Coughing up Blood (Hemoptysis)

What is Hemoptysis? This is the medical term for coughing up blood from the lungs. This is a serious symptom and may reflect a serious underlying condition. This is different than the blood from the nose, mouth, or gastrointestinal tract. Blood from the lungs is usually bright red, but sometimes can be rust-colored. It can include all of the material expectorated (coughed up) or just streaks in the sputum. Sometimes the material can look bubbly, from the mixture of mucus and air.

What causes hemoptysis? There are many causes for hemoptysis, the most common being bronchitis, lung cancer, pneumonia, lung abscess, tuberculosis, bronchiectasis, and pulmonary thromboembolism (blood clot). Conditions that cause massive hemoptysis (see discussion below) are diseases that erode into the bronchial circulation, which is under higher pressure than the pulmonary circulation. Common causes of massive hemoptysis are chronic infections or conditions complicated by infection (such as lung abscess, tuberculosis, bronchiectasis, or cystic fibrosis), as well as cancer. Many times the cause remains undetermined despite extensive work-up.

Other causes  of hemoptysis include: trauma, vasculitis (inflammatory disease of the blood vessels), aspiration of foreign body (especially children), Systemic Lupus Erythematosis, Goodpasture’s Disease, Sarcoidosis, over-anticoagulation, congestive heart failure, mitral stenosis, aspergilloma (fungus ball), and severe coughing.

What happens if I have hemoptysis? In general, hemoptysis requires a systematic and thorough evaluation to discover its cause (Hemoptysis in a patient with chronic bronchitis during an acute exacerbation is a possible exception because it is usually mild and self-limited). However, if the hemoptysis is massive, recurrent, or won’t go away, then further evaluation is indicated.

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  • Is it really hemoptysis? The history in most cases will suggest that blood is actually being coughed up from the lungs, but it may be difficult at times to distinguish hemoptysis from bleeding in the upper respiratory tract (such as the nasopharynx or sinuses), or blood from the gastrointestinal tract that was regurgitated or vomited.
  • Is the bleeding massive (i.e. life-threatening)? This is important not only for necessitating a different approach to management, but will often alter the differential diagnosis, or list of possible causes.  Massive or life-threatening hemoptysis is more than 200 ml (or a little under a half pint) total in one day.  Any amount of bleeding at a high rate, even over a short period of time, should be managed as being potentially life-threatening because blood will flood the airways and cause asphyxiation.
  • What does the medical evaluation consist of? Generally, the initial evaluation will consist of a careful history and thorough physical examination. The doctor will ask about any acute or chronic pulmonary symptoms, including cough, shortness of breath, wheezing, or if you have had any previous lung disease. The history or physical may uncover findings suggesting a certain cause, such as underlying heart disease, vasculitis, or pulmonary thromboembolism. Systemic symptoms, such as fever, night sweats, weight loss, and malaise may be present in chronic infection, cancer, or inflammatory diseases.
  • What tests might be done? Generally, the first test will be a two-view (front and side) chest x-ray. (The chest x-ray can be unrevealing despite the presence of an important disease as the cause for the hemoptysis.) The doctor will often obtain blood tests, including  complete blood count (CBC) and coagulation studies (PT/PTT). Depending on the patient age and clinical circumstances, sputum testing for infection and/or cancer may be obtained. Chest CT scanning (contrast, high-resolution, or spiral) is a non-invasive and sensitive x-ray technique that can help the doctor determine the cause of hemoptysis. Ventilation-Perfusion (V/Q) scan is useful in evaluating for thromboembolic disease. The decision whether to perform fiberoptic bronchoscopy should be made in consultation with a lung specialist (pulmonologist). An echocardiogram can help examine the functioning of the heart and heart valves. On rare occasions, more invasive testing is required, including surgery (such as thoracoscopy, mediastinoscopy, or thoracotomy).

What should you do if you have hemoptysis? If you have unexplained hemoptysis, especially if it is more than a few teaspoons total in a day, call 9-1-1 and go to the nearest Emergency Department. If you have other symptoms, including chest pain, severe shortness of breath, dizziness, or fainting, you should go to the ED. You should not ignore this symptom, as it can be life-threatening. If in doubt, call your doctor right away.

How is hemoptysis treated? The main treatment for hemoptysis targets the underlying disease process. For example, an infection will be treated with the appropriate antibiotic or antimicrobial agent. Otherwise, the treatment is nonspecific. If massive hemoptysis is present, the treatment might require surgery.

Where can I learn more?
National Institutes of Health
National Center for Biotechnology Information (pdf)
Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:402-413.