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Hemoptysis

What Is It, Causes, Diagnosis, Treatment, and More

Author: Georgina Tiarks

Editors: Alyssa Haag,Ian Mannarino, MD, MBA,Kelsey LaFayette, DNP, RN

Illustrator: Jessica Reynolds, MS

Copyeditor: David G. Walker

Modified: 30 Jun 2022


What is hemoptysis?

Hemoptysis is a medical term to describe the expectoration of blood from the lower respiratory tract, which is anywhere from the glottis (i.e., pharynx with vocal cords) to the alveoli. It may be described as massive or non-massive, depending on the amount of blood loss. Hemoptysis is categorized as massive when more than 400 milliliters of blood is coughed up within 24 hours, or 150 to 200 milliliters at one time. Conversely, blood expectoration less than what is described as massive hemoptysis is defined as non-massive hemoptysis.

The lungs have a dual blood supply from both the pulmonary arteries and the bronchial arteries. The pulmonary arteries are supplied by the right ventricle of the heart and travel to the alveoli. Comparatively, the bronchial arterial vessels arise from the aorta to provide blood to the supporting structures of the lung, such as the bronchial tree, hila, and pleural viscera. Around 90% of cases of hemoptysis arise from the  bronchial circulation, while around 5% occur from the pulmonary circulation. Other causes may be due to systemic bleeding.

Illustration of cartoon individual coughing up bright red blood.

How do you pronounce hemoptysis?

Hemoptysis is pronounced huh-maap-tuh-suhs.

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What is the difference between hematemesis and hemoptysis?

Hemoptysis describes spitting up blood from the respiratory system. In contrast, hematemesis describes vomiting blood from the gastrointestinal system.

What causes hemoptysis?

There is a broad differential diagnosis for hemoptysis, including infections, vascular involvement, malignancy, and foreign body aspiration or trauma. In developing countries, one of the most common causes of hemoptysis is tuberculosis. However, in developed countries, other sources such as a bacterial infection superimposed on chronic pulmonary disease, like cystic fibrosis (i.e., inherited disease affecting mucus secretions), may be the origin. Acute bronchitis (i.e., viral etiology causing an upper respiratory infection); pneumonia; and other infectious agents, such as Aspergillus, Nocardia, and non-tuberculosis mycobacteria, may also be responsible.

Dysfunction of the cardiovascular system is another common cause of hemoptysis. Pulmonary venous hypertension, which can occur in the setting of mitral stenosis, heart failure, or pulmonary embolism, results in a back-up of blood into the lungs.  The resultant increase in pressure within the blood vessels of the lungs can result in pulmonary edema. Other vascular conditions, like granulomatosis with polyangiitis, also known as Wegener granulomatosis (i.e., a condition that causes inflammation of blood vessels), or anti-glomerular basement membrane disease, otherwise known as Goodpasture syndrome (i.e., an autoimmune disease that can cause inflammation of the alveolar membranes), can involve the lungs and cause hemoptysis. In addition, arteriovenous malformations (i.e., congenital aberrant connections between the arterial and venous systems) or hereditary hemorrhagic telangiectasia (i.e., a condition characterized by abnormal vascular development) may also play a role in the development of hemoptysis.

Malignancy of the lungs, including small cell lung cancer and squamous cell lung cancer, often arise centrally and can invade the arterial system. Bronchogenic carcinoma is often a common cause. Other possible sources of abnormal cellular growth include metastasis to the lungs or Kaposi sarcoma, (i.e., a cancer that causes lesions in soft tissues, such as blood vessels) in individuals with immunodeficiency.

Finally, bleeding disorders, anticoagulant use, foreign body aspiration, and lung trauma can also be the etiology of hemoptysis.

How is hemoptysis diagnosed?

Diagnosis of hemoptysis can vary based on severity and presentation. Hemoptysis may present similarly to hematemesis and epistaxis (i.e., blood expelled from nasal cavities); therefore, it is important to first identify the source of the blood loss. A healthcare provider may also want to determine whether the individual is experiencing massive hemoptysis or non-massive hemoptysis, which will help to establish the severity. A full medical history, including tobacco use, inhalation exposures, and history of lung disease, may be obtained. A physical exam may also be performed to determine whether signs of hypoxia (e.g., clubbing) or internal bleeding (e.g., petechiae or ecchymoses) are present. Blood work such as arterial blood gas, complete blood count (CBC), coagulation panels, and renal function may also be useful. Imaging such as a chest radiograph or a computed tomography (CT) scan may also be performed to determine the source and underlying cause of the hemoptysis. In some cases, a bronchoscopy may be warranted to identify a bleeding site.

How is hemoptysis treated?

Treatment of hemoptysis depends largely on the underlying cause and severity. In massive hemoptysis or life-threatening hemoptysis, securing the patient’s airway may be a priority. Individuals may be started on oxygen therapy, intubated, or repositioned in the lateral decubitus position (i.e., on their side), which uses gravity to prevent blood from entering the unaffected lung. Intravenous fluid and blood transfusion may be indicated. Individuals may also undergo bronchoscopy to insert a balloon catheter or embolize the bronchial artery in order to stop further bleeding. In some circumstances, surgical intervention may be necessary.

In non-massive hemoptysis, management of the underlying cause may be the primary treatment strategy. Therefore, signs of infection may be treated with antibiotics, antivirals, or antifungals. Signs of malignancy may require a consultation with an oncologist. Underlying chronic pulmonary disease may be treated with glucocorticoids, bronchodilators, mucolytics, chest physiotherapy, or oxygen therapy. Studies have also shown that inhalation of tranexamic acid (i.e., antifibrinolytic) in individuals with mild hemoptysis provides rapid symptomatic relief and shorter hospital stays.

What are the most important facts to know about hemoptysis?

Hemoptysis, pronounced huh-maap-tuh-suhs, is the expectoration of blood from the respiratory system. Hemoptysis can be described as massive or non-massive based on the amount of blood excreted. There are a variety of causes of hemoptysis, including infection, heart failure, pulmonary disease, vascular disorders, malignancy, bleeding disorders, and trauma. Diagnosis of hemoptysis may include a broad work-up using a medical history; physical exam; blood tests; imaging studies; and, in some cases, bronchoscopy. Similarly, treatment may vary based on the underlying cause. In life-threatening hemoptysis, stabilizing the airway is the primary goal while also replenishing blood loss. In non-massive hemoptysis, managing the underlying condition is crucial.

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Related links

Mycobacterium tuberculosis (Tuberculosis)
Cystic fibrosis: Pathology review

Resources for research and reference

Brady, A. K., & Kritek, P. A. (2018). Hemoptysis. In J. L. Jameson, A. S. Fauci, D. L. Kasper, S. L. Hauser, D. L. Longo, & J. Loscalzo (Eds.), Harrison’s Principles of Internal Medicine (20th ed.). McGraw-Hill Education. Retrieved from accessmedicine.mhmedical.com/content.aspx?aid=1155943037

Earwood, J. S., & Thompson, T. D. (2015). Hemoptysis: Evaluation and Management. American Family Physician, 91(4), 243–249.

Nadler, P. L., & Gonzales, R. (2021). Hemoptysis. In M. A. Papadakis, S. J. McPhee, & M. W. Rabow (Eds.), Current Medical Diagnosis & Treatment 2021. McGraw-Hill Education. Retrieved from accessmedicine.mhmedical.com/content.aspx?aid=1175790234

Nadler, P. L., & Gonzales, R. (2022). Hemoptysis. In M. A. Papadakis, S. J. McPhee, M. W. Rabow, & K. R. McQuaid (Eds.), Current Medical Diagnosis & Treatment 2022. McGraw-Hill Education. Retrieved from accessmedicine.mhmedical.com/content.aspx?aid=1184155818

Papadakis, M. A., McPhee, S. J., & Bernstein, J. (2022). Hemoptysis. In Quick Medical Diagnosis & Treatment 2022. McGraw-Hill Education. Retrieved from accessmedicine.mhmedical.com/content.aspx?aid=1185998254