In our Indian subcontinent, innumerable persons of all age groups do suffer from cough at various stages of their lives. Sometimes the frequency of cough suddenly increases with the onset of winter and dry cough gets converted into wet one with white secretions. Sometimes change of weather heralds the onset of episodes of incessant and devastating cough. People in our subcontinent try out all sorts of allopathic medicines as well as homemade concoctions. They do get a temporary relief, but the complaint of cough never goes away completely, because our people do not concentrate on the causes of coughing. Our physicians too do not seem to have enough time to investigate in detail the causes of coughing.
Recurrent episodes of even dry cough should be a cause for worry, let alone passage of blood during coughing. Coughing out blood poses a serious problem. Negligence in such a situation is tantamount to an open invitation to death. Always remember, one should take the problem of coughing-out of blood very seriously and promptly consult a thoracic surgeon, otherwise a precious human life may be lost due to ignorance.

Why does blood come out during coughing?
There are multiple reasons for passing out blood during coughing. In our country the most important cause is tubercular infection. When a tubercular infection due to lack of proper care and treatment reaches a fulminant stage, a sufferer starts coughing out blood. Sometimes, bleeding happens to be so severe that a tubercular infected person dies instantaneously within hours, due to exsanguinations and flooding of opposite normal lung with blood.
Quite frequently it has been observed that even after successful treatment of tuberculosis, though tubercular infection is brought under control, but the patient continues to pass blood during coughing. The reasons is simple: although tubercular infection leaves the lung after successful treatment, but before leaving, it leaves behind residual wound in the form of big cavities inside the lung. In these hollow spaces of lung, other types of germs especially fungi make their entry and stay there permanently. This condition is called in medical term an ‘aspergilloma’ or ‘aspergillosis’. Sometimes, the amount of blood coughed out is so much that a life-threatening situation may arise. In our country, millions of patients suffer from the disease of aspergilloma and they, due to ignorance, keep on trying various types of wrong treatment. On account of this, the remaining healthy part of lung too becomes diseased.

Avoid recurrent infections of lung
The second important reason of cough with bloody phlegm is the disease of bronchiectasis. In this disease the wall of the wind pipe get severely damaged due to persistent swelling and inflammation brought on by repeated infections of wind pipe. This results in either the constriction of branches of windpipes situated inside the lung, or inflation of them like a balloon. This condition of windpipes totally obstructs the mechanism of forcing out phlegm from the chest. On account of this, the sputum instead of going normally out of windpipe and then chest, on the contrary gets thickened and stays inside the windpipe permanently. The blood pipes adjacent to branches of windpipes get thinned-out and become dilated. Because of all these changes, these blood pipes burst out due to increased internal pressure brought on by coughing and the sufferer starts passing bloody sputum from his mouth.
A patient suffering from bronchiectasis should consult a thoracic or a chest surgeon and get the damaged part of lung removed as early as possible; otherwise the remaining healthy part of lung too will get diseased. Such patients pass blood during coughing in such a significant amount that the patient is forced to go to emergency wing of the hospital for urgent blood transfusions, to replenish the lost blood, otherwise the patient may die.

Cancer of the lung
In our country, the third important cause of passage of bloody sputum during coughing is the cancer of lung. In small as well as big cities, due to increasing trend of smoking among youths, the number of patients suffering from lung cancer is steadily rising. Even in villages, the daily group activity of ‘Hukka’ (Hubble-Bubble) smoking in the evening is adding greatly to the number of lung cancer patients. The prevalence of smoking habits among peasants and labourers working in village fields play a great role in the increased incidence of lung cancer.
It has been seen that people living in hilly areas pick up the bad habit of smoking from a very early age. This is a serious matter and the problem should be addressed on a priority basis, because the habit of smoking not only causes cancer of lung but also leads to narrowing of blood pipes, which supply pure oxygenated blood to various organs of body. This results in loss of lung as well as their limbs too. If a chronic smoker passes bloody phlegm during coughing, the possibility of lung cancer cannot be ruled out.

Lung abscess
The fourth important reason in our country of coughing with bloody sputum is the collection of pus inside the lung, which is called commonly as lung abscess. On account of severe infection, the blood pipes become weak and bursts open due to sudden and temporary rise in pressure and this results in spitting of blood during coughing.
Sometimes there is some fundamental deformity in the anatomical architecture of blood pipes situated inside the lung, among young males and females since birth. In this deformity, the blood pipes before supplying the lung are found inter connected since birth. This deformity of blood pipes is called pulmonary arterio venous fistula (P.A.V.M.).
Sometimes it has been observed after a road traffic accident that due to chest injury, pus is collected inside the chest and due to this collection the windpipe existing inside the lung gets connected to the outer surface of the lung. This condition is called in medical term a broncho pleural fistula. In this dangerous situation when the patient coughs, blood may possibly be spitted out along with phlegm.

Where to go?
If you suffer from chronic cough and at the same time you pass bloody phlegm, please do not sit idle. Consult without delay a thoracic surgeon instead of a general surgeon. It is very essential to investigate the cause of chronic cough and bloody phlegm, because only after treating the cause of it, one can get rid of this problem. A patient suffering from this problem should go to a hospital where a full-time thoracic surgeon is available and the surgery of lung as well as heart is done routinely. For determining the cause and extent of the problem, some modern investigations like bronchoscopy, thoracoscopy and mediastinoscopy, CT-guided biopsy and parasternotomy are required. Before entering a hospital make sure whether round-the-clock facility of a modern blood bank, modern I.C.U. and critical care unit is there or not. There must be a good number of ventilators available in the I.C.U. ward, as it helps in better management of the case after operation, especially in a life-threatening situation. Always enquire whether a particular hospital where you want to get treated for such problem is having artery embolization facility or not. This facility comes in handy in an emergency to save the life of a patient, when a life-threatening dangerous bleeding erupts.

What to do when you cough out bloody sputum?
When you cough put bloody phlegm, consult a thoracic surgeon at the earliest. In such a situation, one has to find out the cause of bloody sputum. For investigation, one requires a chest x-ray, multislide CT-scan of chest, MRI of chest and lung biopsy. If any part of a lung is completely destroyed due to infection, try to get rid of that damaged part of lung as early as possible. This is the only way to control the bleeding problem permanently. Another advantage of this removal is that the adjacent healthy portion of remaining lung is saved from destruction.
If a lung cancer happens to be the cause of bloody sputum and cough, the removal of whole lung harbouring cancer is the only alternative to save the life of such patient, and this also prevents the spread of cancer to the lung on the other side. Generally, people have apprehension whether a person after removal of one lung will survive or not. This is only a misconception. One should know that a person who has donated one of his two kidneys, does live normally. Likewise, one can live normal life after one lung has been removed. Therefore one should not hesitate to get rid of the destroyed part of the lung, quickly, as this is the only way out to save the life of the patient.
It has been seen that the surgeons who are involved more with heart surgery do not have enough experience of lung surgery. Therefore one should select a surgeon keeping this fact in mind.

The writer is Senior Thoracic & Cardiovascular Surgeon, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi. [email protected]

Dr KK Pandey