Hemoptysis

HEMOPTYSIS (syn. haemoptysis, haemoptoe), the discharge of blood that has entered the respiratory tract. This blood may originate from the pulmonary vessels, bronchial vessels, or from hemorrhagic foci located adjacent to the respiratory organs that have ruptured into the bronchi or lungs. The amount of blood discharged during hemoptysis can vary from a fatal hemorrhage to completely insignificant traces in the sputum. In large and medium-sized hemoptysis, pure blood of a bright scarlet color is discharged, which is foamy and does not coagulate upon standing. In very severe hemoptysis, the foamy character may be absent, and the blood coagulates. In smaller hemoptysis, the blood is usually mixed with mucus from the bronchi and is discharged in the form of more or less abundant sputa of a dark red color or in the form of red streaks and dots in ordinary sputum. Finally, the blood may completely dissolve in the sputum and give it a rusty hue, characteristic of pneumonic processes. In some cases (lung cancer), the bloody sputum takes on the color and consistency of raspberry jelly, and in cases of bronchiectasis, that of meat washings. Hemoptysis is almost always accompanied by a cough—often dry and uncontrollable—which contributes to the continuation of the hemoptysis. Sometimes patients describe unpleasant sensations of burning in the chest area and even in a specific part of the lungs, complaining of suffocation and a feeling of constriction in the throat. The most frequent cause of hemoptysis is pulmonary tuberculosis; according to Martinet, tuberculosis accounts for 11/12 of all cases of hemoptysis; Laufer and Vitry, who possessed rich dispensary material, found 569 tuberculous cases out of 810 cases of hemoptysis (70%). The character of tuberculous hemoptysis can be extremely diverse. Sometimes severe hemoptysis appears "like a bolt from the blue" in a subject who had not previously shown any signs of tuberculous disease (elevated temperature, discharge of Koch's bacilli in the sputum, physical symptoms, etc.). W. Neumann and others, following Bard, consider them a symptom of so-called abortive tuberculosis, which is prognostically favorable by its very nature; subsequently, in such patients, hemoptysis may recur at more or less long intervals while the general state of health remains good. In women, recurrent hemoptysis often coincides with the premenstrual period. More often, abundant hemoptysis is observed in a far-advanced tuberculous process with cavities or during a period of exacerbation of the tuberculous process; in these cases, hemoptysis is preceded and accompanied by the usual symptoms of these forms of tuberculosis. The prognosis here should be considered unfavorable not only depending on the underlying disease but also because, along with the blood penetrating into the alveoli and bronchi, dissemination of the infection occurs, and aspiration tuberculous pneumonia often develops. Finally, profuse hemoptysis can lead to death in and of itself due to blood loss, collapse, or suffocation. Smaller hemoptysis is observed in 70% of tuberculous patients (Bezancon, de Jong). In some, they occur relatively rarely, accompanying exacerbations of the process, and are sometimes even caused by overfeeding and excessively prolonged bed rest; in others, they represent a constant symptom of the disease. The latter is observed especially in patients with fibrous forms of tuberculosis, so that here the prognostic significance of hemoptysis should be considered rather favorable. Pulmonary hemorrhages in childhood are very rare: according to some authors, in cases of pulmonary tuberculosis at the age of 1–12 years, fatal hemoptysis occurs in 1.3%, and up to 1 year in 1.1%. The reason apparently lies in the fact that the caseous processes with which tuberculosis predominantly proceeds in childhood lead to the obliteration of vessels, whereas hemoptysis is most often caused by a sclerotic process, which is uncharacteristic of childhood. The pathogenesis of tuberculous hemoptysis has not yet been sufficiently clarified. Profuse hemoptysis in abortive tuberculosis is attributed to the rupture of minute aneurysms, and in cavernous tuberculosis to the ulceration of vessels passing through the cavity; profuse, often fatal hemoptysis occurs during the rupture of aneurysms of branches of the pulmonary artery in the cavity of the cavity. Small hemoptysis may depend on circulatory disorders in the vicinity of tuberculous foci and on phenomena of hyperemia accompanying the exacerbation of the process, or originate from small and fragile vessels that form in abundance in fibrous tissue (Bard). Hemoptysis is facilitated by all causes that induce an exacerbation of the process or fluctuations in blood pressure in the pulmonary vessels: colds, overwork, strong emotions, sunbathing, sharp fluctuations in temperature and barometric pressure, and various other meteorological factors (thunderstorms, excessive air humidity, heat), certain medications (iodine, arsenic, creosote), careless use of tuberculin, etc. Among non-tuberculous diseases of the respiratory organs, hemoptysis is encountered: 1) In bronchitis and laryngitis, especially in alcoholics, smokers, and those working in an atmosphere containing irritating vapors and gases—hemoptysis in the form of blood streaks and dots. 2) In bronchiectasis—frequent or constant hemoptysis of medium size, giving the sputum the appearance of "meat washings" and sometimes taking on the character of profuse hemoptysis. 3) In cancer of the bronchi and lung—hemoptysis in the form of raspberry jelly. 4) In pneumonic and bronchopneumonic processes—hemoptysis in the form of rusty sputum, and sometimes obvious admixtures of blood. 5) In abscess and gangrene of the lung—from profuse fatal hemoptysis to constant small admixtures of blood to the sputum, staining it pink. 6) In echinococcus of the lung, both at the beginning of the disease and upon rupture of the cyst, profuse hemoptysis may be observed, and small hemoptysis often accompanies the disease throughout its course. 7) In cavernous and sclerosing forms of pulmonary syphilis. 8) In actinomycosis of the lung and other fungal diseases, which are rare in the USSR, in distomiasis, amoebic bronchitis, Castellani's bronchospirochetosis, etc. 9) In interlobar purulent pleurisy—profuse hemoptysis for several days in a row or with short breaks. 10) In pulmonary infarction (among its causes, postoperative and postpartum thrombophlebitis, fat embolism in limb fractures, and chronic sepsis, especially endocarditis lenta, should be noted here). 11) In trauma to the lung (rib fractures, bullet and knife wounds, punctures of the lung during the induction of pneumothorax, and many others). Hemoptysis can be more or less abundant or even fatal depending on the size of the trauma and the vessels affected by it. Among diseases of other organs, the following should be noted: 1) Heart diseases, which are the most frequent cause of hemoptysis after pulmonary tuberculosis. Among them, mitral stenosis stands in first place, in which hemoptysis is often one of the earliest symptoms; it is usually not abundant then, having the appearance of sputa stained with blood or containing blood streaks and dots. During periods of significant decompensation, hemoptysis may become constant, and the sputa may consist of pure blood or have a foamy character. Very significant hemoptysis can occur in the same patients during pneumonia. Hemoptysis can accompany heart failure caused by any other lesion of the heart valves, disease of the heart muscle, adhesive pericarditis, prolonged arterial hypertension, etc. The pathogenesis of these cases of hemoptysis boils down to congestion in the pulmonary circulation and an increase in pressure within it, the consequence of which is the seepage of blood into the alveolar cavity, rupture of capillaries, infarctions, and pulmonary edema. On this same basis, congestion in the tracheal veins can form, with subsequent tracheal hemoptysis (Avellis). 2) Aneurysms of the aorta, pulmonary artery, and their branches, upon rupture into the respiratory tract, cause fatal hemoptysis. It may be preceded for a long time by small, recurrent hemoptysis. 3) Arterial hypertension (essential, sclerotic, nephritic) can cause hemoptysis due to hemorrhage into the bronchial cavity. 4) Kidney diseases can lead to hemoptysis indirectly: hypertension, heart failure, pulmonary edema. 5) Liver diseases (acute yellow atrophy and its subacute forms, cirrhosis, Weil's disease, icterus gravis, etc.), accompanied by bleeding and hemorrhages into the mucous membranes, often also cause hemoptysis. 6) So-called hemorrhagic diatheses (Werlhof's disease, hemophilia, scurvy, etc.) can, among their diverse manifestations, also lead to hemoptysis. 7) In rare cases, even during autopsies, severe hemoptysis finds no explanation, and one has to admit its neuropathic character of the pulmonary apoplexy type (which is also observed in other systems of the organism, e.g., along the gastrointestinal tract). The differential diagnosis of all these types of hemoptysis usually does not present particular difficulties. Provided there is a sufficiently attentive and detailed examination of the patient, the medical history, the general clinical picture, the appearance of the patient, the state of the organs of the chest and abdominal cavity, and the appearance and smell of the sputum usually provide sufficient data for recognizing tuberculous hemoptysis and hemoptysis of other origins. However, in some cases, these data alone may prove insufficient.

These include: 1) Initial stages of bronchiectasis, where the sputum is not yet particularly abundant and does not have a characteristic appearance; recognition here may rely on bacteriological examination of the sputum and radiography of the lungs, especially with the help of lipiodol. 2) Gangrene of the lungs, in which initially all obvious symptoms may be reduced to an increase in temperature and hemoptysis, and the diagnosis can be made only on the basis of microscopic examination of the sputum. 3) Fungal infections, where the question is also resolved only by examination of the sputum. 4) Initial stages of lung cancer, where, in addition to sputum examination, radiography may also help. 5) Echinococcus of the lungs, where, along with the X-ray picture and sputum examination, biological reactions may also help. 6) Hypertension, where the question is decided by measuring blood pressure, which is usually lowered in pulmonary tuberculosis. Nevertheless, despite all kinds of additional methods of examination, in a number of cases the cause of hemoptysis remains unexplained (4% according to Laufer and Vitry). In relation to these cases, the old rule remains in force that "any hemoptysis of unexplained origin should be considered as tuberculous." In addition, one should not lose sight of the possibility of a combination of pulmonary tuberculosis with any of the above-mentioned diseases, and the clarification of the nature of the hemoptysis naturally becomes even more difficult. From true hemoptysis, one should distinguish admixtures of blood in the sputum originating from the nose, nasopharynx, and oral cavity. Among the conditions that can simulate hemoptysis here, one should note: 1) Nasal hemorrhages, in which blood may sometimes not be discharged through the nose at all, but flow down the nasopharynx and cause coughing with the discharge of blood-tinged sputum. 2) Chronic inflammation of the nasopharynx, adenoid growths, etc., which can be accompanied by the expectoration of small, and sometimes quite significant, blood clots; therefore, in all cases of hemoptysis that are in any way doubtful, it is necessary to perform a thorough examination of the nose and nasopharynx. 3) Stomatitis, especially ulcerative, leading to an admixture of blood to the expectorated saliva. 4) Gingivitis of any origin. 5) Alveolar pyorrhea. 6) Sucking of blood from the gums, practiced by some hysterical patients and malingerers. 7) The so-called hemosialemesis (Josseran), in which the patient spits out in the morning a syrupy, blood-colored liquid consisting of saliva with an admixture of blood originating from the gums, carious teeth, etc. In all these cases, besides the external appearance of the secretions, microscopic examination of them helps in differentiation, which reveals only desquamated squamous epithelium and the usual flora of the oral cavity. The differentiation of profuse hemoptysis from hematemesis (see Haematemesis) often presents a difficult task. Both in its color and in its character, blood in hemoptysis may not differ from that vomited during hematemesis, especially if the hemoptysis is very abundant or caused by the rupture of an arterial pulmonary vessel. Accompanying sensations also sometimes do not give clear indications, since in hemoptysis blood can be swallowed and then ejected by vomiting and even contain food admixtures. Furthermore, the mental state of the patient and those around him is often so panicky during profuse hemoptysis that they subsequently prove unable to give any coherent account of what happened. The anamnesis may also not provide sufficient points of support for the diagnosis. A more constant distinguishing sign is the expectoration of small amounts of bloody sputum continuing for several days after profuse hemoptysis, which is not observed in hematemesis. Treatment. In more or less significant profuse hemoptysis, the main measure remains, even at the present time, rest: the patient must remain in bed in a semi-reclining position, all movement and conversation are forbidden, ice bags are placed on the chest, nutrition is limited to milk, broth, and jelly in a cooled form; hot water bottles are applied to the limbs, and in very severe cases, one resorts to constricting the limbs with elastic or simple bandages with the aim of creating venous stasis in them, thanks to which blood pressure is lowered and blood clotting is accelerated. Extremely important is the mental calming of the patient, achieved through persuasion and with the help of various sedatives. Morphine provides excellent service here, acting simultaneously as a means of calming the nervous system, lowering blood pressure, and facilitating cough (subcutaneously 1/2-1 cm³ of a 1% solution), without at the same time stopping the discharge of sputum. If hemoptysis does not stop or recurs, one resorts to intravenous infusion of hypertonic NaCl solutions (10 cm³ of a 5% solution or 5 cm³ of a 10% solution) or calcium chloride (10-20 cm³ of a 10% solution), to subcutaneous injection of 5 cm³ of horse (anti-diphtheria) serum (remember about anaphylaxis!) or 20-40 cm³ of sterile 10% gelatin (thorough sterilization, danger of tetanus!). Depending on some circumstances unknown to us, in individual patients one or another of these agents works, so that sometimes one has to try them all in turn. In a unilateral tuberculous process with a tendency to hemoptysis, the best remedy is the application of artificial pneumothorax. Preparations of ergot, hydrastis, stypticin, adrenaline, and ferric chloride, which were popular at one time as agents to stop hemoptysis, are now rejected by the majority of authors with good reason, as are the vasodilators amyl nitrite and nitroglycerin. When hemoptysis has stopped, heroin (0.003-0.005), dionin (0.01-0.015), pantopon (0.01-0.02), codeine (0.015-0.02), and morphine hydrochloride (0.003-0.005) are given per os several times a day. In addition, calcium chloride or calcium lactate (10.0 per 200.0 of water, 1 tablespoon several times a day) are used as blood-clotting agents; NaCl 5.0 in solution together with sodium bromide (2.0-4.0) as a sedative, every 1 1/2-2 hours; prophylactic infusions of hypertonic solutions of calcium chloride and NaCl are also frequently used for 2-3 weeks. In very large hemoptysis, when the bronchi are flooded with blood, an emetic is given (Pulv. rad. Ipecac. 0.6, every 10 minutes a powder until action); together with the vomiting, blood is removed from the bronchi; recurrence of hemoptysis is not observed with this. In hemoptysis of small size, and even more so with insignificant admixtures of blood to the sputum, strict bed rest is no longer considered necessary at the present time. There are even observations that such a regime can contribute to hemoptysis, not to mention the harmful effect on the psyche of the patients. In order to facilitate pulmonary blood circulation and lymph circulation in such cases, moderate movement in the fresh air and non-tiring work are even recommended, provided, of course, that there are no contraindications from the underlying disease. All therapeutic efforts should be directed at this same disease. Among symptomatic agents, all those listed above are used. In addition, in tuberculous hemoptysis reaching 200 cm³ per day, a good effect is sometimes observed from the use of Tartarus stibiatus recommended by Mattei and Escudier (Tart. stib. 0.03-0.05, Extr. Opii 0.01, in pills or cachets, 2-3 times a day). Preparations of digitalis (Pulv. fol. Digitalis 0.05 three times a day), which improve impaired heart function, have a very good effect in small hemoptysis associated with cirrhotic tuberculous processes in the lungs and pneumosclerosis of other origins. Despite this entire arsenal of agents, the fight against hemoptysis often proves to be a very thankless task. In such cases, the goal of the physician should be the utmost calming of the patient and convincing him that hemoptysis in itself does not represent anything threatening and that it will disappear with the improvement of the underlying disease.