Tuberculosis - I.T. Pyatnochka 2005

Complications of tuberculosis
Pulmonary hemoptysis and hemorrhage

One of the frequent and dangerous complications requiring emergency care in patients with bronchopulmonary pathology is Pulmonary Hemorrhage and Hemoptysis. Patients, even with minor hemoptysis, must be urgently hospitalized.

In clinical practice, Hemoptysis and pulmonary hemorrhage are distinguished, with the difference between them being mostly quantitative. Hemoptysis is characterized by streaks or traces of Blood in the sputum or saliva, or occasional spits of blood. In pulmonary hemorrhage, a significantly larger amount of pure blood is coughed up all at once (over 10 ml), either continuously or intermittently. Depending on the volume of blood lost, hemorrhages are classified as mild (up to 100 ml), moderate (up to 500 ml), and massive or profuse (over 500 ml).

Based on pathogenetic features, hemoptysis can be schematically divided into the following groups: pseudohemoptysis, hemoptysis without lung disease, hemoptysis in non-tuberculous lung diseases, and hemoptysis in Pulmonary Tuberculosis. Hemorrhagic pulmonary complications in patients with respiratory tuberculosis can occur with any form and phase of the disease, though they are more frequent in destructive forms of tuberculosis and less common in post-tuberculosis pneumosclerosis with Bronchiectasis. Moreover, the majority of pulmonary hemoptysis and hemorrhages originate from the systemic Circulation vessels.

In Pulmonary tuberculosis combined with Liver pathology, pulmonary hemorrhages are significantly more likely to occur (in 15.16%) compared to cases without a concomitant liver disease (in 7.33%). Furthermore, bone mineral density also depends on the functional state of the liver. Osteopenia and Osteoporosis were detected in 80.5% of patients with pulmonary hemorrhages.

External environmental factors significantly affect The Human Body, triggering a complex array of meteotropic reactions. Under unfavorable weather conditions (Type III-IV weather, characterized by cyclonic activity with sharp changes in frontal boundaries and step-like fluctuations of all meteorological elements, alongside sudden shifts in the Earth's electrical field and pronounced magnetic storms in the troposphere), pulse blood volume increases in the upper and middle Zones of the Lungs, primarily due to enhanced Blood supply to medium and small vessels. Our recent studies have shown that pulmonary hemoptysis and hemorrhages are observed more frequently during the autumn-winter period and on days with adverse weather conditions—above all, magnetic storms—during which biological systems in the human body become unbalanced.

According to literature data, hemoptysis is most frequently a symptom of aspergilloma (in 55-85%), adenoma (in 48-55%), bronchogenic carcinoma (in 37-53%), and less commonly observed in bronchiectasis (in 28-53%), abscesses (in 11-15%), and pulmonary tuberculosis (in 6-19%). In recent years, cases of hemoptysis in Chronic Bronchitis have become more frequent (accounting for 30%), typically manifesting as blood streaks in the sputum. Nevertheless, currently in 10-15% of cases, the exact cause of pulmonary hemoptysis cannot be determined.

The immediate causes of pulmonary hemoptysis and hemorrhage in lung diseases are primarily the rupture of a blood vessel wall in a bronchial or pulmonary artery, or their anastomoses, resulting from pulmonary Hypertension, coagulation disorders, enhanced Fibrinolysis, or increased vascular wall permeability.

It is important to know that the loss of 10% of blood (an average of 500 ml) from the total blood volume is compensated by the body, a loss of 10-20% is sublethal, a loss of 20-40% is critical, and a loss of more than 40% is fatal.

Fifteen percent of patients with pulmonary tuberculosis complicated by moderate or profuse hemorrhages do not survive. The direct causes of death include asphyxia, blood loss, aspiration Pneumonia, progression of tuberculosis, cardiopulmonary failure, and Atelectasis.

Clinical presentation and Diagnosis. Clinically, pulmonary hemorrhage and hemoptysis manifest as the expulsion of foamy, usually bright red blood through the Mouth during mild coughing fits, sometimes in a continuous stream and accompanied by signs of acute anemia. During a hemorrhage, the blood is bright red, foamy, and contains small air bubbles, showing no tendency to clot. Even before the blood appears, the patient may experience a tickling sensation in the laryngopharynx, a feeling of tightness behind the Sternum, occasionally localized chest pain, a sense of suffocation, and subsequently a cough accompanied by a gurgling sound in the laryngopharynx. The patient perceives the smell and salty taste of blood. Profuse pulmonary hemorrhage is characterized by anemia, collapse, marked pallor, dizziness, nausea, adynamia, a rapid thready pulse, and a drop in blood pressure. After the hemorrhage or hemoptysis stops, blood clots continue to be coughed up for several days, and body Temperature rises due to blood aspiration. Auscultation reveals moist rales in the lower lung fields, predominantly on the side of the hemorrhage; radiological findings show patterns of atelectasis or aspiration pneumonia.

The diagnosis of pulmonary hemoptysis or hemorrhage involves identifying their source and Etiology. The primary diagnostic Methods are radiological and bronchoscopic examinations.

In each specific case, the following categories of hemoptysis and pulmonary hemorrhage should be excluded: 1. Pseudohemoptysis and pseudopulmonary hemorrhage (blood discharge from the Nose, nasopharynx, Oral Cavity, Esophagus, or Stomach); 2. Hemoptysis and pulmonary hemorrhages without underlying lung disease (due to cardiovascular disorders, particularly mitral stenosis); 3. Hemoptysis and pulmonary hemorrhages associated with non-specific and neoplastic lung diseases; 4. Pulmonary hemorrhages and hemoptysis associated with pulmonary tuberculosis.

In hemoptysis and pulmonary hemorrhage, blood originating from the lungs is bright red and foamy, and is expelled during a cough rather than through vomiting—as occurs in bleeding from the esophagus or stomach, where the blood resembles coffee grounds and lacks air bubbles. In nasopharyngeal bleeding, the blood is dark red and emerges from the nose and mouth, being expelled not by coughing but by spitting. To help identify the true source of bleeding—specifically whether it originates from the nose, lungs, or stomach—we provide differential Table 4.

Treatment boils down to three main objectives: 1) preventing asphyxia; 2) stopping the hemorrhage; 3) treating the underlying disease that caused the hemoptysis or hemorrhage. All these measures must be carried out immediately, and patients with pulmonary hemorrhage should be hospitalized urgently. However, since immediate hospitalization is not always possible, pre-hospital care must be administered at home, namely: 1. Provide conditions for maximum physical and mental rest. Reassure the patient. 2. The patient should be kept in a semi-sitting position (which facilitates the expectoration of sputum and blood). If hemoptysis is minor, complete physical rest is not strictly mandatory. 3. Apply moderate cold to the suspected bleeding site, The Heart area, or the forehead. 4. Diet should be warm and puréed; giving cold Water, food, or ice is strictly prohibited. 5. Administer a hypertonic saline solution to drink (1 tablespoon per Glass of water), taken in small sips over 30-60 minutes, which helps increase intravascular osmotic pressure and draws tissue fluid rich in thromboplastin into the Blood Vessels. 6. Apply tourniquets to the upper third of both thighs—either alternately, or simultaneously on both arms and legs in cases of profuse hemorrhage—for 30 minutes, followed by releasing the tourniquets for 10-15 minutes. The pulse in the extremities must remain palpable. These tourniquets pool venous blood in the extremities and relieve congestion in the lesser circulation; furthermore, Muscle compression releases tissue thromboplastin into the bloodstream, which promotes blood clotting. 7. Administration of a saline laxative and a cleansing enema also helps relieve congestion in the lesser circulation.

Class="center">Table 4 Differential diagnostic features of pulmonary, nasal, and gastric hemorrhages

Specialized care for pulmonary hemoptysis and hemorrhage includes Conservative methods and, when necessary, endoscopic and surgical treatments. Since the main direct causes of pulmonary hemorrhages are the rupture of blood vessel walls due to pulmonary hypertension, enhanced fibrinolysis, impaired Blood Coagulation, and increased vascular permeability, it is first necessary to administer antispasmodics to all patients (Euphylline 2.4% - 10 ml intravenously, Papaverine 2% - 2 ml subcutaneously, Atropine 0.1% - 1 ml subcutaneously), ganglion blockers (Benzhexonium 2.5% - 1 ml intramuscularly, Gangleron 1.5% - 2 ml intramuscularly or subcutaneously, Pentamine 5% - 0.5-1 ml intramuscularly or intravenously in 20 ml of isotonic solution, Arfonad 5% - 5 ml in 5% glucose solution as an intravenous drip), fibrinolysis inhibitors (epsilon-aminocaproic acid 5% - 100 ml as an intravenous drip up to 4 times a day, for hemoptysis - 5.0 g orally 4-5 times a day; Amben 1% - 5 ml intramuscularly, intravenously, or 0.25 g orally 1-2 times a day; Contrical 10-20 thousand units as an intravenous drip), procoagulant drugs (fibrinogen dissolved in water for injections, intravenous drip from 1 to 10 g per day; thromboplastin 3% - one tablespoon 3-4 times a day orally; Dicinone (etamgesylate) 12.5% 2 ml intravenously or subcutaneously, or 0.25 g orally every 4 hours; Hemophobin 1.5% - 5-10 ml intravenously or 3% solution 1 tablespoon 3-4 times a day; fresh frozen plasma transfusion 100-200 ml intravenously; Vikasol 1% - 1-2 ml intramuscularly or orally 0.015 g 3 times a day), vascular permeability-reducing agents (ascorbic acid - 100 mg 4-5 times a day, Ascorutin - 0.5 g 3 times a day, sodium ascorbate 5% - 5-10 ml intramuscularly or subcutaneously 1-4 times a day, calcium chloride or gluconate 10% - 10 ml intravenously), antihistamines (Dimedrol 0.05 g or Diprazin 0.025 g three times a day), glucocorticoids (Prednisolone 15-20 mg or Dexamethasone 0.5-5 mg per day until a clinical effect is achieved).

Modern Methods of hemostatic therapy are quite effective, helping nearly 95% of patients. When conservative therapy fails, semi-radical and radical treatment methods are indicated, including therapeutic pneumothorax, pneumoperitoneum, bronchoscopic arrest of bleeding via bronchial occlusion with a hemostatic sponge, bronchoalveolar lavage using solutions with hemostatic agents, endovascular embolization of bronchial Arteries, and radical surgical intervention. The optimal approach is to perform surgery after the hemorrhage has stopped and the patient has undergone a full clinical evaluation. Forced (emergency) surgeries performed during an active pulmonary hemorrhage often carry a high risk of postoperative complications. After halting a pulmonary hemorrhage, the physician faces two tasks: combating complications (asphyxia, aspiration pneumonia, atelectasis, post-hemorrhagic anemia) and preventing the progression of the tuberculous process.

Upon the appearance of symptoms of asphyxia (suffocation and cyanosis), the Airways must be cleared of blood immediately. A simple and rapid method is the aspiration of blood from the Bronchi using a probe passed through the vocal cords. Tilting the upper half of the body downward facilitates the discharge of blood clots.

The primary method for the Prevention and treatment of pulmonary hemoptysis and hemorrhage is the Treatment of the underlying disease that caused this complication, followed by the prevention of its exacerbations and relapses.

The prevention of recurrent pulmonary hemorrhages involves aerosol therapy using fibrinolysis inhibitors administered via daily inhalations of Contrical (Gordox) at 2,500-5,000 ATP units (course of inhalations: 5-10 days), as well as the administration of immunomodulators (Thymalin, Thymogen).

Patients prone to recurrent pulmonary hemorrhages should follow a more sparing regimen, avoiding physical exertion 1-2 days before adverse weather conditions, particularly "magnetic storms," and for a week after; their diet should be mixed, balanced, and rich in Vitamins AND MINERALS, especially calcium; bowel movements should be regular, and in cases of constipation or flatulence, a saline laxative and a cleansing enema should be prescribed. Concurrently, phytohemostatics such as stinging nettle or yarrow should be prescribed for 2-3 weeks.

For impaired liver function, hepatoprotectors such as Thiotriazolin or Livolene-forte are indicated, as they improve the protein-synthesizing function of The Liver and normalize hemostasis. In the presence of osteopenia or osteoporosis, complex therapy is supplemented with calcium preparations (Sandocal-D, Calcium D₃-Nycomed).