Hemoptysis

Question

Hello.

I would like to find out about blood in the sputum. I am 27 years old with CF, with chronic colonization of staphylococcus and long-term high IGE levels. ABPA (Allergic bronchopulmonary aspergillosis) has been been repeatedly confirmed.
Over Christmas I overcame a virus that was treated with antibiotics. The virus passed, the cough subsided (there was very little sputum), but I found breathing very difficult in the evening. My lungs burned in the evening and it ended with the coughing up of blood. The amount of blood was not great (cca. 1 ml.), but it was very unpleasant. I cannot keep my fear in check and start to shake all over... The physician prescribed Prednison 20 mg., which relieved the feeling that my lungs were stiffening and made me breathe better overnight, but hemoptysis sporadically appears in the sputum. It feels like I have a wound that has never healed in my lungs, and this is more intense under greater strain. Besides that, I take Vitamin K, Dycinon or Panba. I have read on foreign websites that some CF patients inhale epinephrine in the event of hemoptysis.
My doctor has no experience with this alternative. I would like to ask: How do you proceed in the event of hemoptysis treatment? Must inhalations be limited, and if so, which medicines need mainly to be limited?

At the same time, I would like to ask if mental strain can provoke hemoptysis. I personally can exercise as much as I want without difficulties, but I cannot sit in an air-conditioned room; I have problems in speaking for longer times or in working with chalk. Longer trips by car are also a major difficulty. In addition, I cannot go to the theater, films or restaurants… I always return with stiff lungs which leave me with a burning sensation. But when I go out to ride a bicycle or swim for an hour, this is not a problem. My FEV1 is 70 % and FVC is 75 %. What could be related to this, and what can influence it?

Thank you very much for your answer. Best regards, Ingrid

Answer

Hello,

Coughing up blood is a common complication of CF. For an adequate treatment and to judge the hemoptysis, it is important to distinguish between the two following forms:

1. Minor hemoptysis or "Blood streaking" of the sputum is common in patients with CF and this seems to be the case here. If blood streaking persists, this may indicate a pulmonary exacerbation and therefore in your case it is recommended to search for a bacterial or fungal infection and to initiate an appropriate therapy.

2. Major hemoptysis is defined as acute bleeding of a large amount of blood (often defined as 140ml in 24 hrs) which could be life threatening. Recurrent bleeding of substantial volume (e.g. more than 100ml/day) over a short period of time (e.g. 3-7 days) is also termed major hemoptysis. There are several treatment options in case of major hemoptysis: Drugs with influence on coagulation, such as aspirine, NSAID or penicillin should be discontinued. Inhaled drugs which may be pulmonary irritants should be discontinued such as N-acetylcysteine and aerolized antibiotics. One should search for and correct coagulation defects. Pulmonary exacerbations should be effectively treated. There is no evidence that discontinuing physiotherapy is either beneficial or harmless: this decision is left to physician and patient. In very severe cases, arterial closure or operative lobektomie could be an option; for CF patients, however, arterial embolization has been questioned and should be limited to individual cases. Some new trials which are used by some centers are the inhalation of epinephrine (however, there is no proof of the effectiveness by scientific data) and tranexamic acid (based on some case reports).

Mental strain should not bring about the coughing up of blood. Worsened status in the situations described is individual and should be avoided as much as possible. Nothing more can be said in this case; it is necessary to be examined right at the time the worsening takes place - this could, for example, be a temporary case of bronchial asthma.

Best regards, Libor Fila

12.05.2009