Hemoptysis is a discharge of blood from the mouth, from the respiratory tree subglottic, usually during coughing.
This is usually a medical emergency. It requires a rapid assessment of the quantity and respiratory repercussions among often carry a known lung disease patients.
The most urgent need is to assess the importance of hemoptysis, which is easier when the doctor attends it.Hemoptysis is considered significant when it exceeds 500 mL.
She then put directly involved life-threatening and may require treatment in intensive care.
Usually of low abundance, even in the form of trickle of blood, it is almost always a concern and causes a medical consultation.
The amount must be specified as well often overstated. Take concrete images is a good way to estimate the amount: Glass bottom, teaspoon or tablespoon, often puts into perspective and gives time to send the patient directly to an emergency reception service where will be supported and where diagnostic measures will be implemented soon after eliminating the need for care in the ICU.
Differential diagnoses include the original ORL epistaxis and hematemesis of digestive origin.
The history of nosebleeds or posterior pharyngeal flow are sought and retching when bleeding can correct diagnosis.
Assessment of the amount and visibility:
This assessment can guide the conduct to be immediate: start of resuscitation or rather a diagnostic attitude if the clinical condition of the patient is stable.
The clinical signs of acute respiratory failure are primarily analyzed: respiratory rate, cyanosis, drawing, making saturation finger, before the rapid realization of blood gases, for judging the vital urgency.
The danger of hemoptysis lies more in the flooding of the tracheobronchial tree resulting in respiratory distress in hemorrhagic shock who does not have time to build or associating it quickly darkens the immediate prognosis, when the rupture of a large vessel in the tracheobronchial tree.
The blood comes mostly from the bronchial arterial circulation, break like a lung cancer. It may also result from vascular pressure increase at the origin of a blood extravasation into the alveolar sector as in the cardiogenic pulmonary edema, or result from rupture of the alveolar-capillary barrier by immunological mechanisms when vasculitis ( Wegener’s granulomatosis, polyarteritis nodosa, etc.) or connective (systemic lupus erythematosus, etc.)
The appearance is also important. The bronchial arterial blood is red, shiny, airy. It can be pure or accompanied by pus. A hémoptoïque sputum, defined by the presence of blood in your sputum in a patient without breathing history in the context of infectious bronchitis is not the same meaning and the same degree of urgency as in a patient with a tuberculous cavity sequelar colonized by aspergilloma or a patient with cystic fibrosis.
The history is therefore important first step before a patient with a first episode of hemoptysis.
The history of cystic fibrosis or lung cancer are generally known, but bring attention to the history of tuberculosis, which can sometimes be old. The research examined symptoms that evoke dilated bronchi unknown: a history of respiratory infections, etc.
Additional tests include a chest X-ray, complete with a computed tomography (CT) chest CT angiography with injection type if a pulmonary embolism is suspected or with millimetric cuts if the diagnosis of pulmonary parenchymal disease, type bronchiectasis, is suspected.
CT allows to visualize a tumor or look opacities, pneumonic opacity, pulmonary embolism, arteriovenous malformations.
Most often they are complemented with a bronchoscopy under the guidance of CT and used to guide the side and / or the source of bleeding. The presence of a clot is respected as providing hemostasis during a review that may worsen by luimême bleeding. In case of respiratory failure, endoscopy is not performed. The systematic search for mycobacterium direct examination of bronchial aspiration and cytobacteriological review of the three days of sputum bronchoscopy is performed.
Finally, it should be noted that the realization of bronchial biopsies during an endoscopy for diagnostic purposes for any other symptom may be the cause of hemoptysis, usually minimal, and in any case spontaneously reversible in 24 or 48 hours. If this was not the case, the patient should consult urgently.
The main causes are summarized in Box 1.
Box 1. Etiology of hemoptysis
Bronchiectasis, cystic fibrosis
bronchial biopsies (endoscopy)
Bleeding intra-alveolar (lupus, Wegener’s disease, Goodpasture’s syndrome)
The left heart failure can cause hemoptysis via a alveolar hemorrhage and complicate rosé sputum that may be encountered during any intra-alveolar hemorrhages.
Moreover, pulmonary embolism may be accompanied by hemoptysis. It is rarely the inaugural sign. Indeed, it results from the formation of pulmonary infarction succeeding pulmonary arterial obstruction by a fi brinocruorique clot.
She usually follows within days to chest pain classically pleural type inhibiting deep breath and dyspnea. It is usually dark.
The presence of mucocutaneous angiomas associated with a vascular thoracic breath systolodiastolique referred to the diagnosis of arteriovenous fistula under a Osler Rendu disease.
In case of massive hemoptysis, what to do at first, is to ensure the vital functions with immediate oxygenation to maintain a higher oxygen peripheral saturation of 92%, if hemoptysis is important. Meanwhile resuscitative measures, the lateral decubitus development towards the source of bleeding, known or suspected attempts to avoid flooding the blood of the contralateral lung. An infusion should quickly be installed with the taking of a blood group and the search for irregular antibodies.
Intubation may be necessary and is designed to achieve selective intubation of the healthy side to protect the blood flood.
After assuring oxygenation maneuvers are undertaken to dry up the bleeding.
The use of vasopressor drugs (vasopressin) can help to stop the bleeding. If it is insufficient or the risk of dangerous recidivism respiratory insufficient sick, bronchial artery embolization may be necessary. Finally, a hemostasis pneumonectomy may be considered as a last resort with a significant operative risk.
In conclusion, hemoptysis is still a worrying symptom and requires an assessment of the urgency of the treatment. The most common diagnoses are now bronchopulmonary carcinoma who dethroned, compared to the older clinical series, tuberculosis. The absence of cause found hemoptysis is a situation far from uncommon, between 10 and 30% of cases, and should encourage regular radiological and clinical monitoring in patients, especially in smokers.