Hemoptysis

Blood from the lower respiratory tract — range from scant blood-streaked sputum to massive hemoptysis (>200–600 mL/24h); life-threatening from airway flooding, not blood loss

Symptoms / Associated Sx

• Bright red blood coughed up (mixed with sputum or pure blood)

• Sensation of blood gurgling in chest or throat

• Hemoptysis vs. hematemesis (key distinction: hemoptysis = bright red, frothy, alkaline; hematemesis = dark red/coffee-ground, acidic, mixed with food)

• Dyspnea, hypoxia (airway flooding in massive hemoptysis)

• Fever + productive cough (infection)

• Weight loss + night sweats (TB, malignancy)

Denies

• Nausea preceding blood (rules out hematemesis as primary)

• Coffee-ground appearance or food mixed (rules out GI source — hemoptysis is bright red and frothy)

• Epistaxis draining posteriorly (rules out nasopharyngeal source — examine nares)

• Prior TB diagnosis, treatment completion (reduces active TB likelihood)

Social History (SHx)

Smoking history (malignancy, bronchitis), TB exposure or prior TB (TB, bronchiectasis from prior TB), prior lung cancer diagnosis, anticoagulation use (bleeding risk), autoimmune disease (ANCA vasculitis, anti-GBM — rare but important), HIV (PCP, Kaposi's, fungal), foreign travel (TB, parasites, fungal), bronchiectasis history (cystic fibrosis, non-CF bronchiectasis), coagulopathy.

Main Etiology

• Bronchitis / pneumonia — most common cause of mild hemoptysis

• Bronchiectasis — most common cause of recurrent or moderate hemoptysis

• Lung cancer — most common cause of new hemoptysis in smoker >40 years

• Tuberculosis — cavitary disease; erosion of Rasmussen aneurysm

• Pulmonary embolism with infarction

• Vasculitis — ANCA (GPA, MPA), anti-GBM disease — diffuse alveolar hemorrhage

• Mitral stenosis — pulmonary venous hypertension

• Anticoagulation, coagulopathy (facilitates bleeding from any underlying lesion)

Most Common DDx

• Hematemesis (upper GI source — dark red or coffee-ground; acidic pH; mixed with food; nausea precedes; nasogastric tube aspirate bloody; treat with endoscopy)

• Epistaxis with posterior draining (nasopharyngeal source — examine nares; blood from nasopharynx swallowed/aspirated)

• Lung cancer (smoking history; weight loss; progressive hemoptysis; CXR/CT mass; bronchoscopy biopsy)

• Bronchiectasis (recurrent infections; dilated bronchi with mucus plugging on CT; Pseudomonas; chronic productive cough)

• TB (night sweats + weight loss + cavitary disease; AFB smear + culture; upper lobe predilection; endemic exposure)

• DAH / vasculitis (diffuse bilateral infiltrates; bilateral infiltrates on CXR; falling Hgb; ANCA + anti-GBM; urinary sediment — red cell casts; hemoptysis + renal failure = pulmonary-renal syndrome)

DATA

• CBC (Hgb — blood loss; leukocytosis → infection)

• Coagulation panel — PT/INR, PTT, platelets (coagulopathy as contributing factor)

• BMP (creatinine — pulmonary-renal syndrome if vasculitis suspected)

• CXR (infiltrate/consolidation; mass; cavitation — TB; bilateral infiltrates — DAH)

• CT chest with contrast (gold standard — mass, bronchiectasis, cavitation, vascular anomaly; CT angiography for vascular source)

• Sputum: AFB smear × 3 + culture (TB), Gram stain + culture (infection), cytology (malignancy)

• Bronchoscopy (direct visualization of bleeding source; bronchoalveolar lavage; biopsy of lesion)

• ANCA panel (c-ANCA/PR3, p-ANCA/MPO) and anti-GBM antibody (if vasculitis/DAH suspected)

• Urinalysis (red cell casts → pulmonary-renal syndrome)

• Type and screen (massive hemoptysis)

• CT pulmonary angiography (vascular malformation, Rasmussen aneurysm from TB)

Home Meds

• Anticoagulants (hold; reversal if massive hemoptysis)

• Antiplatelets (hold)

• NSAIDs (hold — worsen platelet function)

• Bevacizumab, sorafenib (anti-VEGF agents — increase hemorrhagic risk; hold)

Plan

• Massive hemoptysis (>200–600 mL/24h or rate causing airway compromise) — emergency:

  • Airway first: position patient bleeding-side down (protects contralateral lung from flooding)

  • Intubate if unable to protect airway; use large-bore ETT (8.0+) to allow bronchoscopy

  • Rigid bronchoscopy (interventional pulmonology/thoracic surgery) → direct visualization + hemostasis

  • IR embolization (bronchial artery embolization — BAE): first-line definitive treatment for massive hemoptysis; 80–90% immediate success; recurrence 20–30%

  • Surgery (lobectomy) if BAE fails or bleeding source is surgical (abscess, AVM, mycetoma)

  • ICU; 2 large-bore IVs; type and crossmatch; hold anticoagulants; correct coagulopathy

• Non-massive hemoptysis (most cases — blood-streaked or small amounts):

  • CT chest (first-line imaging — characterize source)

  • Bronchoscopy (if CT inconclusive or active bleeding visualizable)

  • Treat underlying cause:

• Pneumonia/bronchitis: Antibiotics per CAP protocol; hemoptysis resolves with infection treatment

• Bronchiectasis exacerbation: Antibiotics (Pseudomonas coverage if prior culture — see bronchiectasis section); airway clearance; tranexamic acid 500–1000 mg PO TID (adjunct antifibrinolytic)

• TB: Airborne precautions + 4-drug RIPE therapy (see TB section); bronchial artery embolization if massive hemoptysis from Rasmussen aneurysm

• Lung cancer: Palliative radiotherapy (most effective for hemoptysis control); bronchoscopic ablation (APC, laser); BAE; oncology-directed systemic therapy

• ANCA vasculitis / anti-GBM: See DAH section (cyclophosphamide + steroids + plasma exchange)

• Tranexamic acid (systemic or inhaled nebulized — 500 mg in 5 mL NS nebulized TID): adjunct in moderate hemoptysis; reduces fibrinolysis

• Hold anticoagulants; reverse if massive; restart timing per indication after bleeding controlled (hematology/pulmonology guidance)

• Serial CBC, coags, SpO2; CXR daily; trend volume of hemoptysis

• Pulmonology consult (bronchoscopy); IR for BAE; thoracic surgery if surgical candidate

• PT/OT — breathing exercises; limit strenuous exertion

• Discharge: Treat underlying cause; follow-up CXR; bronchoscopy report follow-up; malignancy workup if mass identified; anticoagulation restart plan; pulmonology follow-up 1–2 weeks

Red Flags

• Massive hemoptysis (>200 mL/episode) → airway compromise (not blood loss) → position bleeding-side down + intubation + rigid bronchoscopy + BAE urgently

• Hemoptysis + bilateral infiltrates + falling Hgb → DAH → ANCA/anti-GBM urgently; plasma exchange ± cyclophosphamide + steroids

• Hemoptysis + renal failure + urinary red cell casts → pulmonary-renal syndrome (Goodpasture's, GPA, MPA) → emergency immunosuppression + plasma exchange

• TB hemoptysis + Rasmussen aneurysm → massive hemorrhage risk → BAE + continued RIPE; thoracic surgery on standby

• Post-procedural hemoptysis (post-bronchoscopy, transbronchial biopsy) → repositioning + balloon tamponade through bronchoscope

Senior IM Resident Pearls

• Hemoptysis kills by asphyxiation, not exsanguination — 200–400 mL in the airways can cause fatal airway flooding; position the patient bleeding-side DOWN to protect the unaffected lung

• Bronchial arteries are the source in 90% of hemoptysis (not pulmonary arteries) — BAE is first-line treatment for massive hemoptysis; pulmonary artery source (PE, vasculitis) is less common

• Rasmussen aneurysm — pulmonary artery aneurysm from erosion by TB cavity; massive hemoptysis in TB; CT angiography shows aneurysm; BAE is urgent treatment

• Tranexamic acid nebulized or systemic is an effective adjunct for moderate non-massive hemoptysis (bronchiectasis, cancer, post-procedural) — underused in clinical practice

• Common mistake: CT chest before bronchoscopy in active massive hemoptysis — in a bleeding patient, CT cannot localize the specific bronchial segment; go to bronchoscopy or BAE first when actively bleeding massively

• Common mistake: Positioning the massive hemoptysis patient in the lateral decubitus wrong side up — always put the BLEEDING side DOWN; this prevents blood flooding the healthy lung and maintains gas exchange