Pulmonary hemorrhage is a dangerous complication of various respiratory diseases, accompanied by the outflow of blood from bronchial or pulmonary vessels and its release through the airways. Pulmonary bleeding is manifested by coughing with the release of liquid scarlet blood or clots, weakness, dizziness, hypotension, fainting. For diagnostic purposes, lung X-ray, tomography, bronchoscopy, bronchography, angiopulmonography, selective angiography of the bronchial arteries is performed for pulmonary bleeding. Stopping pulmonary bleeding may include conservative hemostatic therapy, endoscopic hemostasis, endovascular embolization of bronchial arteries. In the future, surgical treatment is indicated to eliminate the source of pulmonary bleeding, taking into account etiological and pathogenetic factors.
ICD 10
R04.8 R04.2
Meaning
Pulmonary hemorrhage is one of the most dangerous conditions that complicate the course of a wide range of diseases of the bronchopulmonary and cardiovascular systems, diseases of the blood system and hemostasis. Therefore, the problem of emergency care for pulmonary bleeding is relevant for specialists in the field of pulmonology, phthisiology, oncology, cardiology, hematology, rheumatology. Delay in carrying out emergency hemostatic measures can cause rapid death of patients. Depending on the severity of blood loss and the condition that caused it, the mortality from pulmonary hemorrhage varies from 5-15% to 60-80%. Among patients with pulmonary hemorrhage, persons of mature age (50-55 years old) with a burdened somatic pathology predominate.
Causes of pulmonary hemorrhage
The frequent occurrence of hemoptysis and pulmonary hemorrhage is determined by the polyetiology of these conditions. The first place in the structure of causes of pulmonary hemorrhage belongs to pulmonary tuberculosis (over 60% of cases). A significant role in the etiology of pulmonary bleeding is assigned to nonspecific and purulent-destructive diseases – bronchitis, chronic pneumonia, bronchiectasis, pneumosclerosis, abscess and lung gangrene.
Often the causes of pulmonary bleeding are bronchial adenoma, malignant tumors of the lungs and bronchi, parasitic and fungal lesions (ascariasis, echinococcosis, schistosomatosis, actinomycosis of the lungs), pneumoconiosis (silicatosis, silicosis). Pulmonary bleeding may be caused by inadequate local hemostasis after endoscopic or transthoracic biopsy, surgical intervention on the lungs and bronchi. Foreign bodies in bronchus, chest injuries (rib fractures, etc.) can lead to pulmonary bleeding.
In addition to respiratory diseases, hemoptysis and pulmonary bleeding can occur in diseases of the heart and blood vessels: PE, mitral stenosis, aortic aneurysm, arterial hypertension, atherosclerotic cardiosclerosis, myocardial infarction. Relatively rare causes of pulmonary hemorrhage include pulmonary endometriosis, Wegener’s granulomatosis, systemic capillaritis (Goodpascher syndrome), hereditary telangiectasia of the skin and mucous membranes (Rendu-Osler syndrome), hemorrhagic diathesis, etc. Pulmonary hemorrhage may be caused by a violation of blood clotting during prolonged and poorly controlled anticoagulant therapy.
Factors provoking pulmonary bleeding can be physical or emotional stress, infections, insolation, hemodynamic disorders, pulmonary hypertension, menstruation, etc.
Pathogenesis
The morphological basis for pulmonary bleeding is thinned and aneurysmally dilated branches of the pulmonary artery or bronchial arteries, as well as pulmonary veins. Rupture or arrosion of altered vessels may be accompanied by pulmonary bleeding of varying severity. At the same time, the magnitude of pulmonary bleeding is largely determined by the caliber of the damaged vessel, and the severity of disorders occurring in the body is the rate and intensity of blood loss.
Developing further disorders are associated with the obstruction of the respiratory tract by the spilled blood and the actual amount of blood loss. Getting into the bronchi even in small quantities, blood causes the development of obstructive atelectasis and aspiration pneumonia. In turn, this leads to a decrease in the volume of functioning lung tissue, gas exchange disorders, a progressive increase in respiratory failure, hypoxemia.
Hypovolemia and anemia, accompanying acute and chronic (with recurrent pulmonary bleeding) blood loss, lead to a general violation of homeostasis. This is primarily expressed in the activation of fibrinolytic and anticoagulant mechanisms, which causes an increased tendency to hypocoagulation, increased permeability of vascular walls. The cumulative result of such changes determines the pathological readiness of the body to resume pulmonary bleeding at any time.
Classification
In the clinical aspect, it is important to distinguish between pulmonary bleeding and another, less dangerous, but more common condition – hemoptysis. Hemoptysis differs in volume and rate of blood release from the airways. In some cases, hemoptysis precedes massive pulmonary hemorrhage, therefore it also requires a full clinical and radiological examination and urgent measures to stop it. Usually, hemoptysis is understood as the discharge of sputum with streaks or an admixture of blood when coughing; at the same time, the amount of blood released does not exceed 50 ml per day. An increase in the volume of coughed up blood is regarded as pulmonary bleeding.
Depending on the volume of blood released during coughing, there are small pulmonary bleeding (50-100 ml per day), medium (100-500 ml per day), heavy or heavy pulmonary bleeding (over 500 ml of blood per day). Especially dangerous are “lightning-fast” profuse bleeding that occurs simultaneously or within a short period of time. As a rule, they lead to acute asphyxia and death.
Unlike hemothorax, pulmonary hemorrhage refers to external bleeding. Mixed pulmonary-pleural bleeding also occurs.
Symptoms of pulmonary hemorrhage
The clinic of pulmonary hemorrhage consists of a symptom complex caused by general blood loss, external bleeding and pulmonary heart failure. The onset of pulmonary bleeding is preceded by the appearance of a strong persistent cough, dry at first, and then with the separation of mucous sputum and scarlet blood or coughing up blood clots. Sometimes, shortly before pulmonary bleeding, there is a feeling of gurgling or tickling in the throat, a burning sensation in the chest on the side of the lesion. In the initial period of pulmonary hemorrhage, the separating blood has a bright red color, later becomes darker, rusty-brown. When the bronchus is obstructed by a blood clot, pulmonary bleeding may stop on its own.
The general condition is determined by the severity of blood loss. Patients with pulmonary hemorrhage are characterized by a frightened appearance, adynamia, pallor of the skin of the face, cold sticky sweat, acrocyanosis, decreased blood pressure, tachycardia, dizziness, tinnitus and head, shortness of breath. With copious pulmonary bleeding, visual impairment (amaurosis), fainting, sometimes vomiting and convulsions, asphyxia may occur. On 2-3 days after pulmonary bleeding, a picture of aspiration pneumonia may develop.
Diagnostics
To determine the cause of pulmonary bleeding, a diagnostic consultation is often required with the participation of specialists in pulmonology, phthisiology, thoracic surgeons, oncologists, radiologists, vascular surgeons, cardiologists, otolaryngologists, rheumatologists, hematologists. During auscultative examination, moist medium-bubbly wheezes in the lungs and gurgling wheezes in the sternum are determined. During blood aspiration, there is a shortening of the percussion sound, the noise of pleural friction, a weakening of breathing and vocal trembling.
The source of the bleeding can presumably be determined by the color of the blood. The release of scarlet, foamy blood, as a rule, indicates pulmonary bleeding; dark red, coffee-colored blood indicates gastrointestinal bleeding. Sometimes the hemoptysis clinic can simulate nosebleeds, therefore, for the purpose of differential diagnosis, it is important to consult an otolaryngologist and rhinoscopy. In doubtful cases, in order to exclude bleeding from the gastrointestinal tract, EGDS may be required.
To confirm the source of bleeding in the lungs, an X-ray examination is performed: polypositional lung x-ray, linear and computed tomography, MRI of the lungs. If necessary, they resort to in-depth X-ray examination: bronchography, bronchial arteriography, angiopulmonography.
The leading method of instrumental diagnosis for pulmonary bleeding is bronchoscopy. Endoscopic examination allows you to visualize the source of bleeding in the bronchial tree, perform aspiration of washing waters, forceps and scarification biopsy from the area of pathological changes.
Hypochromic anemia, poikilocytosis, anisocytosis, and a decrease in the hematocrit number are detected in peripheral blood with pulmonary bleeding. In order to assess the severity of changes in the coagulation and anticoagulation systems of the blood, the coagulogram and the number of platelets are examined. Sputum tests (microscopic, PCR, for acid-resistant mycobacteria) can detect atypical cells, Mycobacterium tuberculosis, indicating the etiology of pulmonary bleeding.
Treatment for pulmonary hemorrhage
Conservative methods, local hemostasis, palliative and radical surgical interventions are used in the treatment of pulmonary bleeding. Therapeutic measures are used for pulmonary bleeding of small and medium volume. The patient is assigned rest, a semi-sitting position is given, venous tourniquets are applied to the limbs. Tracheal aspiration is performed to remove blood from the tracheal lumen. In case of asphyxia, emergency intubation, blood suction and ventilation are required.
Drug therapy includes the introduction of hemostatic drugs (aminocaproic acid, calcium chloride, vikasol, sodium ethamzylate, etc.), hypotensive agents (azamethonium bromide, hexamethonium benzosulfonate, trimetaphane camsilate). In order to combat posthemorrhagic anemia, replacement transfusion of erythrocyte mass is performed; native plasma, rheopolyglucin, dextran or gelatin solution is injected to eliminate hypovolemia.
If conservative measures are ineffective, they resort to instrumental stopping of pulmonary bleeding with the help of local endoscopic hemostasis. Therapeutic bronchoscopy should be performed in the operating room, in conditions of readiness for transition to emergency thoracotomy. For endoscopic hemostasis, local applications with adrenaline, ethamzylate, and hydrogen peroxide can be used; the installation of a hemostatic sponge, electrocoagulation of the vessel at the site of blood flow, short-term occlusion with an inflatable Fogarty-type balloon or temporary obturation of the bronchus with a foam seal. In some cases, endovascular embolization of the bronchial arteries, carried out under the control of X-rays, is effective.
In most cases, these methods allow you to temporarily stop pulmonary bleeding and avoid urgent surgery. Final and reliable hemostasis is possible only with surgical removal of the source of bleeding.
Palliative interventions for pulmonary bleeding may include surgical collapse therapy for pulmonary tuberculosis (thoracoplasty, extrapleural filling), ligation of the pulmonary artery or a combination of this surgical technique with pneumotomy. Palliative interventions are resorted to only in forced situations when radical surgery is impossible for some reason.
Radical operations for pulmonary bleeding involve the removal of all pathologically altered areas of the lung. They may consist in partial resection of the lung within healthy tissues (marginal resection, segmentectomy, lobectomy, bilobectomy) or removal of the entire lung (pneumonectomy).
Forecast
Even a single and self-stopped pulmonary hemorrhage is always potentially dangerous in terms of resumption. Copious pulmonary bleeding threatens the patient’s life. In severe cases, death occurs as a result of asphyxia caused by blockage of the airways by blood clots and simultaneous spastic contraction of the bronchi. The percentage of postoperative complications and mortality in operations performed at the height of pulmonary hemorrhage is more than 10 times higher than similar indicators in planned operations.
Literature
- Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017 Sep;9(Suppl 10):S1069-S1086. link
- Yendamuri S. Massive Airway Hemorrhage. Thorac Surg Clin. 2015 Aug;25(3):255-60. – link
- Fartoukh M, Khoshnood B, Parrot A, Khalil A, Carette MF, Stoclin A, Mayaud C, Cadranel J, Ancel PY. Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis. Respiration. 2012;83(2):106-14. – link
- Mondoni M, Carlucci P, Job S, Parazzini EM, Cipolla G, Pagani M, Tursi F, Negri L, Fois A, Canu S, Arcadu A, Pirina P, Bonifazi M, Gasparini S, Marani S, Comel AC, Ravenna F, Dore S, Alfano F, Sferrazza Papa GF, Di Marco F, Centanni S, Sotgiu G. Observational, multicentre study on the epidemiology of haemoptysis. Eur Respir J. 2018 Jan;51(1) – link
- Tsoumakidou M, Chrysofakis G, Tsiligianni I, Maltezakis G, Siafakas NM, Tzanakis N. A prospective analysis of 184 hemoptysis cases: diagnostic impact of chest X-ray, computed tomography, bronchoscopy. Respiration. 2006;73(6):808-14. – link
