Hemoptysis

Hemoptysis is the coughing up of blood. Few symptoms produce as much alarm in patients as does hemoptysis. Careful description of the hemoptysis is crucial because what is produced can include clots of blood, as well as blood-tinged sputum. The implications of each are very different. Coughing up clots of blood is a symptom of extreme importance because it often heralds a serious illness. Clots of blood are usually indicative of a cavitary lung lesion, a tumor of the lung, certain cardiac diseases, or pulmonary embolism. Blood-tinged sputum is usually associated with smoking or minor infections, but it can be seen with tumors and more serious diseases as well. When a patient complains of coughing up blood, the examiner should ask the following questions:

''Do you smoke?" If yes, ''What do you smoke? How much, and for how long?''

''Did the coughing up of blood occur suddenly?''

''Have there been recurrent episodes of coughing up blood?''

''Is the sputum blood-tinged, or are there actual clots of blood?''

''How long have you noticed the blood?''

Table 13-2 Appearances of Sputum

Appearance

Mucoid

Possible Causes

Mucopurulent Yellow-green, purulent Rust-colored, purulent Red currant jelly Foul odor

Gravel

Pink, blood-tinged

Asthma, tumors, tuberculosis, emphysema, pneumonia

Asthma, tumors, tuberculosis, emphysema, pneumonia

Bronchiectasis, chronic bronchitis

Pneumococcal pneumonia

Klebsiella pneumoniae infection

Lung abscess

Streptococcal or staphylococcal pneumonia Broncholithiasis

Pink, frothy

Profuse, colorless (also known

Alveolar cell carcinoma

Pulmonary edema as bronchorrhea) Bloody

Pulmonary emboli, bronchiectasis, abscess, tuberculosis, tumor, cardiac causes, bleeding disorders

''What seems to bring on the coughing up of blood? vomiting? coughing? nausea?'' ''Have you ever had tuberculosis?'' ''Is there a family history of coughing up blood?'' Have you had recent surgery?'' ''Do you take any 'blood thinners'?'' ''Are you aware of any bleeding tendency?'' Have you had any recent travel on airplanes?''

' 'Have you had night sweats? shortness of breath? palpitations? irregular heartbeats? hoarseness? weight loss? swelling or pain in your legs?''

Have you felt any unusual sensation in your chest after coughing up blood?'' If so, Where?''

(For a woman with hemoptysis) ' 'Do you use oral contraceptives?''

Any suppurative (associated with the production of pus) process of the airways or lungs can produce hemoptysis. Bronchitis is probably the most common cause of hemoptysis. Bronchiectasis and bronchogenic carcinoma are also major causes. Hemoptysis results from mucosal invasion, tumor necrosis, and pneumonia distal to bronchial obstruction by tumor. Pneumococcal pneumonia characteristically produces rust-colored sputum. Pink and frothy sputum can result from pulmonary edema.

On occasion, patients have a warm sensation in the chest at the location from which the hemoptysis originated. Therefore, it is useful to ask patients with recent hemoptysis whether they experienced such a sensation. This information may lead to a more careful review of the physical examination and x-ray films of that area.

Patients who have undergone recent surgery or have traveled for long periods of time on airplanes are at risk for deep vein thrombophlebitis with pulmonary embolism. Women taking oral contraceptives are likewise at risk for pulmonary embolic disease. Hemoptysis occurs when pulmonary emboli result in infarction, with necrosis of the pulmonary parenchyma.

Recurrent episodes of hemoptysis may result from bronchiectasis, tuberculosis, or mitral stenosis. Atrial fibrillation is a common cause of ''irregular heartbeats'' and embolic phenomena.

Sometimes it is difficult to ascertain whether the patient coughed up or vomited blood. Most patients can provide a sufficiently clear history. Table 13-3 lists characteristics that help distinguish hemoptysis from hematemesis (vomiting of blood).

Table 13-3 Characteristics Distinguishing Hemoptysis from Hematemesis Features Hemoptysis Hematemesis

Prodrome Past history

Appearance Color

Manifestation Associated symptoms

Coughing

Possible history of cardiopulmonary disease

Frothy

Bright red

Mixed with pus

Dyspnea

Nausea and vomiting

Possible history of gastrointestinal disease

Not frothy

Dark red, brown, or ''coffee grounds''

Mixed with food

Nausea

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