Hemoptysis (Coughing Up Blood) - What does the blood look like?


Hemoptysis (which is pronounced he-MOP-tis-is) is coughing up blood from the respiratory tract. Blood can come from the nose, mouth, throat, the airway passages leading to the lungs, or the lungs. The word "hemoptysis" comes from the Greek "haima," meaning "blood," and "ptysis," which means "a spitting".

Blood-tinged mucus in a healthy nonsmoker usually indicates a mild infection. Indeed, the most common cause for coughing up blood is the least serious—a ruptured small blood vessel caused by coughing and/or a bronchial infection.
In patients with a history of smoking and those who are otherwise at risk for lung disease, however, hemoptysis is often a sign of serious illness. Serious conditions that can cause hemoptysis include bronchiectasis (chronic dilation and infection of the bronchioles and bronchi), pulmonary embolus (a clogged artery in the lungs that can lead to tissue death), pneumonia (a lung infection), and tuberculosis.

Hemoptysis can also result from inhaling a foreign body (e.g., particle of food) that ruptures a blood vessel. Whatever the suspected cause, hemoptysis should always be reported to a physician.

Hemoptysis refers specifically to blood that comes from the respiratory tract. Blood also may come from the nose, the back of the throat, or part of the gastrointestinal tract. When blood originates outside of the respiratory tract, the condition is known as "pseudohemoptysis." Vomiting up blood, medically known as hematemesis, is one type of pseudohemoptysis. Differentiating between hemoptysis and hematemesis is an integral part of diagnosis. Since they involve different parts of the body, treatments and prognose (prospect of recovery) are not the same.

Classifying hemoptysis as mild or massive (some practitioners classify it as trivial, moderate, or massive) is difficult because the amount of blood is often hard to accurately quantify. Life-threatening, "massive" hemoptysis, which requires immediate medical attention, is differentiated from less severe cases.
Massive hemoptysis

Hemoptysis is considered massive, or major, when there is so much blood that it interrupts breathing (generally more than about 200-240 mL, or about 1 cup, in 24 hours). Massive hemoptysis is a medical emergency: the mortality rate for patients with massive hemoptysis can be as high as 75%. Most patients who die from hemoptysis suffer from asphyxiation (lack of oxygen) due to too much blood in the airways.
Mild hemoptysis
If there is a small amount of blood or sputum streaked with blood, the spitting is considered mild hemoptysis. In 60% to 70% of mild hemoptysis cases, the underlying disorder is benign and disappears on its own without causing serious problems or permanent damage.

Even mild hemoptysis can result in critical breathing problems, depending on the underlying cause for the bleeding. Additionally, hemoptysis tends to occur intermittently and recur sporadically, and there is no way to predict if patients with mild hemoptysis are at risk for massive hemoptysis. Diagnosis is important to prevent a more serious condition.

The first step in the evaluation of hemoptysis is to decide if it is really hemoptysis—that is, is the blood coming from the bronchial tree or lungs or from some other site? In most cases, history will suggest that blood is actually being coughed up from the airways or lungs, but it may be difficult at times to distinguish blood being coughed up from the respiratory system from blood coming from two other sites: bleeding in the upper respiratory tract, in the nasopharynx or sinuses, or blood originating in the gastrointestinal tract that was regurgitated or vomited.

A history of frequent nosebleeds, hoarseness, or some other change in the voice or history of mouth lesions might suggest bleeding from the upper respiratory tract. If bleeding is not clearly from the lungs then a thorough examination of the upper respiratory system is indicated. If the source remains equivocal, i.e., no abnormality in the upper respiratory tract is found on initial examination and no source is found after further pulmonary work-up as described below, then an examination by an otolaryngology specialist may be warranted. Hematemesis occasionally may be difficult to distinguish from hemoptysis; moreover, blood from a respiratory source may be swallowed and may present as coffee-ground emesis. Gastrointestinal symptoms suggest an upper GI work-up when the bleeding source is unclear.

The second question to be asked is whether the bleeding is massive (or life-threatening), which if present changes the approach to management as well as affecting the differential diagnosis. Massive or life-threatening hemoptysis has usually been defined by the rate of bleeding, defined as greater than 200 ml per day by various authors. The bleeding rate is critical since the problem with massive hemoptysis is not exsanguination but asphyxiation from blood that floods alveoli or clots that functionally obstruct airways. Thus, any amount of bleeding at a high rate, even over a short period of time, should be managed as being potentially life-threatening. The approach to massive hemoptysis is described in more detail below.


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