Hemoptysis

Terminology: haemoptysis and pulmonary hemorrhage

In Russian medical practice, it is customary to clearly distinguish between two clinical concepts that require different approaches:

• Haemoptysis (haemoptysis). Characterized by the presence of blood streaks in the sputum. The volume of blood is small, mixed with mucus or pus.
• Pulmonary hemorrhage (haemoptoe). Manifests as coughing up pure bright red blood in the form of separate clots or a liquid mass. The blood is usually frothy and has an alkaline reaction, which is an important differential sign.

Of particular concern is massive pulmonary hemorrhage, in which blood loss exceeds 200 ml per day. In such situations, immediate bronchoscopy and evaluation for surgical intervention are required. Surgical tactics may include bronchial artery or bronchial occlusion, ligation of bleeding vessels, and in severe cases, resection of the affected lung segment or lobe.

Main etiological groups

The causes of blood in the sputum are extremely diverse. For diagnostic convenience, they are divided into several major groups:

1. Inflammatory and infectious diseases. The most frequent cause. This includes acute respiratory viral infections, bronchitis, pneumonia (especially caused by Klebsiella pneumoniae and lobar pneumonia), pulmonary tuberculosis, as well as destructive processes (lung abscess and gangrene). In bronchiectasis, bleeding occurs due to mucosal erosion in areas of inflammation and damage to small vessel walls.
2. Oncological pathology. Bronchogenic lung cancer must be ruled out first.
3. Vascular and cardiac emergencies. Pulmonary embolism (PE), pulmonary infarction, primary pulmonary hypertension. Cardiac causes include acute left ventricular failure, chronic congestive heart failure, and heart defects (mitral stenosis).
4. Trauma and mechanical factors. Chest contusions, foreign bodies in the airways, and rupture of small vessels due to a sharp increase in intrapulmonary pressure during exhausting cough.

Differential diagnosis by sputum characteristics

The appearance of the sputum and the features of the clinical course allow the physician to suspect a specific nosology even before instrumental test results are available:

• Lobar pneumonia. The classic marker is "rusty sputum". This specific shade is due to the presence of altered (broken-down) blood.
• Acute left ventricular failure. Acute blood congestion develops in pulmonary capillaries, leading to pulmonary edema. The patient coughs up a large amount of frothy fluid mixed with blood (so-called "pink froth").
• Bronchogenic carcinoma. Typically moderate, but persistent, daily recurring haemoptysis. If streaks of blood appear in a male patient with a long smoking history, this warrants urgent oncological evaluation. In advanced stages, with pronounced tumor breakdown, the sputum may acquire the appearance of "raspberry jelly".
• Destructive lesions and vasculitis. In cavitary tuberculosis, abscesses, systemic vasculitis (e.g., Wegener's granulomatosis), or hemorrhagic alveolitis, there is an extremely high risk of the symptom transforming into profuse pulmonary hemorrhage due to infectious or aseptic necrosis of the lung tissue.

Rules of the diagnostic workup

The algorithm for examining a patient with blood in the sputum is based on strict rules:

1. Ruling out extrathoracic sources. Before initiating the search for pulmonary pathology, it is necessary to ensure that blood is not originating from the nasopharynx, laryngeal ulcerations, upper airway polyps, or the gastrointestinal tract (e.g., from esophageal varices).
2. Thorough history taking. Assess the connection with recent ARVI and identify risk factors. It is important to examine the patient's legs: asymmetric swelling may indicate deep vein thrombosis, which sharply increases the probability of PE and pulmonary infarction.
3. Principle of re-evaluation. This is a crucial rule of clinical practice. If a patient experiences recurrent haemoptysis, diagnostics must start from scratch. The new appearance of blood is not necessarily related to the previously established diagnosis, even if a full workup was performed very recently.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Clinical and radiological criteria for lung abscess and gangrene.
• Emergency care algorithm for massive pulmonary hemorrhage.
• Differential diagnosis of pulmonary embolism and pulmonary infarction.
• Pathogenesis of bronchiectasis formation and clinical features of bronchiectasis.
• Signs of gastrointestinal bleeding and portal hypertension.

Other topics in the "Respiratory System" section

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