Haemoptysis

Haemoptysis, the coughing up of blood from the lungs or airways, can range from a small amount of blood-streaked mucus to a life-threatening medical emergency requiring immediate attention.

Table of contents

• What is haemoptysis?
• What causes haemoptysis?
• How to recognize haemoptysis
• How is the cause found?
• When to seek medical help
• How is haemoptysis treated?

What is haemoptysis?

hemoptysis, coughing up blood

Haemoptysis is the medical term for coughing up blood from your lungs or airways. The blood comes from the lower respiratory tract, which includes the lungs and the tubes that carry air to your lungs (bronchial tubes and trachea)^[1][2].

The amount of blood can vary greatly. It may appear as small streaks of blood mixed with mucus or phlegm that you cough up, or it may be a large amount of blood. In most cases, haemoptysis involves small amounts of blood. More than 90% of cases are mild and stop on their own^[7].

However, massive haemoptysis can be life-threatening. This occurs when large amounts of blood are coughed up—typically defined as more than 100 milliliters per hour or more than 500 milliliters (about a pint) in 24 hours. Massive haemoptysis can block your airways, cause your oxygen levels to drop dangerously low, and lead to severe blood loss^[1][2]. When haemoptysis is life-threatening, death typically results from lack of oxygen due to airway blockage rather than from blood loss itself^[14][15].

The blood in haemoptysis usually comes from the bronchial arteries, which are blood vessels that supply the airways. These arteries operate at high pressure, which is why bleeding from them can be severe. In about 90% of cases, the bronchial arteries are the source of the bleeding^[15].

What causes haemoptysis?

Haemoptysis can result from many different conditions. The most common cause worldwide is infection, which accounts for 60 to 70 percent of cases. Infections cause inflammation and swelling of the airways, which can lead to rupture of small blood vessels^[7].

Common infectious causes include:

• Bronchitis (inflammation of the airways), which causes about 26% of cases in some studies
• Pneumonia (lung infection), responsible for about 10% of cases
• Tuberculosis, particularly common in certain parts of the world, accounting for 8% of cases in some settings

These infections often come with other symptoms such as cough, fever, and production of mucus^[1][7].

Another common cause is bronchiectasis, a condition where the large airways in the lungs become damaged and widened. People with this condition often have repeated chest infections and cough up mucus regularly^[1].

Lung cancer is an important cause, accounting for about 17% to 23% of cases in adults, particularly in people over 40 who smoke^[2][7].

Other causes include:

• Chronic obstructive pulmonary disease (COPD)
• Pulmonary embolism (a blood clot in the arteries that supply blood to the lungs)
• Lung abscess (a collection of pus in the lung)
• Cystic fibrosis
• Bleeding disorders or problems with blood vessels
• Lung injury, including from medical procedures
• Heart conditions such as congestive heart failure
• Taking medicines that affect blood clotting (anticoagulants or blood thinners)
• Drug use, particularly crack cocaine
• Foreign objects stuck in the airway (more common in children)
• Autoimmune or inflammatory conditions affecting the lungs

Despite thorough investigation, doctors cannot find a cause in 20% to 50% of cases. This is called cryptogenic haemoptysis, and in most instances, the bleeding stops on its own within six months^[1][2][7].

How to recognize haemoptysis

It’s important to confirm that the blood is actually coming from your lungs or airways and not from other sources like your nose, throat, or stomach. Blood from haemoptysis typically has certain characteristics that help identify it^[1][2].

When the blood comes from your lungs or airways (true haemoptysis), it usually:

• Appears bright red or pink in color
• Looks frothy or bubbly (because it’s mixed with air)
• Is mixed with mucus or spit
• Comes up when you cough

This is different from:

• Blood in your saliva from bleeding in your mouth
• Blood from your nose that drips down your throat
• Vomited blood, which usually looks darker (like coffee grounds) and may be mixed with food

Sometimes it can be difficult to tell where the bleeding is coming from. Your doctor may need to perform tests to determine the source^[1][2].

Depending on what’s causing your haemoptysis, you might also experience other symptoms such as:

• Fever
• Persistent cough
• Night sweats
• Unintentional weight loss
• Tiredness or fatigue
• Difficulty breathing or shortness of breath
• Chest pain, especially when breathing deeply

The appearance of blood can provide clues about the underlying cause. For example, blood-streaked purulent (containing pus) sputum may suggest bronchitis, bronchiectasis, or pneumonia, while blood-tinged white frothy sputum may indicate congestive heart failure^[3].

How is the cause found?

Finding the cause of haemoptysis is essential for proper treatment. Your doctor will take several steps to determine why you are coughing up blood^[2][7].

The first step involves a detailed medical history and physical examination. Your doctor will ask you:

• How much blood you’ve coughed up
• How long you’ve been coughing up blood
• What the blood looks like
• Whether this is the first time or if it has happened before
• About other symptoms you’re experiencing
• About your smoking history
• About any medications you’re taking
• About your medical history, including any lung diseases

Your doctor will also perform a physical examination, including listening to your chest and checking your vital signs^[1][2].

Diagnostic tests typically include:

Chest X-ray: This is usually the first imaging test performed. While it may not always identify the exact cause or location of bleeding, it can show abnormalities in the lungs and help guide further testing^[7][10].

CT scan (computed tomography): A CT scan of the chest, particularly with intravenous contrast, is more accurate than a chest X-ray for determining the site and cause of bleeding. CT angiography can also show which blood vessels are involved^[7][10].

Bronchoscopy: This procedure involves inserting a thin, lighted tube through your mouth or nose into your airways. It allows the doctor to look directly at your airways and lungs, identify the bleeding site, and sometimes take tissue samples. Bronchoscopy can be used for both diagnosis and treatment^[2][10].

Other tests that may be performed include:

• Blood tests to check for infections, anemia, and blood clotting ability
• Sputum culture to identify bacteria or other organisms
• Lung function tests
• Angiography to examine blood flow in the lungs

The specific tests ordered will depend on your symptoms, the amount of bleeding, and how quickly you need treatment^[1][2].

When to seek medical help

You should see a doctor if you cough up any amount of blood, even if it’s just a small amount. While many cases are not serious, only a medical professional can determine the cause and appropriate treatment^[1][2].

Call emergency services immediately (triple zero in Australia, or your local emergency number) if you or someone else:

• Is coughing up a lot of blood
• Is coughing up blood and also has shortness of breath or difficulty breathing
• Is vomiting blood

Seek urgent medical attention if you have any of the following signs, which may indicate a serious condition:

• Blood in mucus that lasts longer than a week
• Blood that is severe or getting worse
• Bleeding that comes and goes repeatedly
• Chest pain
• Unexplained weight loss
• Heavy night sweats
• Fever higher than 38 degrees Celsius (101 degrees Fahrenheit)
• Shortness of breath with usual activities
• Feeling dizzy or lightheaded
• Blood in urine or stools

Even small amounts of blood in the airways can be dangerous for people with underlying lung disease or reduced lung function^[1][2][14].

How is haemoptysis treated?

Treatment for haemoptysis focuses on three main goals: stopping the bleeding, preventing aspiration (breathing blood into the lungs), and treating the underlying cause. The specific treatment depends on how much blood you’re coughing up and what’s causing it^[7][10].

For mild haemoptysis (small amounts of blood), treatment often includes:

• Treating the underlying infection with antibiotics if bacteria are the cause
• Monitoring your condition closely
• Resting and avoiding strenuous activities
• Staying hydrated
• Cough suppressants in some cases (though this is controversial)

Mild haemoptysis often stops on its own and can be managed on an outpatient basis with close follow-up^[7].

For massive or life-threatening haemoptysis, immediate hospital treatment is necessary. Initial management includes:

• Ensuring adequate oxygen supply
• Positioning the patient with the bleeding side down (if the side is known) to prevent blood from entering the healthy lung
• Protecting the airway, which may require inserting a breathing tube
• Replacing lost blood if needed
• Stopping any blood-thinning medications

Bronchoscopy procedures: If the bleeding site can be reached through a bronchoscope, various techniques can be used to stop the bleeding, including applying medications that constrict blood vessels, using cold saline, or applying pressure^[10][15].

Bronchial artery embolization: This is often the first-line treatment for massive haemoptysis. During this procedure, a specialist inserts a thin tube (catheter) through a blood vessel, usually in the groin, and guides it to the bleeding artery in the lung. Materials are then injected to block the artery and stop the bleeding. This procedure is successful in stopping bleeding in 75% to 98% of cases^[7][10].

Surgery: Surgical removal of the affected part of the lung may be necessary when other treatments fail or in specific situations such as traumatic injury, certain types of fungal infections (like aspergilloma), or localized disease that continues to bleed. However, surgery is generally reserved for cases where less invasive treatments haven’t worked^[7][10].

Treating the underlying cause is crucial to prevent haemoptysis from recurring. This might involve:

• Antibiotics for bacterial infections
• Anti-tuberculosis medications for tuberculosis
• Cancer treatment for lung cancer
• Blood thinners for pulmonary embolism
• Medications to manage heart conditions

If you have risk factors for lung cancer or if bleeding recurs, further evaluation with bronchoscopy or CT imaging is important even if initial tests were normal. Smokers over 40 years old with unexplained haemoptysis require particularly close follow-up^[7].

Managing haemoptysis requires close collaboration between different specialists, including lung doctors (pulmonologists), radiologists, and sometimes surgeons. If your haemoptysis persists despite treatment, consulting with a lung specialist is recommended^[7][15].