Overview
Haemoptysis
Quick Reference
Critical Alerts
- Massive haemoptysis is a medical emergency: Death from asphyxiation, not exsanguination
- Bleeding side identification is critical: Position patient bleeding-side down
- Airway protection is paramount: Intubate early if massive or compromised airway
- Most common cause in developing world: Tuberculosis
- Most common cause in developed world: Bronchitis, bronchiectasis, lung cancer
- CT angiography + bronchoscopy: Key investigations for localization
Key Diagnostics
| Test | Finding | Significance |
|---|---|---|
| CXR | Mass, infiltrate, cavity | Initial assessment |
| CT Chest (with contrast) | Lesion localization, vascular abnormality | Better anatomic detail |
| CT Angiography | Bronchial artery abnormality | Pre-embolization planning |
| Bronchoscopy | Direct visualization, bleeding site | Diagnostic and therapeutic |
| Sputum (AFB, cytology) | TB, malignancy | Etiology |
Emergency Treatments
| Condition | Treatment | Details |
|---|---|---|
| Airway protection | Intubation | Large ETT (≥8.0), bleeding-side down |
| Massive haemoptysis | IV access, blood products, position | Bleeding-side dependent position |
| Bleeding control | Bronchoscopy + interventions | Iced saline, epinephrine, balloon tamponade |
| Definitive control | Bronchial artery embolization | Interventional radiology |
| Temporizing | Tranexamic acid | 1g IV |
Definition
Overview
Haemoptysis is the expectoration of blood originating from the lower respiratory tract (below the glottis). It ranges from blood-streaked sputum to massive life-threatening hemorrhage. The immediate priority is securing the airway and preventing aspiration, followed by localization and control of bleeding.
Classification
By Volume:
| Category | Volume | Management |
|---|---|---|
| Mild (trivial) | Streaky or <20 mL/day | Outpatient workup often appropriate |
| Moderate | 20-200 mL/day | Inpatient observation, workup |
| Severe | 200-600 mL/day | Aggressive management, consider intervention |
| Massive | >600 mL/24h OR >00 mL/hr OR any amount causing respiratory compromise | Emergency; ICU, intervention |
By Clinical Impact (More Practical):
- Non-massive: Hemodynamically stable, able to clear secretions
- Massive/Life-threatening: Airway compromise, hemodynamic instability, or respiratory failure
Epidemiology
- Incidence: 1-4% of pulmonary medicine consultations
- Massive haemoptysis: 5-15% of all haemoptysis cases
- Mortality from massive haemoptysis: 30-50% without treatment
- Common etiologies vary by region: TB common in developing countries
Etiology
Most Common Causes (Developed Countries):
| Category | Examples |
|---|---|
| Infection | Acute bronchitis (most common), pneumonia, lung abscess |
| Malignancy | Bronchogenic carcinoma (especially squamous cell) |
| Bronchiectasis | Chronic infection, CF-related |
| TB | Reactivation, Rasmussen aneurysm |
| Idiopathic | Up to 30% have no identified cause after workup |
Causes by Mechanism:
| Mechanism | Causes |
|---|---|
| Airway disease | Bronchitis, bronchiectasis, bronchogenic carcinoma |
| Parenchymal | Pneumonia, TB, fungal (Aspergillus), vasculitis (GPA), Goodpasture |
| Vascular | PE, AVM, Dieulafoy lesion, bronchial artery aneurysm |
| Cardiovascular | Mitral stenosis, pulmonary edema, aorto-bronchial fistula |
| Iatrogenic | Post-biopsy, pulmonary artery catheter erosion |
| Coagulopathy | Anticoagulation, DIC, thrombocytopenia |
| Other | Trauma, foreign body, cocaine, catamenial (endometriosis) |
Pathophysiology
Vascular Anatomy
Two Vascular Systems:
| System | Pressure | % Pulmonary Blood | Role in Haemoptysis |
|---|---|---|---|
| Bronchial arteries | Systemic (high) | 1% | 90% of massive haemoptysis |
| Pulmonary arteries | Low pressure | 99% | 10% of massive haemoptysis |
Bronchial Arteries:
- Arise from descending thoracic aorta (T5-T6 level)
- Supply airways, pleura, esophagus, mediastinum
- Hypertrophy in chronic lung disease (bronchiectasis, TB)
- Target for embolization
Mechanisms of Bleeding
| Cause | Mechanism |
|---|---|
| Bronchitis | Mucosal inflammation, superficial vessel erosion |
| Bronchiectasis | Bronchial artery hypertrophy, vessel erosion |
| Tuberculosis | Rasmussen aneurysm (pulmonary artery), parenchymal destruction |
| Lung cancer | Tumor neovascularization, invasion of vessels |
| Pulmonary embolism | Pulmonary infarction, alveolar hemorrhage |
| AVM | Abnormal vessel prone to rupture |
| Aspergilloma | Fungal ball eroding into bronchial arteries |
Why Massive Haemoptysis Kills
- Death is from asphyxiation, not exsanguination
- 150-200 mL of blood can fill the tracheobronchial tree
- Prevents gas exchange
- Leads to hypoxia → cardiac arrest
Clinical Presentation
History
Essential Questions:
Localization Clues:
Physical Examination
Vital Signs:
Airway Assessment:
| Finding | Significance |
|---|---|
| Ability to speak | Patent airway |
| Stridor, gurgling | Blood in upper airway |
| Desaturation | Alveolar flooding |
| Blood in oropharynx | Active bleeding |
Chest Examination:
Other Systems:
True Haemoptysis vs Pseudohaemoptysis
| Feature | Haemoptysis | Pseudohaemoptysis (Upper GI or Nasopharynx) |
|---|---|---|
| Source | Lower respiratory tract | Upper GI (hematemesis) or nasopharynx |
| Character | Frothy, bright red, mixed with sputum | Dark, "coffee grounds," no sputum |
| pH | Alkaline | Acidic (if from stomach) |
| Associated | Cough, dyspnea | Nausea, vomiting, epistaxis |
Quantity of blood (teaspoons, tablespoons, cups)
Common presentation.
Color (bright red = fresh arterial; dark = older)
Common presentation.
Association with cough, sputum
Common presentation.
Duration and frequency
Common presentation.
Associated symptoms
fever, weight loss, night sweats, dyspnea, chest pain
Smoking history
Common presentation.
TB exposure or prior TB
Common presentation.
Any recent procedures (bronchoscopy, biopsy)
Common presentation.
Current medications (anticoagulants, antiplatelets)
Common presentation.
Recent travel
Common presentation.
Red Flags
Life-Threatening Presentations
| Finding | Concern | Action |
|---|---|---|
| >00 mL/hour bleeding | Massive haemoptysis | ICU, intubation, IR/surgery |
| Hypoxia or respiratory distress | Airway compromise | Immediate airway management |
| Hemodynamic instability | Massive blood loss | Resuscitation, blood products |
| Known lung cancer with haemoptysis | Tumor erosion into vessel | High risk for massive bleed |
| Aspergilloma with haemoptysis | Risk of massive hemorrhage | ICU monitoring, OR standby |
| Post-procedure (biopsy, PAC) | Iatrogenic injury | Immediate bronchoscopy |
High-Risk Features
- Prior massive haemoptysis
- Active tuberculosis
- Known bronchiectasis
- Lung malignancy
- On anticoagulation
- Pulmonary artery catheter in situ
- Aortic aneurysm (aorto-bronchial fistula)
Differential Diagnosis
By Symptom Association
| Symptom | Consider |
|---|---|
| Fever + productive cough | Pneumonia, lung abscess |
| Weight loss + smoking | Lung cancer |
| Night sweats + risk factors | Tuberculosis |
| Sudden dyspnea + pleuritic pain | PE |
| Recurrent sinusitis + hematuria | Granulomatosis with polyangiitis |
| Hematuria + haemoptysis | Goodpasture syndrome |
| Menses-associated | Catamenial haemoptysis (pulmonary endometriosis) |
Common Causes by Age
| Age Group | Common Causes |
|---|---|
| Young (<40) | Bronchitis, TB, bronchiectasis, CF, AVM |
| Middle-aged | Malignancy, bronchiectasis, TB |
| Elderly | Malignancy, bronchitis, bronchiectasis |
Diagnostic Approach
Immediate Assessment
ABC Assessment:
- A (Airway): Is it patent? Is blood compromising it?
- B (Breathing): Oxygen saturation, respiratory rate
- C (Circulation): Hemodynamic status
If Massive Haemoptysis: Prioritize airway over diagnosis
Laboratory Studies
| Test | Purpose |
|---|---|
| CBC | Hemoglobin (blood loss), WBC (infection), platelets |
| Type and Screen | Prepare for transfusion |
| PT/INR, aPTT | Coagulopathy |
| BMP/CMP | Renal function (for contrast, Goodpasture) |
| ABG | Hypoxia, A-a gradient |
| Sputum for AFB | Tuberculosis |
| Sputum cytology | Malignancy |
| Urinalysis | Hematuria (pulmonary-renal syndromes) |
| BNP | Cardiac cause |
| ANCA, anti-GBM | If vasculitis/Goodpasture suspected |
Imaging Studies
Chest X-Ray (First-Line):
- May show mass, cavity, infiltrate, or be normal
- Helps lateralize bleeding in some cases
- Normal CXR does not exclude significant pathology
CT Chest (Standard of Care for Workup):
| Type | Indication | Information Provided |
|---|---|---|
| CT without contrast | Parenchymal disease, mass | Lesion characterization |
| CT with contrast | Vascular lesions, AVM | Vessel abnormalities |
| CT Angiography | Pre-embolization planning | Bronchial artery anatomy |
| HRCT | Bronchiectasis, interstitial disease | Detailed parenchyma |
Bronchoscopy:
| Timing | Purpose |
|---|---|
| Emergent (massive) | Localize bleeding, therapeutic intervention |
| Urgent (active significant) | Localize before imaging if needed |
| Elective | Diagnostic for mass, biopsy |
- Flexible bronchoscopy: Most common; diagnostic and some therapeutic
- Rigid bronchoscopy: Better suction, airway control; for massive bleed
Angiography:
- Bronchial artery angiography with embolization
- Performed by interventional radiology
- Definitive treatment for bronchial artery source
Treatment
Principles of Management
- Airway first: Protect from aspiration and asphyxiation
- Bleeding-side down: If known, position to protect non-bleeding lung
- Resuscitation: IV access, fluids, blood products as needed
- Localize and control: Bronchoscopy, embolization, surgery
- Treat underlying cause: Infection, malignancy, etc.
- Correct coagulopathy: Reverse anticoagulation if safe
Airway Management
Positioning:
- Bleeding-side down (lateral decubitus)
- Prevents blood from flooding non-bleeding lung
- If side unknown, trend towards right (larger right main bronchus)
Intubation Indications:
- Inability to maintain oxygenation
- Inability to clear secretions
- Altered mental status
- Massive ongoing hemorrhage
Intubation Technique:
- Large ETT (≥8.0 mm) - allows bronchoscopy through tube
- Single-lumen initially; switch to double-lumen if needed
- Selective main bronchus intubation to protect non-bleeding lung
Double-Lumen ETT / Bronchial Blockers:
- Lung isolation for massive unilateral hemorrhage
- Allow ventilation of non-bleeding lung while blocking bleeding side
Resuscitation
- 2 large-bore IVs
- Type and crossmatch (prepare 4-6 units)
- Correct coagulopathy: FFP, platelets, vitamin K, PCC as indicated
- Transfuse for significant blood loss
Pharmacological Treatments
| Agent | Dose | Mechanism |
|---|---|---|
| Tranexamic acid | 1g IV q8h or 500mg nebulized TID | Antifibrinolytic |
| Cold saline lavage | 10-20 mL aliquots via bronchoscope | Vasoconstriction |
| Topical epinephrine | 1:20,000 via bronchoscope | Local vasoconstriction |
Reversal of Anticoagulation:
| Agent | Reversal |
|---|---|
| Warfarin | Vitamin K + 4-factor PCC |
| Heparin | Protamine |
| DOACs | Idarucizumab (dabigatran), andexanet (factor Xa inhibitors), 4F-PCC |
Bronchoscopic Interventions
| Technique | Description |
|---|---|
| Cold saline lavage | Vasoconstrictive effect |
| Topical epinephrine | 1:20,000 solution |
| Balloon tamponade | Fogarty catheter via working channel |
| Oxidized cellulose | Promotes hemostasis |
| Argon plasma coagulation | For visible lesion |
| Laser photocoagulation | For visible lesion |
Bronchial Artery Embolization (BAE)
Indications:
- Massive haemoptysis not controlled by conservative measures
- Recurrent moderate haemoptysis
- Patient not surgical candidate
Efficacy:
- Immediate control: 85-95%
- Recurrence: 10-30% within months (common in bronchiectasis, aspergilloma)
Complications:
- Chest pain (most common)
- Spinal cord ischemia (1-2%) - if anterior spinal artery inadvertently embolized
- Esophageal necrosis
- Bronchial necrosis
Surgical Management
Indications:
- Failed bronchoscopy and embolization
- Localized disease amenable to resection
- Mycetoma (aspergilloma) with massive bleed
- Bronchial artery or AVM not amenable to embolization
- Trauma (arterial laceration)
Procedures: Lobectomy, pneumonectomy
Mortality: High in emergency setting (25-40%)
Disposition
Admission Criteria
- Moderate-to-massive haemoptysis
- Hypoxia or respiratory distress
- Abnormal vital signs
- Significant underlying disease (malignancy, TB)
- Need for bronchoscopy or intervention
- Anticoagulated patient with more than trivial bleeding
- New diagnosis requiring inpatient workup
ICU Criteria
- Massive haemoptysis
- Airway compromise or intubated
- Hemodynamic instability
- Active ongoing bleeding
- Post-embolization monitoring
Discharge Criteria (Outpatient Workup)
- Trivial (blood-streaked sputum) with stable vitals
- No obvious serious cause
- Able to arrange prompt outpatient follow-up
- Not on anticoagulation (or held appropriately)
- Reliable patient
Follow-Up
| Situation | Follow-Up |
|---|---|
| Discharged with trivial bleed | PCP or pulmonology within 1-2 weeks; CT chest |
| Post-admission, controlled | Pulmonology in 1-2 weeks |
| Known malignancy | Oncology urgent |
| TB suspected | Infectious disease + public health |
Patient Education
Condition Explanation
- "You are coughing up blood, which can come from your lungs or airways. We need to find out why and make sure it doesn't become a serious problem."
- "Even small amounts of blood can indicate an underlying issue that needs to be investigated."
Self-Care Instructions
- No smoking
- Avoid NSAIDs, aspirin unless prescribed
- Stay hydrated
- Keep track of amount of blood expectorated
- Avoid strenuous activity until evaluated
Warning Signs Requiring Immediate Return
- Coughing up more blood (especially bright red or clots)
- Feeling short of breath
- Lightheadedness or dizziness
- Chest pain
- Fever
Special Populations
Tuberculosis
- Common cause in endemic areas
- Risk of Rasmussen aneurysm (pulmonary artery) with massive bleed
- Isolation precautions: Airborne + negative pressure room
- Anti-TB therapy
- Embolization less effective due to pulmonary artery source
Cystic Fibrosis / Bronchiectasis
- Chronic bronchial artery hypertrophy
- Recurrent haemoptysis common
- Embolization often needed repeatedly
- Optimize pulmonary hygiene
Malignancy
- Squamous cell carcinoma most likely to bleed
- May have brisk hemorrhage from tumor erosion
- Palliative care consideration in advanced disease
- Radiation therapy may help for palliation
Pulmonary Embolism
- Haemoptysis in 20-30% of PE
- Usually small volume
- Anticoagulation is treatment (seems paradoxical but appropriate)
Anticoagulated Patients
- Higher risk of significant bleeding
- Reverse anticoagulation for massive bleed
- Balance against indication for anticoagulation
- Hematology input may be helpful
Pregnancy
- Consider trophoblastic disease, amniotic fluid embolism
- Avoid unnecessary radiation (shield or use MRI)
- Bronchoscopy safe if needed
Quality Metrics
Performance Indicators
| Metric | Target | Rationale |
|---|---|---|
| Chest imaging within 12h of massive bleed | 100% | Localization |
| Lateralization assessment documented | 100% | Positioning, treatment planning |
| Bronchoscopy within 24h for significant bleed | >0% | Localization and control |
| TB precautions if cavitary lesion | 100% | Infection control |
| Coagulation studies checked | 100% | Identify coagulopathy |
Documentation Requirements
- Estimated volume of blood
- Color and character of blood
- Duration and frequency
- Initial CXR findings
- Lateralization if determined
- Oxygen requirements
- Interventions performed
- Disposition plan
Key Clinical Pearls
Diagnostic Pearls
- Death is from asphyxiation, not exsanguination: Very little blood can drown the lungs
- Massive = life-threatening by volume OR by compromise: Not just >600mL
- Bronchial arteries cause 90% of massive bleeds: Target for embolization
- Normal CXR doesn't exclude serious pathology: CT is superior
- Ask the patient which side: They often can localize
- Spurious sources: Rule out ENT and upper GI (pseudohaemoptysis)
Treatment Pearls
- Bleeding-side DOWN: Protects the "good" lung
- Large ETT for intubation: Facilitates bronchoscopy (≥8.0 mm)
- Selective mainstem intubation: If unilateral, can isolate bleeding lung
- Tranexamic acid may help: IV or nebulized
- BAE is the intervention of choice: High success rate
- Surgery is last resort: High mortality in emergency setting
Disposition Pearls
- All massive haemoptysis to ICU: Require close monitoring
- TB isolation if cavity or risk factors: Before diagnosis confirmed
- Outpatient workup for trivial bleeds: CT chest within 2 weeks
- Smoking cessation is essential: Reduces recurrence and cancer risk
References
- Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration. 2010;80(1):38-58.
- Yoon W, et al. Massive hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT. Radiology. 2003;227(1):232-238.
- Davidson K, Shojaee S. Managing Massive Hemoptysis. Chest. 2020;157(1):77-88.
- Radchenko C, et al. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086.
- Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000;28(5):1642-1647.
- Lordan JL, et al. The pulmonary physician in critical care. 11. Critical care management of massive hemoptysis. Thorax. 2003;58(9):814-819.
- Fartoukh M, et al. An integrated approach to diagnosis and management of severe hemoptysis. Am J Respir Crit Care Med. 2007;176(1):113-117.
- UpToDate. Evaluation and management of life-threatening hemoptysis. 2024.