Pulmonary Hemorrhage

What is Pulmonary Hemorrhage?

Pulmonary hemorrhage, or bleeding in the lungs, is a serious problem in the field of lung health. It often shows up as hemoptysis, or coughing up blood, in a range of lung diseases like bronchiectasis, tumors, tuberculosis, aspergilloma, and cystic fibrosis. Hemoptysis happens when a person coughs up blood, either by itself or mixed with mucus, that comes from the lower part of the respiratory tract (below the vocal cords). The severity of hemoptysis can range from mild to life-threatening and could possibly result in a dangerous loss of stable blood flow and fatal outcomes caused by choking or shock.

Usually, pulmonary hemorrhage involves bleeding from the blood vessels in the lungs or bronchial tubes, often from the high-pressure bronchial system. Earlier ways of categorizing pulmonary hemorrhage focused on measuring blood loss, which can be tough. Nowadays, doctors find it more useful to classify pulmonary hemorrhage based on its severity and effect on the body. It’s vital to rapidly assess and stabilize a person dealing with pulmonary hemorrhage because before the development of a certain technique to block off part of the blood supply to the lungs (bronchial artery embolization), the condition had a high mortality rate – as high as 70%. This fast response involves pinpointing the cause of the bleeding and creating a treatment plan that can include protecting the airway, ensuring enough oxygen and proper breathing, and getting images of the lungs for a long-term solution.

What Causes Pulmonary Hemorrhage?

The typical cause of a very serious lung bleed is the network of blood vessels that supply the bronchi, the tubes that carry air in and out of your lungs. This network can cause as much as 90% of intense lung bleeding. Other areas where bleeding could occur include abnormal connections between an artery and bronchus (aortobronchial fistulas), burst aneurysms, and non-bronchial areas and lung blood vessels (each being about 5% of the time).

In a study from a specialized hospital in France that looked at 1087 patients, the most common reasons for massive lung bleeding were:

* Tuberculosis (25%; with 12% from active tuberculosis and 13% from after-effects of tuberculosis)
* Bronchiectasis (20%, a condition where the bronchi are permanently widened)
* Mycetomas (6%, fungal infections)
* Unknown causes of lung bleeding (18%)
* Lung cancer (17%)
* Other sources: Injuries and medical procedures

A more recent study from Italy looked at 606 patients from 5 hospitals, revealing the most common causes as:

* Lung cancer (19.1%)
* Pneumonia or a lung abscess (18.6%)
* Bronchiectasis (14.9%)
* Acute bronchitis (13.7%)
* Tuberculosis (5%; active cases were 3.3% and after-effects were 1.7%).

In a study from Greece, it was found that bronchiectasis and tumors are the most common cause of moderate-to-huge lung bleeds. This study defined moderate bleeding as losing 20-500 milliliters of blood in 24 hours, and huge bleeding as a loss of over 500 milliliters within 24 hours.

Risk Factors and Frequency for Pulmonary Hemorrhage

Hemoptysis, which is the medical term for coughing up blood from the respiratory tract, can be influenced by many factors. These include a person’s overall health condition and where they live. It’s more a symptom than a condition in itself, usually tied to respiratory infections, long-term lung diseases, and cancers. Generally, it only involves mild bleeding, usually less than 100 mL of blood in a 24-hour period. But, sometimes, it can become severe, even life-threatening, requiring immediate medical attention. Such severe cases are rare though, making up 5% to 15% of hemoptysis cases.

The rate at which people experience hemoptysis can also vary widely depending on the area and population. Areas with high rates of tuberculosis (TB), bronchiectasis, and lung cancer are typically more affected. In developed countries, chronic bronchitis and bronchiectasis are major causes of hemoptysis, while in developing regions, TB is a key cause. There are two main age peaks where hemoptysis can be more common: younger adults due to infections like TB and older adults due to cancers like lung cancer. In a French study, the majority of patients were aged around 54, were men, and had a history of smoking. Another study showed similar results with a median age of 67 and most patients being men with a history of smoking.

• Hemoptysis usually involves mild bleeding, typically less than 100 mL of blood in a 24-hour period.
• Sometimes, hemoptysis can become severe and potentially life threatening, although these cases are rare (5% to 15%).
• The prevalence of hemoptysis varies by region and is notably higher in areas with high rates of diseases like tuberculosis (TB), bronchiectasis, and lung cancer.
• The main causes of hemoptysis also differ by region: in developed countries, it is typically chronic bronchitis and bronchiectasis, whereas in developing regions, TB is a prominent cause.
• Two age groups are more commonly affected: younger adults due to infections like TB and older adults due to cancers like lung cancer.
• Studies show that most patients affected by hemoptysis are typically men in their mid-50s to late 60s with a history of smoking.

Signs and Symptoms of Pulmonary Hemorrhage

Figuring out if bleeding is coming from the stomach or lungs is crucial. Doctors can sometimes tell the difference by asking the patient if the blood is coming up when they cough or vomit. It’s also important to know how much blood was lost, when the bleeding started, and if the patient has had any fevers, a history of Tuberculosis, went to any places where certain diseases are common, or if they have a history of smoking or cancer. Night sweats, weight loss, and use of blood-thinning medication are also significant. Knowing how active the patient was before the bleeding can indicate whether they would be able to recover well from a surgery to remove a lung lobe if it’s needed.

The first evaluation of the patient includes checking their airway, breathing, and circulation. The airway must be clear, and the doctor will look in the throat for any bleeding at the back. The main part of the physical check will be to establish stability and rule out any non-lung-related sources of the bleeding, such as bleeding from the stomach or nosebleed. Checking the color of the patient’s skin and how quickly blood returns after lightly pressing on a fingernail or the skin can help decide if the patient urgently needs a blood transfusion. Examining the lungs might reveal if the bleeding is only coming from one lung.

It’s hard to be sure about the exact amount of blood lost when a patient is coughing up blood, as figures in medical science vary from 100 to 200 millilitres. A person’s lungs and airways can hold about 200 millilitres of air, so if a patient shows signs of distress, breathlessness, and low oxygen levels, along with significant coughing up of blood, this should prompt immediate efforts to revive them. Instead of trying to measure and calculate the exact amount of blood lost, doctors should base their actions on these clinical signs.

Testing for Pulmonary Hemorrhage

If your doctor suspects you might have a health issue related to your blood, such as low blood supply (hemoglobin and hematocrit) or low platelet count (thrombocytopenia), they will conduct a full blood test. Additionally, they may run other tests to understand your overall wellbeing. These can include checking your basic body’s chemicals (basic metabolic panel), blood type, compatibility of your blood with donor blood (crossmatch), levels of oxygen and carbon dioxide in your blood (arterial blood gas), and how well your blood can clot (coagulation panel).

A chest x-ray might also be performed to check for any issues on one side of your lungs. While it can help find where the problem is 45% to 65% of the time, it only finds the cause of the problem 25% to 35% of the time. If you’re feeling stable, it might be a good idea to get a chest CT scan, another type of x-ray that gives a more detailed image of your chest. The CT scan can better outline the cause of your symptom – it may even be more sensitive than a bronchoscopy, a procedure where a doctor looks inside your lungs using a thin, lighted tube. Because of this, some experts even see it as the first step in examining lung conditions.

Treatment Options for Pulmonary Hemorrhage

If the X-ray of the chest shows bleeding on one side or if it’s found during a physical, the doctor might suggest placing the bleeding side lower. This helps to isolate the bleeding and protect the rest of the lung. The doctor might also suggest changing your position to help control the bleeding.

And, in some cases, a procedure called “intubation” might be required. This involves putting a tube, usually at least 8 mm in size, into your throat to help you breathe. It might also be used for bronchoscopy, an examination of your lung, and to block the bleeding bronchial tubes. If the bleeding is too severe, the doctor may choose to ‘intubate’ the main bronchial tube on the right side. Equally, if the bleeding is originating from the left lung and a bronchoscope is not available, placing you to the right can help control the bleeding.

Previous studies showed that doctors can choose the lung they want to intubate by first conducting the procedure, then rotating the tube towards the side required, and moving it further until there is resistance. With this strategy, doctors accomplished appropriate placement 72.3% of the time for the left lung and 94% for the right lung. If this method is not successful, it may be possible to intubate the right main stem with a smaller tube (5 mm), allowing either ventilation of the right lung if it’s healthy, or isolating the right lung if it’s bleeding.

The doctor might also need to reverse any blood-thinning medications you might be taking. Research has also shown that a drug called tranexamic acid (TXA), which can be given either through an intravenous (IV) drip or as an inhaled mist, may be helpful in controlling pulmonary bleeding.

To further treat heavy bleeding, your doctor may use bronchoscopy. This procedure involves inserting a thin, flexible tube into your airway to examine the source of bleeding. The doctor may use this procedure to remove blood and blood clots, especially from the lung that’s not bleeding. There are two types of bronchoscopies: flexible and rigid. Rigid bronchoscopy also allows the doctor to control the bleeding, if possible.

Bronchial blockers might also be used. This treatment involves using a special catheter that can be used to control the bleeding. The blocker is typically placed into the main bronchial tube, providing temporary control until more definitive treatment can be given.

Your doctor also has direct treatments that can be given through a bronchoscope, such as cold saline rinse, epinephrine injections, and blood clotting medications. If a definitive source of bleeding is present and reachable, procedures such as electrocautery, cryotherapy, laser, or argon plasma coagulation can also be used.

An ultimate alternative is bronchial artery embolization, where the bronchial artery is deliberately blocked to stop the bleeding. This procedure is often considered the first line of treatment in massive lung hemorrhage. Still, it’s important to note re-bleeding occurs in about 30% of patients within 30 days. Therefore, if eligible, removing the lobe from the lung may be considered.

In severe cases, lung resection, or surgical removal of part of the lung, may be needed. This is considered the last resort because of the high risks associated with it. Emergency resections have a high rate of fatalities (35%), but this decreases significantly for resections done after bleeding control (4%), and goes to zero for resections scheduled after patient discharge. Therefore, it’s often recommended to provide temporary bleeding control when possible, to avoid emergency resection.

What else can Pulmonary Hemorrhage be?

If someone is experiencing lung bleeding, doctors would need to consider several possible causes. These could include:

• Aspergilloma (a fungal ball in the lungs)
• Alveolar hemorrhage (bleeding into the air sacs in the lungs)
• Arteriovenous malformations (abnormal connections between arteries and veins)
• Bronchitis (inflammation of the bronchial tubes)
• Bronchiectasis (widening of the bronchial tubes)
• Coagulopathy (a disease that affects the blood’s ability to clot)
• Embolism in the lungs (a blocked artery in the lungs)
• Lung abscess (a pus-filled cavity in the lung)
• Mitral stenosis (narrowing of the heart’s mitral valve)
• Tuberculosis (an infectious disease that mostly affects the lungs)
• Lung tumors

What to expect with Pulmonary Hemorrhage

How well someone recovers from a lung bleed, or pulmonary hemorrhage, greatly depends on a few factors. These include what caused the bleeding, how severe the bleeding was, and how quickly and effectively it was dealt with. The sooner this condition is identified and treated, the better the outcome usually is.

Lung bleeds can be life-threatening, particularly if they’re very severe — in the past, up to 70% of severe cases were fatal before a procedure called BAE was introduced. However, if the lung bleed is mild to moderate, and the cause of it can be effectively treated, the outlook is usually positive. Medical or surgical treatments can effectively manage conditions like bronchiectasis (a long-term condition where the airways of the lungs become abnormally widened, leading to a build-up of excess mucus that can make the lungs more vulnerable to infection), tuberculosis, and aspergilloma (a fungal ball in the lungs).

Severe lung bleeds are more of a concern. It’s crucial to promptly and efficiently manage these cases to ensure the patient’s breathing is protected and bleeding is stopped. Techniques like BAE can help improve survival rates significantly, boasting success rates of up to 90% in suitable patient groups. However, there’s still a risk that the patient might bleed again — this happens roughly 30% of the time within a month of the initial bleed, which may require further intervention.

So, the outcome for a person with a lung bleed depends on how quickly they receive treatment, the availability of advanced medical and surgical techniques, and their overall health and other health conditions. Thanks to advances in medical technology and teamwork across different healthcare areas, patient outcomes for lung bleeding are continuing to improve.

It’s very important to have an effective team of healthcare professionals to help manage cases of lung bleeds. This team’s role is to determine the severity of cases, guide treatments, and decide whether a patient needs to stay in hospital. Having such a team in place can help ensure resources are efficiently used, treatments are timely, and patient outcomes are improved by effectively managing the root cause of the lung bleed and any acute bleeding episodes.

Possible Complications When Diagnosed with Pulmonary Hemorrhage

Pulmonary hemorrhage, or lung bleeding, can often lead to serious, even life-threatening complications due to the severity of the condition. Here are the main complications linked with pulmonary hemorrhage:

• Respiratory failure: The blockage of airways by blood can result in a lack of oxygen, too much carbon dioxide, and severe respiratory distress syndrome.
• Hemodynamic instability: A significant amount of blood loss due to massive pulmonary hemorrhage can result in low blood volume, causing a severe condition known as hypovolemic shock.
• Infection: Blood in the airways and lungs can cause infections, including pneumonia. This risk is higher in patients who require intubation and mechanical ventilation for an extended period.
• Complications from interventions: Procedures to stop the bleeding can sometimes lead to complications. For instance, nontarget embolization can cause lack of blood supply in non-target areas, including the spinal cord, possibly resulting in paralysis.
• Cardiovascular complications: Severe pulmonary hemorrhage can strain the heart, leading to right ventricular failure due to an increase in resistance in the blood vessels inside the lungs.
• Neurological damage: Severe lack of oxygen due to respiratory failure can cause brain injury.
• Mortality: Despite improvements in treatment, massive pulmonary hemorrhage is often linked with high death rates. The risk is higher for those with severe bleeding and in patients with lung cancer or bleeding disorders.

To manage pulmonary hemorrhage effectively and improve patient outcomes, a team of specialists, including lung doctors, critical care doctors, radiologists who specialize in procedures, and chest surgeons, needs to work together.

Preventing Pulmonary Hemorrhage

Prevention and patient understanding are key components in managing pulmonary hemorrhage, which is a condition marked by severe bleeding in the lungs that can greatly affect a patient’s health. Taking active steps can stop these bleeding episodes from happening, especially for those with a high risk. These steps can involve monitoring and controlling existing lung diseases like bronchiectasis (a condition that causes mucus to collect in the lungs), tuberculosis, cystic fibrosis, and chronic bronchitis. Quitting smoking, taking vaccinations against lung infections, and treating lung infections swiftly can all lower the chance of complications in the lungs. Also, patients who are more likely to experience pulmonary hemorrhage should be trained to notice the early warning signs and symptoms. This helps them to seek immediate medical help to prevent severe consequences.

Teaching patients about pulmonary hemorrhage is crucial in helping them manage the disorder. Coughing up blood can be alarming to patients and their loved ones, hence reassurance and providing proper care are crucial to improve their condition. Patients should be made aware of potential reasons for their symptoms and the need for sticking to treatment plans for their pre-existing diseases. Education should also stress the importance of hospital follow-ups, taking medications consistently, and lifestyle changes to lower risk factors. By giving patients knowledge and reassurance, healthcare professionals can help reduce patient anxiety, encourage proactive health actions and improve the overall quality of life for patients prone to pulmonary hemorrhage.