Pharm D
As a nurse, you may have encountered patients with complaints about blood in their sputum. This condition, known as hemoptysis, occurs when the patient coughs blood from the respiratory tract.
In this blog, we’ll delve into the various aspects of hemoptysis, including its diagnosis, causes, and the crucial role of nurses in its management.
Blood circulates in the lungs through two main pathways. The majority (around 95%) flows through pulmonary arteries, which have low pressure and end up in the capillary bed, where gas exchange occurs. The remaining 5% of the blood circulates through bronchial arteries, which have high pressure. These arteries originate at the aorta and supply the supporting structures and significant airways.
When a patient coughs up blood, it generally arises from the bronchial circulation, with the following exceptions: when the pulmonary arteries are damaged because of tumors; erosion of a calcified or granulomatous lymph node; or high intravascular pressure caused by high pressure in the pulmonary veins or left ventricle.
Blood-streaked sputum can result from minor illnesses, such as viral or bacterial respiratory tract infections, or a long-term cough. But it can also occur due to severe conditions, such as:
Other causes of hemoptysis include pulmonary endometriosis, the use of thrombolytics or anticoagulants, and systemic coagulopathy. In children, the most common causes are lower respiratory tract infections and foreign body aspiration.
When a patient presents with hemoptysis, taking an appropriate medical history is essential in diagnosing the underlying cause. Include present illness with duration and temporal patterns, such as cyclical recurrence or abrupt onset. Ask the patient about provoking factors of hemoptysis, such as exposure to cold, exertion, allergens, and lying in the supine position. Also ask about the volume of hemoptysis. They can explain it as streaking, a cup, or a teaspoon quantity.
While obtaining their medical history, make sure the patient differentiates between true and pseudo hemoptysis: bleeding from the nasopharynx coming with cough, and hematemesis is blood from the gastrointestinal tract. To make the distinction, ask about postnasal drip from the nares without coughing that indicates pseudo hemoptysis, or nausea and vomiting with black, brown, or coffee-ground–colored blood (a characteristic of hematemesis).
True hemoptysis is characterized by bright red blood and frothy sputum, and if massive, it can be accompanied by a choking sensation.
And don’t forget to discuss risk factors for hemoptysis, including:
As you obtain the patient’s complete medication history, be sure to rule out whether or not they take anticoagulants or blood thinners or have taken them recently, which can cause hemoptysis.
To treat hemoptysis, you need to rule out the underlying cause. However, the initial treatment has two goals:
It can be difficult to protect the uninvolved lung because initially, it is unclear which lung is bleeding. Once the side is identified, strategies can be implemented, such as positioning the patient with the bleeding lung side in a dependent position, selectively intubating the uninvolved lung, or obstructing the bronchus going to the bleeding lung.
To prevent exsanguination, reverse bleeding diathesis and direct efforts to stop the bleeding. If bleeding is caused by clotting deficiencies, reverse it with fresh frozen plasma and factor-specific or platelet transfusions. Use desmopressin to reverse platelet dysfunction associated with uremia and kidney disease. Tranexamic acid is an antifibrinolytic drug that helps promote hemostasis. Laser therapy, cauterization, or direct injection with epinephrine or vasopressin can be done via bronchoscope to stop hemoptysis.
Moreover, embolization via bronchial artery angiography is the preferred method to stop massive hemoptysis. It has a success rate of up to 90%. For massive hemoptysis, not controlled by embolization or rigid bronchoscopy, emergency surgery is the last resort.
Hemoptysis can have various causes, ranging from mild to severe conditions. Ruling out the cause remains essential in clinical practice and diagnosing the underlying cause. The patient with hemoptysis may be anxious about the condition. Calm them down and explain the risk factors and treatment options. Compel the patient to report to the physician soon if they have massive hemoptysis with a choking sensation.
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