What Is The Term Hemoptysis?

Hemoptysis is the medical term for coughing up blood. It refers to blood coming from the lower respiratory tract (airways and lungs).

There can be many different causes of hemoptysis. The most common causes are not life-threatening, but some causes can be serious. That’s why it’s important to get this symptom checked out by a healthcare provider.

Hemoptysis refers to coughing up blood originating in the lower respiratory tract. If the source of the bleeding is in the upper respiratory tract or gastrointestinal tract, it is called pseudohemoptysis, a condition that can mimic hemoptysis.

Common Misconceptions About Coughing Up Blood

A common misconception about coughing up blood is that it indicates a serious medical condition such as lung cancer. However, many conditions can cause this symptom, most of which are treatable. For example, chronic cough in smokers can cause blood-streaked sputum; however, this does not mean it is lung cancer. Many causes can lead to hemoptysis, such as bronchitis or throat irritation, as a result of smoke exposure.

However, hemoptysis can sometimes be potentially life-threatening, and it is important to seek timely medical care. Pay attention to how much blood you cough up - if it is more than a few teaspoons, seek immediate medical attention. Keep in mind that coughing up blood or bloody mucus is completely different from vomiting blood. Also, see your doctor without delay if hemoptysis is persistent or worsening or is accompanied by other symptoms such as chest pain, dizziness, fever, shortness of breath, malaise, or unexplained weight loss.

Causes of Coughing Up Blood (Hemoptysis)

Acute Respiratory Infections

Bacterial, viral, parasitic, and fungal infections of the respiratory tract can cause mild hemoptysis. For example, bronchitis (an inflammation of the airways) and pneumonia (an infection in the lungs) are common causes of hemoptysis and blood-streaked mucus.

Chronic Conditions

Chronic respiratory conditions can cause you to cough up blood, for example:

Bronchiectasis (widening, thickening, and formation of pouches in the airways), which involves coughing up yellow or green mucus and coughing up blood streaked mucus.
Chronic obstructive pulmonary disease (COPD) - restricted air flow and breathing problems.
Lung abscess - a pus-filled cavity in the lung.

Malignancies

Coughing up blood is a symptom in some lung cancer patients, especially people over the age of 40 who are smokers. It occurs due to the formation of new blood vessels in and around the tumor, necrosis (tissue death) within the tumor, irritation caused by coughing, and invasion of the tumor into a nearby blood vessel. Certain cancer treatments can also make hemoptysis worse.

Tuberculosis

Coughing up blood or blood mixed with mucus is a common symptom in people with tuberculosis (TB). This is a bacterial infection that mainly affects the lungs. Other symptoms of active TB include a cough lasting more than 3 weeks, chest pain, fever, chills, night sweats, loss of appetite, and unintended weight loss.

Hemoptysis is particularly common before antibiotic treatment is started and tends to get better over time. However, significant blood loss due to major or massive hemoptysis in TB patients can be fatal.

Other Less Common Causes

Other potential causes of coughing up blood include:

Irritation and damage to the airways due to excessive coughing.
Lung injury causing damage to the arteries in the lungs.
Irritation after a lung procedure such as bronchoscopy or biopsy.
Pulmonary embolism (a blood clot in the lung).
Pulmonary aspiration (blood, throat secretions, or food going into the lungs).
Pulmonary edema (excess fluid in the lungs).
Blood coughed up due to an obstruction in the airway from a foreign body (common in children).
Congestive heart failure, a condition characterized by inefficient pumping of blood by the heart, resulting in decreased blood flow to the body.
Disorders that cause inflammation of the blood vessels, such as vasculitis or Wegener’s granulomatosis.
Complications of lupus.
Cystic fibrosis, an inherited disorder that causes severe damage to the lungs and other organs in the body.
Bleeding disorders that affect the blood’s ability to clot.
Recreational drug use (for example, crack/cocaine).
Use of certain prescription medications such as blood thinners or anticoagulants.

Diagnosis and Tests

What Are the Red Flags of Coughing Up Blood?

The red flags of coughing up blood are:

How much blood you’re coughing up: A few thin streaks of blood are not concerning but coughing up more than a few teaspoons of blood should be evaluated.
How often you cough up blood and whether the symptoms are worsening: The cause of recurrent hemoptysis should be identified and treated.
How long you’ve had blood coughing: Symptoms lasting more than a week should be investigated.
How much blood is present in bloody mucus or sputum (see below).
Additional symptoms such as difficulty breathing, chest pain, fever, or loss of appetite.

How Much Coughed Up Blood is Bad?

Infections and inflammation typically cause mild hemoptysis (defined as less than 100 mL in 24 hours). Major hemoptysis is coughing up 200 mL or more of blood in 24 hours. Massive hemoptysis refers to coughing up 1000 mL or more of blood in 24 hours.

It is easy to underestimate the volume of coughed-up blood at home. Do not delay seeking medical attention if you have persistent or worsening symptoms. Unless you know the cause (such as smoke or fume exposure), or if you have been diagnosed with bronchitis, it is best to seek medical care.

Diagnostic Tests

In addition to obtaining a medical history and performing a physical exam, your doctor may order one or more of the following tests to find out the cause of hemoptysis:

Chest X-ray to look for tumors or fluid in the lungs.
Computed Tomography (CT) scan to obtain detailed images of your respiratory system.
Bronchoscopy to view the airways and find the source of bleeding.
Blood tests such as a complete blood count (CBC) to see if there is an infection.
Sputum culture to look for infectious causes of coughing up blood.
Pulmonary arteriography to check blood flow in the lungs.
Coagulation tests to check for a bleeding disorder.
Urinalysis and kidney function tests to look for autoimmune diseases that can affect the kidneys and lungs.

Differential Diagnosis: What Is the Difference Between Hematemesis and Hemoptysis?

As noted, hemoptysis refers to coughing up blood from the lower part of the respiratory tract. Hematemesis is the medical term for vomiting blood. It is a sign of internal bleeding in the upper gastrointestinal tract and should be evaluated by a healthcare professional immediately.

The causes and treatments for hemoptysis and hematemesis are different, so it is important to distinguish between them.

It can be difficult to tell the difference between hematemesis vs hemoptysis at home, especially in children. One clue is that hemoptysis blood is generally bright red blood or rust-colored blood. It can be very thin blood, frothy sputum streaked with blood, or blood mixed with sputum or phlegm.

In contrast, hematemesis blood is dark red or brown in color and may be mixed with food particles. Hematemesis is also typically accompanied by retching or vomiting.

When Is Coughing Up Blood Life-Threatening?

Coughing up blood (hemoptysis) can be life-threatening if it leads to excessive blood loss or it is a symptom of a severe underlying health condition, such as pulmonary embolism, pulmonary edema, or heart failure exacerbation.

See a healthcare provider without delay if you have recurrent hemoptysis. You should seek emergency care if you are coughing up large amounts of blood or have persistent or worsening hemoptysis with the following symptoms: fever, chest pain, trouble breathing, or weight loss.

Management and Treatment

Severe blood loss due to hemoptysis is managed in the emergency department (ED) or intensive care unit (ICU), where doctors first stop the bleeding before trying to find out what is causing it. Surgical interventions are typically rare, but necessary in severe cases.

Once the bleeding source is identified, healthcare providers can use medications such as tranexamic acid (TXA) to stop bleeding and prevent further blood loss. Vasoconstrictors (such as epinephrine or vasopressin) work to narrow blood vessels and can also stop bleeding.

Procedures for Hemoptysis

Procedures for hemoptysis and related blood loss may include:

Bronchoscopy to remove a blood clot if it is identified as the source from where blood flows in the airways.
Procedures on the bronchial arteries, such as bronchial artery angiography and bronchial artery embolization, to stop blood flow at the source of bleeding in a major blood vessel.

Treating The Underlying Condition

Once the cause of hemoptysis has been found based on the history, physical examination, and diagnostic tests, a treatment plan is developed. It will consist of treating the underlying cause or risk factors. For example, healthcare providers may prescribe the following medications to treat hemoptysis:

Cough suppressants to stop coughing.
Antibiotics to treat a respiratory infection such as pneumonia or tuberculosis.
Steroids for inflammatory conditions.
Cancer treatment, including chemotherapy, radiation, surgery, and others for malignancies.

After the bleeding has been controlled and the cause identified, you will need to return to your doctor’s office or hospital for monitoring and follow-up care.

Special Considerations

Massive Hemoptysis and Mortality Risk

Massive hemoptysis (more than 1,000 mL blood loss in 24 hours) is a medical emergency. It is associated with a 30% to 50% mortality rate. However, massive hemoptysis is uncommon in developed countries such as the US because of the availability of effective diagnostic and therapeutic measures for lung conditions.

Pediatric vs. Adult Patients

The causes of hemoptysis in children tend to be different from those in adults. The most common causes in adults are bronchitis, bronchiectasis, tuberculosis, and lung cancer.

On the other hand, in pediatric patients, hemoptysis is frequently due to infections, tracheostomy-associated problems, or foreign body aspiration.

While most cases of coughing up blood in children are mild and self-limited, there is a risk of potentially life-threatening hemoptysis related to arteriovenous malformations, pulmonary vascular anomalies, congenital heart disease (for example, valvular heart disease such as mitral stenosis).

High-Risk Patient Populations

People at risk of hemoptysis or coughing up blood include those with chronic cough and lung conditions such as chronic obstructive pulmonary disease, as well as people taking blood thinning medications.

Tuberculosis Endemic Areas

TB-endemic areas include sub-Saharan Africa, Asia, and Eastern Europe. If you are traveling to these areas, take the following precautions:

Avoid close contact with people who might have TB, for example, those in crowded places like hospitals, medical clinics, homeless shelters, and prisons.
Avoid close contact with people who look sick or are coughing.
Take special precautions when you’re around people with known TB, for example, by wearing an N95 respirator. People working in health care settings abroad should consider getting tested for TB before leaving the US, and if negative, repeating the test 8-10 weeks after returning to the US. There is a TB vaccine available, but it is only for specific individuals, and not travelers to TB-endemic areas.

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