Hemoptysis causes and how to treat. Hemoptysis: causes, diagnosis and treatment. Initial treatment measures: Stabilization of the patient's condition

Hemoptysis is the discharge from the lungs and bronchi of sputum mixed with blood, blood streaks or blood-stained spittle. This symptom can occur with various diseases.

Causes

Hemoptysis can occur due to various reasons. Most often, this symptom is observed in the following diseases and conditions:

• infectious lung diseases such as pneumonia, lung abscess, tuberculosis, bronchiectasis, aspergillosis and others;
• malignant tumor diseases (for example, lung cancer);
• diseases of the cardiovascular system leading to the development of pulmonary edema and pulmonary embolism;
• chest injuries;
• systemic idiopathic diseases (idiopathic pulmonary hemosiderosis, Wegener's granulomatosis, Goodpasture's syndrome, etc.).

Symptoms of hemoptysis

With hemoptysis, the following symptoms may develop:

• the patient's condition may be quite satisfactory;
• blood impurities in sputum can have different colors and look different;
• if the sputum is rust-colored, this is usually due to the decomposition of hemoglobin in the lungs (this symptom is often observed with pneumonia);
• in some diseases, sputum may have the color and consistency of raspberry or blackcurrant jelly (such sputum, as a rule, indicates the breakdown of lung tissue);
• with hemoptysis, sputum may be uniformly colored pink color and have a foamy structure.

Diagnostics

At the first stage, the doctor analyzes the patient’s complaints and collects an anamnesis of the disease. Hemoptysis can be determined visually (the presence of blood in the sputum).

The main task of diagnosis for hemoptysis is to determine the disease that caused this symptom. For these purposes, the following diagnostic methods can be used:

• General examination of the patient. The doctor examines the skin, chest, and listens to the lungs using a phonendoscope.
• General blood analysis . In some cases, anemia is detected.
• General sputum analysis. In particular, sputum is analyzed for the presence of pathogenic microflora and its sensitivity to antibiotics.
• X-ray of the chest organs.
• Computed tomography of the chest organs.
• Bronchoscopy - examination of the bronchi using a bronchoscope. Often this examination helps determine the source of blood discharge.
• Other research methods (at the discretion of the doctor).

Patient Actions

Detection of blood in coughed up sputum is a reason to consult a doctor as soon as possible. The sooner you contact a specialist, the greater the chances of successfully treating the underlying disease and reducing the risks of complications.

Treatment of hemoptysis

Treatment for hemoptysis is reduced to eliminating the underlying disease (for example, pneumonia, lung cancer, tuberculosis, Wegener's granulomatosis, idiopathic hemosiderosis and others). Symptomatic therapy with the use of hemostatic drugs is also carried out.

Complications

Complications of hemoptysis are determined by the causative disease that caused this symptom. The patient may experience pulmonary hemorrhage - the release of large quantities of scarlet blood from the lungs.

Prevention of hemoptysis

Prevention of the development of hemoptysis involves:

• Timely diagnosis of diseases of the respiratory system, cardiovascular system and systemic diseases that can lead to hemoptysis.
• Compliance with the principles of rational and balanced nutrition.
• Daily walks fresh air(at least 2 hours).

What is hemoptysis?

Hemoptysis is the coughing up of any amount of blood, which can be represented by separate single veins or big amount fresh blood. With a large amount of blood output, more than 100 ml per day, the condition is defined as pulmonary hemorrhage. Hemoptysis is considered massive if a person produces more than 400 ml of blood in three hours. The reasons for this may be infectious pathologies, various injuries, bronchiectasis, etc.

Diagnosis requires a medical history, laboratory tests, and other research methods. Diagnosis is carried out in two directions: identifying the causes of hemoptysis and determining the patient’s condition. It is worth remembering that the causes of blood discharge with cough can be not only diseases of the respiratory system, but also pathologies digestive tract, throat and nasopharynx.

Unfavorable factors

Unfavorable factors for the development of hemoptysis include the following:

• disturbances in the normal rhythm of breathing;
• lack of oxygen in the body;
• release of large amounts of blood from the lungs;
• old age;
• history of lung and heart diseases;
• state of shock.

Causes of hemoptysis

In older people

Single or few streaks of blood in sputum are often found in respiratory diseases such as ARVI, bronchitis, tracheitis and others. In older people, in most cases, the causes of hemoptysis are: bronchiectasis, pneumonia various types, bronchitis or tuberculosis.

In rare cases, the appearance of blood in the sputum may be a sign of more serious illness. The most dangerous of them is lung cancer. It usually develops in older people, who often smoke.

Other causes of hemoptysis, which are much less common, include: laryngeal cancer, fungal infections of the lungs, lung abscess, silicosis, heart failure, aspergilloma and others.

In children

In childhood, the appearance of hemoptysis most often indicates that a foreign object has entered the bronchi. In the same way, prolonged uncontrolled use of heparin drugs, the action of which is aimed at thinning the blood, can occur. Such medicines can cause bleeding in various locations.

Another possible cause of hemoptysis in children can be trauma. Blood in sputum in varying quantities is observed in infectious diseases of the lower respiratory system.

The reasons for the release of large amounts of blood in children include: bronchiectasis, various types of pneumonia, bronchogenic carcinoma.

Common Causes of Bloody Sputum

The causes of hemoptysis are quite varied. They can be hidden in lung diseases of various types, damage to other organs of the respiratory system, heart pathologies, neoplasms in the chest area and other factors.

There are cases where hemoptysis appeared and disappeared spontaneously, but the reasons for this condition could not be established. It was given the name cryptogenic, or idiopathic, hemoptysis.

Determining causes by symptoms

Lungs

Manifestations various diseases may vary significantly. Lung pathologies are manifested by the following symptoms:

Symptoms of pathologies of the bronchi and trachea are:

1. Tumor processes. In these cases, the first signs include increased night sweats, fatigue, weight loss, constant weakness and desire to sleep, and coughing attacks.
2. In acute bronchitis, there is first a dry and then a wet cough, which may contain streaks or traces of blood. Chronic bronchitis in the acute stage is practically no different in symptoms from the acute form of the disease.
3. Bronchiectasis. The patient has a prolonged cough with sputum, and calcified lymph nodes are also detected.
4. The entry of foreign objects into the bronchi is manifested by difficulty breathing, lack of air, shortness of breath and bouts of severe coughing, often with blood.

Vessels

When blood vessels are damaged, the following symptoms may occur:

1. Thromboembolism of the pulmonary artery. Manifestations: severe sharp pain at the beginning, decreased breathing rhythm and slow heart rate, shortness of breath.
2. Venous pulmonary hypertension. Signs of this disease are: severe shortness of breath when lying down, symptoms of volume overload, and moist rales.
3. Rupture of the pulmonary artery: weakening and sometimes complete absence of respiratory movements on the affected side, rapid increase in symptoms of anemia, severe chest pain, weakness.

Hemoptysis - coughing up blood - can be manifested by separate streaks of blood in the sputum, or spit can consist of only blood. Coughing up a large amount of blood (more than 100 ml per day) is called pulmonary hemorrhage. If 600-800 ml of blood is lost within 24 hours, there is a threat to life due to aspiration of blood and asphyxia. However, the division into hemoptysis and pulmonary hemorrhage is relative. Any hemoptysis is a sign of an emergency, since it is never possible to say with certainty that minor hemoptysis will not be followed by heavy pulmonary hemorrhage. The source of bleeding can be the vessels of the pulmonary artery system or bronchial vessels. Provoking factors can be exercise stress, decreased atmospheric pressure, infection, insolation.

Etiology and pathogenesis.

Hemoptysis can occur with a number of lung diseases, including inflammatory diseases (bronchiectasis, , , ), neoplasms (lung cancer, bronchial adenoma), heart and vascular diseases (mitral stenosis, aorta), chest injuries, autoimmune diseases ( Goodpasture's syndrome, Wegener's granulomatosis). Hemoptysis is observed in diseases of the lungs, accompanied by the breakdown of lung tissue, with the involvement of pulmonary vessels in the area of ​​decay, and disruption of the integrity of the vascular wall. In this case, the amount of bleeding largely depends on the caliber of the damaged vessel. Among lung diseases, tuberculosis remains one of the common causes of hemoptysis. Hemoptysis can complicate any form of pulmonary tuberculosis: hematogenous dissemination, fibrocavernous process. It should be borne in mind that sometimes hemoptysis is the first symptom of tuberculosis noticeable to the patient. Usually it is not profuse and life-threatening, but one must always remember the possibility of fatal bleeding. Anamnestic data help in diagnosing tuberculosis: the presence of pulmonary tuberculosis in the past, symptoms of exacerbation of the process and tuberculosis intoxication - fever, night sweats, weight loss, increased fatigue, debilitating cough. Most common cause hemoptysis are non-tuberculous suppurative diseases of the lungs, and among them primarily bronchiectasis and lung abscess. A change in the structure of pulmonary diseases and a decrease in the proportion of tuberculosis have led to the fact that in recent decades, bronchitis and bronchiectasis as the cause of hemoptysis have been in first place, causing almost half of all cases of hemoptysis. Hemoptysis with bronchiectasis and abscesses is usually not profuse, but tends to recur frequently, especially during periods of exacerbation of the chronic suppurative process. Perennial cough a large number of sputum, especially in the morning (a mouthful), changes in the nail phalanges of the fingers in the form of “drum sticks” or nails in the form of “watch glasses”, percussion and auscultation signs of emphysema and pneumosclerosis reliably help in the diagnosis of bronchiectasis as a cause of hemoptysis. An admixture of blood to mucous sputum or coughing up pure blood is often observed in the acute period of pneumonia (especially viral influenza). In these cases, hemoptysis is combined with chills, high temperature, often shortness of breath, chest pain when breathing. Objective examination reveals shortening of percussion sound and moist rales in the area of ​​inflammation. Hemoptysis is a common symptom of lung neoplasm. About a quarter of all cases of hemoptysis are caused by benign and malignant lung tumors. The admixture of blood to the sputum gives the latter the appearance of raspberry jelly. It should be emphasized that hemoptysis and a persistent debilitating cough may be the early and for some time the only complaints of a patient with lung cancer. In these cases, the success of subsequent surgical treatment often depends on how soon after the onset of cough and hemoptysis the patient was sent to X-ray examination and was diagnosed with lung cancer. In addition to lung diseases, hemoptysis can occur with heart diseases, accompanied by stagnation of blood in the pulmonary circulation, especially with narrowing of the left venous opening - mitral stenosis. Hemoptysis in this case occurs as scarlet blood, in the form of streaks, usually not very profuse, after which shortness of breath sometimes decreases and the well-being of patients improves. Anamnestic information about rheumatism and heart disease, characteristic appearance patient with mitral disease (acrocyanosis, “mitral blush”), data from an objective examination of the heart (expansion of the borders of the heart upward and to the right, popping tone and diastolic murmur at the apex, opening click of the mitral valve, accent and bifurcation of the second tone on the pulmonary artery, usually atrial fibrillation arrhythmia). Prescribing appropriate cardiac and diuretic drugs to patients with hemoptysis with mitral stenosis usually significantly improves the condition and leads to a significant reduction or cessation of hemoptysis. Hemoptysis can be caused by stagnation in the vessels of the pulmonary circulation due to acute and acute failure of the left ventricle of the heart in patients with hypertension, atherosclerotic cardiosclerosis, and myocardial infarction. Typically, hemoptysis in these patients is preceded by an attack of cardiac asthma, or shortness of breath increases so sharply that patients cannot lie down and are forced to sit for days with their legs down. Hemoptysis is not profuse. First, patients cough up spitting scarlet blood, which gradually darkens as the hemoptysis decreases. A repeated attack of suffocation can lead to relapse of hemoptysis, i.e. hemoptysis appears with increasing failure of the left ventricle of the heart and increased congestion in the lungs. Effective cardiotonic and diuretic therapy in these patients usually leads to cessation of hemoptysis along with improvement in condition, reduction of shortness of breath and pulmonary congestion. A relatively rare cause of pulmonary hemorrhage is the rupture of an aortic aneurysm into the bronchus. Bleeding usually leads to instant death. However, sudden bleeding is sometimes preceded several days or weeks by the so-called premonitory hemoptysis, caused by both compression of the bronchial mucosa and the leakage of small amounts of blood through the thinned wall of the aneurysm into the bronchus. One of the causes of hemoptysis is pulmonary infarction. In this case, hemoptysis is combined with sudden shortness of breath, chest pain, and fever. Anamnestic information and examination data can detect pathology of the heart and blood vessels (heart disease or cardiosclerosis with atrial fibrillation, venous thrombosis lower limbs), the ECG reveals signs of overload of the right heart. Hemoptysis can be observed with chest injuries, accompanied by hemorrhage into the lung tissue, sometimes even in the absence of visible damage to the skin and damage to the integrity of the ribs. The cause of hemoptysis may be foreign bodies that enter the lungs during old wounds or are aspirated into the bronchi. In these cases, hemoptysis is caused by the breakdown of lung tissue as a result of the formation of a bedsore from a foreign body, reactive inflammation and atelectasis.

Diagnostics.

Diagnosis of hemoptysis, as a rule, is not difficult. It never occurs in a dream, since coughing wakes the patient. During pulmonary hemorrhage, blood is always coughed up and is usually scarlet in color and foamy. In rare cases, difficulties arise in differential diagnosis between pulmonary and gastric bleeding, especially if the patient swallowed part of the blood during pulmonary bleeding and subsequently experienced hematemesis. Below is Comparative characteristics gastric and pulmonary bleeding (Table 3).

Table 3. Differential diagnosis of pulmonary and gastric bleeding

Clinical data	Stomach bleeding	Pulmonary hemorrhage
Anamnesis Conditions of bleeding The nature of the blood released Impurities Duration of bleeding Subsequent symptoms Character of the chair	Liver and stomach diseases, dyspepsia Vomiting blood Dark blood, clots, "coffee grounds" In addition to blood, vomit may contain food debris Bloody vomiting is usually short-lived and profuse. No subsequent hemoptysis After stomach bleeding, stool becomes tarry	Lung diseases Coughing up blood, hemoptysis Scarlet blood, almost uncoagulated, foamy Blood may be coughed up with sputum Hemoptysis continues for several hours, sometimes for several days After profuse hemoptysis, coughing up spit of gradually darkening blood No tarry stools unless blood was swallowed

Treatment.

Basic principles of therapeutic tactics for pulmonary hemorrhage:

1. As a rule, hemoptysis is not profuse and stops on its own without special therapy. It is necessary to reduce the conversation with the patient to a minimum and give him an elevated, semi-sitting position or a lying position on the sore side to prevent blood from entering the other lung. Swallowing small pieces of ice helps reduce hemoptysis. Hemoptysis, especially when occurring for the first time, usually frightens the patient and others, so you need to reassure the patient if possible. However, sedatives are used with great caution because they can reduce protective reflexes and mask increasing respiratory failure; Tranquilizers that have a muscle relaxant effect (including on the diaphragm) are especially dangerous.

2. After rendering emergency care a patient with hemoptysis is subject to mandatory hospitalization. Transportation should be carried out on a stretcher with a raised head end on an ambulance in the presence of a doctor or paramedic. Only in a hospital setting is it possible to carry out a full range of treatment measures aimed at stopping pulmonary hemorrhage, and a more detailed examination to determine its cause. In particular, patients with hemoptysis require urgent consultation with a pulmonary surgeon, since cavernous tuberculosis, anaerobic abscess and lung cancer are indications for surgical treatment. If it is known that the patient suffers from tuberculosis, in case of hemoptysis he should be sent not to general hospitals, but to specialized anti-tuberculosis institutions.

3. The main goal of drug therapy is to suppress the resulting cough, which can aggravate the severity! patient's condition. For this purpose, codeine is used in a hospital setting, which is prescribed orally; in case of persistent painful cough and profuse pulmonary bleeding, 0.5-1 ml of 2% promedol solution is administered intravenously or subcutaneously as emergency treatment (narcotic analgesics effectively suppress the cough center). However, opiates should not be abused, since complete suppression of the cough reflex can lead to aspiration of spilled blood and the development of severe aspiration pneumonia.

4. In case of profuse, life-threatening pulmonary hemorrhage, not associated with pulmonary embolism or other cardiovascular pathology, hemostatic therapy is carried out in the hospital. Antifibrinolytic agents can be effective in the presence of a local increase in fibrinolysis: aminocaproic acid is administered intravenously - up to 100 ml of a 5% solution over 30 minutes and then repeat the infusion every 4 hours until the bleeding stops; tranexamic acid - intravenously or intramuscularly in a dose of 5-10 ml (1-2 ampoules) of a 5% solution; In addition, transfusion of fresh frozen plasma is effective.

5. In case of massive bleeding and signs of hypovolemia, colloidal (for example, 400 ml of polyglucin) or saline solutions are administered intravenously to replenish the volume of circulating blood (they, however, may need 4 times more volume than colloidal ones).

Presumable diagnosis

• Pulmonary infarction
• Acute bronchitis
• Bronchial adenomas
• Cystic fibrosis
• Infections
• Pulmonary hypertension
• Tumor formations
• Coagulation disorder
• Foreign bodies of the bronchi

Additional examinations necessary to make a diagnosis

• Complete blood count, ESR
• Glucose, SRV
• Markers of inflammation
• Coagulation markers
• General urine analysis
• Sputum culture
• X-ray, CT, MRI
• Bronchoscopy
• Blood test for Mycobacterium tuberculosis

Key questions for diagnosis

• Blood volume, intensity
• Provoking factors
• Related factors
• Temperature change
• Colds
• Chills, sweats
• Taking medications
• History of tuberculosis, trauma

Inspection data

• General inspection
• Auscultation of the lungs
• Percussion of the lungs
• Wheezing, crepitus
• Condition of the lymph nodes
• Examination of the throat, pharynx
• Hyperemia, plaque

Massive hemoptysis - the release of more than 400 ml of blood in 3 hours. Its most common causes are bronchiectasis, bronchial carcinoma, infectious diseases (for example, tuberculosis, lung abscess or aspergillosis) and trauma.

Often the reason becomes clear after clarifying the anamnesis. In patients with pulmonary hemorrhage, its location can be determined by a characteristic “gurgling” sound heard on auscultation. Find out whether the patient smokes and takes any medications.

The patient is examined to identify the disease causing the bleeding and to assess the hemodynamic and respiratory response to the bleeding.

It should be remembered that the source of bleeding can be not only the lungs, but also the upper respiratory tract, nasopharynx, and gastrointestinal tract.

Hemoptysis is the release of blood with sputum from the respiratory tract. The criterion for massive hemoptysis is the release of >600 ml of blood during the day.

Most of the blood (95%) reaches the lungs through low-pressure vessels (pulmonary arteries). About 5% of the blood circulates through high-pressure vessels (bronchial arteries), which supply the main airways and supporting structures. When hemoptysis occurs, blood comes from the bronchial arteries.

Poor prognostic factors

• Elderly and senile age.
• Pre-existing heart and lung diseases.
• Respiratory disorders (changes in respiratory rate, cyanosis).
• Hypoxia (PaO 2<10 кПа при дыхании воздухом).
• Continued pulmonary hemorrhage with large discharge
  amount of fresh blood.
• Shock (postural hypotension or horizontal hypotension)
  position is rarely observed).

Causes of hemoptysis

Sputum streaked with blood occurs in many respiratory diseases, for example, ARVI and viral bronchitis.

Differential diagnosis includes a large number of nosologies.

In adults, the causes of hemoptysis in 70-90% of cases are:

• Bronchitis.
• Bronchiectasis.
• Tuberculosis.
• Necrotizing pneumonia.

Primary lung cancer is the leading cause in smokers >40 years of age, but metastases rarely cause hemoptysis. The cause of hemoptysis is increasingly becoming an aspergillus infection with the formation of cavities, but less often than lung cancer.

In children, the main causes of hemoptysis are:

• Lower respiratory tract infections.
• Foreign body aspiration.

Massive hemoptysis. Main reasons:

• Bronchogenic carcinoma.
• Bronchiectasis.
• Tuberculosis and other types of pneumonia.

Common causes of hemoptysis

• Bronchostatic disease (with or without infection).
• Bronchial carcinoma.
• Infectious diseases.
• Tuberculosis.
• Pneumonia.
• Lung abscess.
• Aspergilloma.
• Bronchitis.
• Injury.
• Arteriovenous malformation.
• Pulmonary embolism.
• Mitral stenosis.
• Congenital heart defect.
• Aortic aneurysm.
• Microscopic polyangiitis.

Causes of hemoptysis, Source - trachea and bronchi

Cause	Manifestations	Diagnostic algorithm
Tumor (bronchogenic, bronchial metastatic, Kaposi's sarcoma)	Night sweats. Weight loss, Intensive smoking. Risk factors for Kaposi's sarcoma (HIV infection)	X-ray of the chest organs. CT. Bronchoscopy
Bronchitis (acute or chronic)	Acute: productive or non-productive cough. Chronic: productive cough most days of the month or 3 months of the year for 2 years in a patient with COPD or a smoker	Acute: clinical examination. Chronic: chest x-ray
Bronchiectasis	Chronic cough and sputum production in patients with recurrent infections	High resolution CT. Bronchoscopy
Bronchodilators	Calcified lymph nodes in patients with a history of granulomatous disease	CT scan of the chest. Bronchoscopy
Foreign body (usually chronic and undiagnosed)	Chronic cough (usually in children younger age) in the absence of ARVI symptoms. In some cases - fever	X-ray of the chest organs. In some cases - bronchoscopy

Causes of hemoptysis, Source - lung parenchyma

Causes of hemoptysis, Primary source in the blood vessel

Cause	Manifestations	Diagnostic algorithm
Arteriovenous malformations	The presence of telangiectasia on the skin and mucous membranes or peripheral cyanosis	CT angiography. Angiopulmonography
Pulmonary embolism	Acute onset: acute chest pain, tachypnea, tachycardia, especially in patients with risk factors for pulmonary embolism	CT angiography or ventilation-perfusion scintigraphy. Duplex scanning of the veins of the lower extremities
Venous pulmonary hypertension (especially with mitral stenosis, left ventricular heart failure)	Wet wheezing. Symptoms of central and peripheral volume overload. Orthopnea or paroxysmal nocturnal dyspnea	ECG. MNE. Echocardiography
Aortic aneurysm with bleeding into the lung parenchyma	Back pain	X-ray of the chest organs (mediastinal widening). CT angiography
Pulmonary artery rupture	Recent pulmonary artery catheter insertion	Emergency CT angiography or pulmonary angiography

Various causes of hemoptysis

Cause	Manifestations	Diagnostic algorithm
Pulmonary endometriosis (hemoptysis during menstruation)	Recurrent hemoptysis during menstruation	Clinical examination In some cases, a trial prescription of oral contraceptives
Systemic coagulopathy or use of anticoagulants or thrombolytics	Patients receiving systemic anticoagulants for pulmonary embolism, deep vein thrombosis, or atrial fibrillation Patients receiving thrombolytics for stroke or myocardial infarction In some cases, family history	Prothrombin time, partial activated thromboplastin time or antifactor Xa level Stopping hemoptysis when correcting coagulation disorders

Diagnosis of hemoptysis

All patients should undergo the following tests:

• OAK, urea and electrolyte concentrations, coagulogram,
  analysis for group and Rh affiliation.
• Arterial blood gases.
• X-ray of the chest organs.
• Sputum analysis (microscopy, culture, cytology).
• Bronchoscopy with a flexible bronchoscope.

Anamnesis. The history of the present disease includes duration (acute onset, cyclical repetition), provoking factors (allergens, cold air, physical activity, horizontal position), blood volume (individual veins, teaspoon, glass). It is necessary to distinguish true hemoptysis from false - vomiting with blood or bleeding from the nasopharynx. A feeling of postnasal drip or bleeding from the nasal passages without coughing indicates false hemoptysis. When vomiting blood, the vomit has the characteristic color of coffee grounds. True hemoptysis is indicated by frothy sputum, discharge of scarlet blood and a feeling of choking.

Additional symptoms indicate possible reason hemoptysis: fever and sputum (pneumonia); night sweats, weight loss and fatigue (cancer, tuberculosis); chest pain and shortness of breath; pain and swelling of the leg; hematuria (Goodpasture syndrome); bloody issues from the nasal cavity (Wegener's granulomatosis).

Risk factors include: HIV infection, use of immunosuppressants (tuberculosis, fungal infection); contact with a tuberculosis patient; long-term smoking (cancer); immobilization after surgery, cancer, history of thrombosis or in relatives, pregnancy, use of drugs containing estrogen, long-distance travel (pulmonary embolism).

Life history includes diseases that can cause hemoptysis: chronic pulmonary diseases (COPD, bronchiectasis, tuberculosis, cystic fibrosis), cancer, bleeding, heart failure, thoracic aortic aneurysm, pulmonary-renal syndromes. Attention should be paid to contact with tuberculosis patients, especially in patients with HIV infection or other immunodeficiency.

Frequent nosebleeds, a tendency to form hematomas, and liver disease indicate coagulopathy. You should pay attention to taking anticoagulants and antiplatelet agents.

Objective examination. Systemic symptoms (for example, cachexia) and the degree of respiratory failure (participation of additional muscle groups in the act of breathing, breathing through pursed lips, agitation, depression of consciousness) are important.

A complete examination of the lungs is carried out: the nature of air movement during inhalation and exhalation, symmetry of breathing, dry and moist rales, stridor. You should pay attention to the presence of egophony, dullness of percussion sound. The cervical and supraclavicular lymph nodes are palpated.

The neck veins are examined, the legs and groin area are palpated for swelling. During auscultation, you should pay attention to the sonority of heart sounds and the presence of murmurs, which can confirm the diagnosis of heart failure and pulmonary hypertension.

When palpating the abdomen, you should pay attention to the condition of the liver: liver enlargement or the presence additional education indicates cancer or esophageal varices, which may be a source of bleeding.

Examination of the skin and mucous membranes is carried out for ecchymoses, petechiae, telangiectasia, gingivitis, or signs of bleeding from the mouth or nose.

If an episode of hemoptysis is observed during the examination, it is necessary to evaluate the color and amount of blood.

Attention. The following symptoms are of particular importance:

• Massive hemoptysis.
• Backache.
• Presence of a catheter in the pulmonary artery.
• Feeling unwell, weight loss or fatigue.
• Long history of smoking.
• Shortness of breath at rest, absence or weakening of breathing.

Interpretation of the obtained data. Data from the anamnesis and objective examination allow us to suggest the cause of shortness of breath and choose an algorithm of action.

In the absence of chronic diseases, pathology during an objective examination and risk factors (tuberculosis, pulmonary embolism), with an acute onset of the disease with cough and fever, hemoptysis is most likely due to ARVI; chronic diseases are unlikely. However, if risk factors are present, relevant diseases should be suspected. Clinical prognosis is used to assess the risk of pulmonary embolism. Normal oxygen saturation does not exclude thromboembolism.

If hemoptysis is caused by diseases of the lungs (COPD, cystic fibrosis, bronchiectasis) or the cardiovascular system (heart failure), then patients have a corresponding history, and hemoptysis is not the first manifestation.

In immunocompromised patients, hemoptysis may be due to tuberculosis or fungal infection.

If symptoms of a chronic disease are present in the absence of a relevant history, cancer or tuberculosis should be suspected, although hemoptysis may be the first symptom of lung cancer.

Renal failure or hematuria indicate the presence of pulmonary-pulmonary syndrome. In patients with Wegener's granulomatosis, lesions of the nasal mucosa are observed. Visible telangiectasias indicate arteriovenous malformations. Petechiae and/or purpura may be seen in patients with coagulopathy. Recurrent hemoptysis during menstruation indicates pulmonary endometriosis.

Examination. Patients with massive hemoptysis are kept in the intensive care unit until their condition stabilizes. For minor hemoptysis, patients can be examined on an outpatient basis.

Imaging is performed on all patients; X-rays are required. Patients with normal findings, relevant medical history, and minor hemoptysis are treated empirically for bronchitis. If there are pathological changes on the radiograph and there is no characteristic history, CT and bronchoscopy are performed. CT allows you to identify lung lesions that cannot be diagnosed with radiography and determine their location for subsequent bronchoscopy and biopsy.

Fiberoptic inspection. When it is necessary to differentiate between hemoptysis and vomiting of blood, bleeding from the nasopharynx or oropharynx, the pharynx, larynx, respiratory tract and esophagus are examined using fiber optics.

Blood test, determination of prothrombin time and activated partial thromboplastin time. Patients receiving low molecular weight heparin are tested for antifactor Xa. To exclude glomerulonephritis, a blood test is performed (hematuria, proteinuria, casts). If tuberculosis is suspected, it is carried out skin test and sputum culture. However negative results do not exclude the need for repeated sputum collection or bronchoscopy to obtain samples for testing for acid-fast bacilli.

Cryptogenic hemoptysis. The prognosis is favorable, hemoptysis usually resolves within 6 months.

Treatment of hemoptysis

Massive hemoptysis. Treatment goals:

• Prevention of aspiration of blood into a healthy lung (threat of asphyxia).
• Prevention of blood loss during ongoing bleeding.

Protecting a healthy lung is difficult because the source of the bleeding often cannot be identified. If bleeding is present, the patient is placed on the affected side and the appropriate bronchus is selectively intubated and occluded.

Initial treatment measures: Stabilization of the patient's condition

• To treat patients with pulmonary hemorrhage, it is necessary to involve a cardiothoracic surgeon; if this is not possible, the patient must be transported to medical institution, which has a department of cardiothoracic surgery.
• Oxygen therapy is carried out with a high oxygen content.
• Provide the patient with a stable lateral position on the side corresponding to the source of bleeding in the lungs (if known) in order to preserve the intact lung from aspiration of blood.
• If there is a threat of aspiration of blood, an anesthesiologist is immediately called to perform anesthesia, intubation and ventilation. In order to isolate the intact lung, tracheal intubation can be performed with a double-lumen tube, but its narrow lumen can make bronchoscopy difficult.
• Peripheral venous access is established using a large-bore catheter, and then catheterization of the central vein is performed, preferably the internal jugular vein, to avoid the development of pneumothorax.
• Maintain hemodynamics: hemoptysis is rarely so severe that it requires blood transfusion. Patients with hypotension should receive intravenous colloidal solutions before receiving blood for transfusion.
• Monitor diuresis, pulse, blood pressure, and, if necessary, central venous pressure.

Hemoptysis: further treatment

Determining the source of bleeding

X-ray of the chest organs. Radiographs should be carefully evaluated to identify tumor-like lesions, lymph nodes at the hilum of the lungs, bronchiectasis (tram track shadows), pre-existing or new cavities that may indicate aspergilloma. They try to identify the cause of hemoptysis with a small admixture of blood.

Fiber optic or rigid bronchoscopy. Should be performed urgently in all cases of massive hemoptysis. Bronchoscopy is not a method that allows one to clearly localize the source of bleeding, but it helps the surgeon and radiologist in identifying the affected lung and lobe. Bleeding can be stopped by endobronchial administration of epinephrine using a bronchoscope, and in case of massive pulmonary hemorrhage, by inserting and inflating a catheter balloon for 24-48 hours at the level of segmental or subsegmental bronchi.

Selective angiography of pulmonary vessels. Allows you to determine the source of bleeding in 90% of cases, and when carried out simultaneously with embolization in 90% of patients, it allows you to stop bleeding. Several procedures may be required.

CT chest with high resolution. Allows you to identify parenchymal damage to the lungs and peripheral bronchi.

Specific therapeutic measures

Coagulopathy is corrected: with minor hemoptysis, it may be sufficient to correct a significantly increased MHO to a therapeutic level using fresh frozen plasma. When hemoptysis occurs in patients with prosthetic heart valves, it is necessary to normalize coagulation as best as possible. Consult with a hematologist and cardiologist. If thrombocytopenia is less than 50x109/l, platelet concentrate should be administered.

Consider the need for inhalation of P2-agonists through a nebulizer and/or intravenous administration of aminophylline in order to stimulate mucociliary clearance and eliminate bronchospasm in a patient with bronchial asthma or COPD.

A patient with minor hemoptysis should be thoroughly evaluated. The cause of hemoptysis cannot be detected in approximately 10% of patients.

Patients with massive hemoptysis should urgently undergo fiberoptic bronchoscopy to localize the source of bleeding.

Angiography with embolization should be performed in all patients with massive hemoptysis before surgery.

If angiography is impossible and bleeding continues to exceed 600 ml/day, as well as with an established diagnosis (for example, lung abscess, aspergilloma, trauma), surgical treatment is indicated.

All cases of hemoptysis should be consulted with the thoracic department. Patients with massive hemoptysis should be treated in specialized centers with the involvement of cardiothoracic surgeons and radiologists. If the patient’s condition is stable, he should be transported to such a center (if the patient’s condition is unstable, the patient must first be transferred to mechanical ventilation).

Hemoptysis is the release of blood from the organs of the respiratory system during coughing. This pathological condition is not considered a disease, but is a sign of respiratory injury or a symptom of various diseases.

Causes of hemoptysis

The most common causes of hemoptysis are: chronic and acute bronchitis, pulmonary tuberculosis, bronchiectasis and lung cancer. In approximately 20% of patients, the provoking factor for this pathology cannot be identified.

Diagnostics

Today, when hemoptysis syndrome appears, the following laboratory and instrumental studies are resorted to: a complete CBC (complete blood count), urinalysis, coagulogram (if bleeding is suspected), sputum examination, biochemical analysis(potassium, sodium, creatinine, urea), bronchoscopy, chest radiography, bronchography and CT scan breasts

Since pulmonary hemoptysis is quite alarming symptom, then the treatment of this pathology must be approached with the utmost seriousness. As a rule, a small discharge of blood at the time of coughing is not profuse, and it stops on its own without any therapy. If the amount of blood released exceeds the permissible norm, then in such situations the treatment of hemoptysis consists of providing emergency care.

The main elements of assistance for hemoptysis are: absolute rest of the patient, half-sitting position, patients are forbidden to speak, the health worker must convince the patient to hold back his cough and breathe deeply. In addition, help with hemoptysis includes the administration of a 12.5% ​​etamsylate solution, a 10% calcium chloride solution, or a 5% aminocaproic acid solution. When helping with massive hemoptysis, there should be a tray with pieces of ice near the patient. The patient should be given one piece to swallow every 15 minutes.

As for the treatment of hemoptysis with unconventional methods, it is aimed at eliminating the underlying disease, which provoked this symptom. Treatment of hemoptysis folk remedies nowadays is quite effective method, which requires mandatory consultation with a doctor. All hemostatic herbs can be used as symptomatic drugs. The most common herbs for eliminating bloody pulmonary discharge are: chicory, yarrow, geranium root, nettle leaves, pepper knotweed, plantain leaves, white grass, snake knotweed, three-leaved watch, agrimony, medicinal burnet roots and horsetail.