hemoptysis.

One of the most important steps in the management of coughing up blood is thoroughly evaluation for the presence of cancer in high risk individuals (old age and/or history of smoking tobacco).

Mild hemoptysis caused by non-malignant conditions is usually treated conservatively on outpatient basis. Treatment depends upon the cause of hemoptysis. For e.g. bronchitis and pneumonia is treated with antibiotics. Chest X-Ray, CT-Scan and Bronchoscopy are the main diagnostic modalities used for the evaluation of hemoptysis.

Massive hemoptysis requires immediate intensive care with hospitalization. Maintaining airway for respiration is the most important step as death is usually caused by the asphyxiation (and not blood loss). Emergency surgery might be needed depending upon the cause of the hemoptysis.


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