Hemoptysis from the point of view of a bronchologist in the framework of a general hospital

INTRODUCTION
Hemoptysis is the coughing up of blood from the respiratory system. It is a worrying symptom and at the same time a clinical sign that most often leads the patient to the doctor. Massive (abundant) hemoptysis is the coughing up of over 600 ml of blood (approximately the amount that corresponds to one kidney-shaped vessel, the so-called kidney) in 24 hours. Coughing up blood is quite common and is usually not a serious finding. Cough with admixtures of blood can be the result of an infection or a more serious process, so it definitely requires diagnostic workup to find out what is behind its appearance. Th e causes of hemoptysis in 20% are tumors, especially lung cancer. In a smoker over 40 with hemoptysis, doctors look for lung cancer even when
the cough is only blood tinged. Pulmonary infarction can also cause hemoptysis. Endoscopic examination is a basic and doctrinal procedure in a patient who reports
hemoptysis to the pneumophthisiology clinic of a general hospital. Bronchial artery embolization has become the main method that successfully stops profuse hemoptysis
in up to 90% of cases. Urgent surgical intervention is indicated for profuse hemoptysis that cannot be stopped by rigid bronchoscopy or embolization and generally represents
the last possibility. Treatment of scantier hemoptysis is directed at the cause. Bleeding due to mitral stenosis or cardiac decompensation from another cause usually responds
to specific cardiological therapy. Bleeding due to pulmonary embolism is rarely profuse (massive) and almost always stops spontaneously. If the embolism recurs and the
bleeding continues, anticoagulant therapy may be contraindicated, and the therapeutic choice is the placement of a filter in the inferior saphenous vein. Since bleeding from bronchiectasis is usually a consequence of infection, it is important to carry out appropriate antibiotic therapy and local drainage.
OBJECTIVE
The aim of the work is to review the bronchoscopy findings in patients who gave anamnestic information about coughing up bloody secretions or clear blood (regardless of the amount), and who had a normal radiograph (no pathological changes in the lung fields, mediastinum, cardiac silhouette or in the chest wall were no observed on the chest radiography).
MATERIAL AND METHODS
A retrospective analysis of 3140 bronchoscopy reports from the protocols of the pulmonology clinic of the City General Hospital “8-mi Septemvri” and the Dispensary for Lung Diseases and Tuberculosis of the former Military Hospital in Skopje was performed. A period of 40 years (1983-2023) was considered. Reports where the indication for endoscopic examination was the diagnosis of hemoptysis – ICD code
R04.2 – bloody sputum (Hemoptysis) was taken into consideration. We rarely found other codes with an indication for a bronchoscopy examination, such as: R04
bleeding from the respiratory tract (Hemorrhage tractus respiratoryorum), R04.1 bleeding from the pharynx (Hemorrhage pharyngis), R04.8 bleeding from other parts
of the respiratory tract (Hemorrhage partum tractus respiratoryorum aliarum) and R04.9 bleeding from the respiratory tract, unspecifi ed (Hemorrhagic partium tractus respiratoryorum non specifi cata). Only cases that had normal radiological findings were considered (chest radiograph within physiological findings for a given
age, without observed pathological parenchymal or mediastinal changes in terms of consolidation/infiltration, free phrenicocostal sinuses, cardiac silhouette with a
preserved cardiothoracic index and no changes in chest wall). Th e age ranged from 18 to 88 years. Endoscopic examination was performed in all patients with a flexible
instrument (Olympus and Stortz brands) under local anesthesia. The review was performed in accordance with standards and norms. Premedication with apaurin or
atropine was rarely used. Intubation was mostly trans nasal (oral in a smaller number, and only rarely through a tracheal tube).
RESULTS
We classified and divided the endoscopic fi ndings into the following groups – Diff use hemorrhages on the mucous membrane N 140 (4.5%) – Unilateral hemorrhage (deposits of blood or clots on the mucous membrane) N 310 (10%) – Minimal finding of blood content (punctate bruises on one or both sides) - N 316 (10%) – Bleeding from the upper respiratory tract (pouring of blood and bloody contents in the trachea and bronchi) – N 248 (8%) – Hyperemia, edema, increased vulnerability of the bronchial mucosa (no traces of blood were found) – N 810 (26%) – Normal finding (finding within
the physiological range, absence of pathological substrate, no traces of blood were seen – the finding fits into the physiological range for the age group) – N 1306 (41.5%) –
Anatomical variety of the bronchial tree (false pathological finding – excessive or lack of mouth at the anatomical location, atresia and dead ends of segmental/subsegmental
branches) – N 8 (0.2%) – Endoscopic finding of infiltration of the bronchial mucosa (a finding highly suspicious for malignant changes) – N 2 (0.06%) – biopsies were taken in
these two patients and bronchogenic neoplasm (NSCLC was histologically confirmed). The results of this study showed that the largest number of patients with a history of
hemoptysis had normal bronchoscopy findings. It was a minor hemoptysis. Taking into account the anatomy and physiology of the pulmonary blood flow, most of the blood in
the lungs (about 95%) circulate through the pulmonary arteries where the pressure is low and ends up in the pulmonary capillary network where gas exchange occurs. About
5% of the blood that reaches the lungs circulates through the high-pressure system of the bronchial arteries, which are branches of the aorta and which supply the large
bronchi and supporting tissues (nutritional blood flow). In hemoptysis, as a rule, the blood originates from the bronchial bloodstream, except in the case of damage to the pulmonary arteries. Th e obtained results indicate that in chronic bronchopulmonary conditions, the creation of anastomoses (communication of bronchial-systemic and
pulmonary capillaries) that bleed due to inflammation or microinjury, during which the blood collects and drains out, often occurs.
CONCLUSION
patients with a history of coughing up blood or bloody secretions, in whom the radiographic findings are within the physiological range, absolutely indicate endoscopic
examination. Bronchoscopy examination in hemoptysis should be taken as a doctrinal position from the point of view of a pneumophthisiologist - bronchologist and within a general hospital, regardless of the circumstances or other possible causes. Radiographic and endoscopic findings within the physiological framework for age do not exclude the possibility of intrapulmonary causes of hemoptysis. Systemic pulmonary arterial communication is the most common cause of hemoptysis. Th e endoscopic finding of hyperemia and minimal blood vessels, as well as the vulnerability of the bronchial
mucosa, did not provide a sufficient explanation of the cause. Consequently, in case of recurrent hemoptysis, further diagnostic interventional procedures are indicated, as well as an expanded hematological research package.
KEYWORDS
Hemoptysis, bronchoscopy, bloody expectoration, bronchologist