Hemoptysis is the expectoration of blood or bloody sputum from the lower respiratory tract, including the lungs or tracheobronchial tree. It is often alarming to the patient and can be life-threatening if massive. Distinguishing true hemoptysis from bleeding originating from the mouth, nasopharynx, or gastrointestinal tract is essential.

• Massive hemoptysis: Expectoration of ≥200 mL in a single episode, ≥400 mL in 3 hours, or ≥600 mL in 16 hours, representing a medical emergency.

• Common causes include chronic bronchitis, bronchiectasis, lung cancer, tuberculosis (TB), and necrotic pulmonary infections.

Pathophysiology

Hemoptysis arises from bleeding into the respiratory tract through the pulmonary or bronchial vasculature. Mechanisms include:

1. Hemorrhage or diapedesis of red blood cells from pulmonary microvasculature into alveoli.

2. Necrosis of lung tissue causing inflammation, vessel rupture, or alveolar hemorrhage.

3. Ruptured aortic aneurysm into the tracheobronchial tree.

4. Pulmonary hypertension–related vessel rupture (e.g., secondary to mitral stenosis).

5. Pulmonary arteriovenous fistula rupture or rupture of collateral bronchial/pulmonary vessels.

6. Sloughing of caseous TB lesions into the airways.

7. Bronchial epithelial ulceration and erosion from infections or malignancy.

History and Physical Examination

History

• Onset, duration, and frequency of hemoptysis

• Estimated volume of expectorated blood

• Associated symptoms: cough, dyspnea, chest pain, fever, night sweats, weight loss

• History of lung, cardiac, or coagulation disorders

• Medication history: anticoagulants, antiplatelets, chemotherapeutic agents

• Smoking and environmental exposures

• Recent infections or TB exposure

Physical Examination

• Vital signs: tachycardia, hypotension, hypoxemia

• Respiratory assessment: use of accessory muscles, retractions, abnormal chest movement

• Inspection: nose, mouth, pharynx for bleeding source; skin lesions

• Palpation: chest tenderness, diaphragm level, fremitus

• Percussion: detect dullness, hyperresonance, or asymmetry

• Auscultation: breath sounds, crackles, wheezes, pleural rubs, heart murmurs

• Laboratory: sputum for color, odor, consistency, and blood content

Differential Diagnosis

• Hemoptysis: Typically frothy, bright red, alkaline pH; associated with cough and airway origin.

• Hematemsis: Vomiting of coffee-ground or bright red blood; acid pH; may contain food particles.

• Red/brown sputum: Oxidized bronchodilators, pneumonia (e.g., Serratia marcescens), or ruptured abscess.

Common Medical Causes

Other causes

• Iatrogenic: bronchoscopy, lung biopsy, mediastinoscopy

• Medications: anticoagulants, antiplatelets, thrombolytics

Emergency interventions

• Maintain airway: endotracheal intubation if massive hemoptysis

• Frequent suctioning, lavage for thick secretions

• Lateral decubitus positioning with bleeding lung down (caution: avoid hypoxemia)

• IV access for fluids, blood transfusions, and medications

• Emergency bronchoscopy to localize bleeding site

• Monitor vital signs: hypotension, tachycardia

• Arterial blood gas for respiratory status

Diagnostic workup

• CBC, coagulation profile

• Sputum smear, culture, cytology

• Chest X-ray, CT scan, pulmonary angiography

• Bronchoscopy or lung biopsy

Patient counseling

• Advise reporting recurrent hemoptysis immediately

• Educate on proper sputum collection

• Address anticoagulant use and potential interactions

Pediatric considerations

• Causes: Goodpasture’s syndrome, cystic fibrosis, idiopathic pulmonary hemosiderosis

• Hemorrhage in first 2 weeks of life has poor prognosis

Geriatric considerations

• Evaluate anticoagulant therapy, diet, and medications affecting clotting

• High vigilance for cardiopulmonary and infectious causes

References

• Menchini, L., Remy-Jardin, M., Faivre, J. B., et al. (2009). Cryptogenic hemoptysis in smokers: Angiography and results of embolization in 35 patients. European Respiratory Journal, 34(5), 1031–1039.

• Shigemura, N., Wan, I. Y., Yu, S. C., et al. (2009). Multidisciplinary management of life-threatening massive hemoptysis: A 10-year experience. Annals of Thoracic Surgery, 87, 849–853.