Coughing Up Blood (Hemoptysis)

Hemoptysis refers to coughing up blood that originates from the lungs or airways below the voice box (larynx). It's important to distinguish true hemoptysis from blood that comes from the nose, mouth, or stomach. Blood from the lungs is usually bright red, frothy, and mixed with sputum, while blood from the stomach is often darker and may look like coffee grounds.

The amount of blood can vary from small streaks in sputum to life-threatening hemorrhage. Even small amounts warrant medical attention because they may be the first sign of a serious condition. The blood comes from the bronchial arteries (90%) or pulmonary arteries (10%), and bleeding can result from inflammation, infection, tumors, or blood vessel problems.

The significance of hemoptysis depends on the amount of blood, the patient's overall health, and the underlying cause. While bronchitis is the most common cause, especially in smokers, more serious conditions like lung cancer, tuberculosis, or pulmonary embolism must be ruled out. Age, smoking history, and associated symptoms help determine the urgency and extent of evaluation needed.

Infections

• Acute bronchitis: Most common cause, especially in smokers
• Pneumonia: Bacterial, viral, or fungal
• Tuberculosis: Classic cause worldwide
• Lung abscess: Localized infection
• Bronchiectasis: Damaged, widened airways
• Fungal infections: Aspergillosis in cavities
• Parasitic infections: In endemic areas

Malignancies

• Lung cancer: Primary lung tumors
• Metastatic cancer: Spread from other organs
• Carcinoid tumors: Neuroendocrine tumors
• Kaposi's sarcoma: In immunocompromised
• Lymphoma: Can involve lungs

Cardiovascular Causes

• Pulmonary embolism: Blood clot in lung
• Left heart failure: Pink frothy sputum
• Mitral stenosis: Heart valve problem
• Pulmonary hypertension: High lung pressure
• Arteriovenous malformation: Abnormal vessels
• Aortic aneurysm: If eroding into lung

Other Causes

• Trauma: Chest injury, lung contusion
• Foreign body: Aspirated object
• Bleeding disorders: Clotting problems
• Medications: Anticoagulants, antiplatelets
• Autoimmune diseases: Lupus, Goodpasture's
• Idiopathic: No cause found in 15-30%

Hemoptysis often occurs with other symptoms that help identify the underlying cause:

• Chronic cough: May precede hemoptysis
• Chest pain: Pleuritic or constant
• Shortness of breath: From lung disease
• Fever: Suggests infection
• Night sweats: TB or cancer
• Weight loss: Cancer or chronic infection
• Fatigue: From anemia or disease
• Wheezing: Airway involvement
• Leg swelling: Heart failure or clots
• Purulent sputum: Bacterial infection
• Hoarseness: Vocal cord involvement
• Skin rash: Autoimmune disease

• Smoking: Major risk for lung cancer and COPD
• Age over 40: Higher cancer risk
• History of lung disease: COPD, bronchiectasis
• Immunosuppression: HIV, transplant recipients
• Travel history: TB endemic areas
• Occupational exposure: Asbestos, silica
• Family history: Lung cancer, bleeding disorders
• Anticoagulation therapy: Blood thinners
• Previous TB: Scarred lungs
• Cocaine use: Lung damage
• Recent procedures: Bronchoscopy, lung biopsy

Medical History

• Amount and frequency of blood
• Color and consistency
• Duration of symptoms
• Associated symptoms
• Smoking history
• Medical conditions
• Medications
• Travel history

Physical Examination

• Vital signs assessment
• Lung auscultation
• Heart examination
• Neck inspection
• Lymph node palpation
• Extremity examination
• Skin inspection

Diagnostic Tests

• Chest X-ray: Initial imaging study
• CT scan: Detailed lung imaging
• Bronchoscopy: Direct airway visualization
• Sputum tests: Culture, cytology, AFB
• Blood tests: CBC, coagulation studies
• Arterial blood gas: Oxygenation status
• Echocardiogram: If cardiac cause suspected
• Pulmonary angiography: For embolism

Immediate Actions

• Stay calm and sit upright
• Note the amount and appearance of blood
• Save a sample if possible for doctors
• Avoid lying flat
• Do not take aspirin or blood thinners
• Call your doctor or seek emergency care
• Keep track of associated symptoms

Information to Provide

• How much blood (teaspoons, tablespoons)
• Color (bright red, dark, pink frothy)
• How long it's been happening
• Other symptoms present
• Medical history
• Current medications
• Recent travel or exposures

• Quit smoking: Most important preventive measure
• Avoid secondhand smoke: Protects lung health
• Treat infections promptly: Prevents complications
• Manage chronic conditions: COPD, heart disease
• Take medications as directed: Especially blood thinners
• Regular check-ups: Early detection of problems
• TB screening: If at risk
• Occupational safety: Protective equipment
• Vaccinations: Flu, pneumonia vaccines
• Healthy lifestyle: Exercise, good nutrition
• Avoid irritants: Chemicals, pollution
• Prompt evaluation: Of persistent cough

See a Doctor Immediately For:

• Any amount of blood in sputum
• Blood-streaked phlegm lasting days
• Coughing blood with no apparent cause
• History of smoking with new hemoptysis
• Associated concerning symptoms
• Recent travel to TB areas
• Known lung disease with new bleeding

Call 911 For:

• Large amounts of blood
• Difficulty breathing
• Chest pain with hemoptysis
• Signs of shock
• Altered mental status
• Severe dizziness or fainting
• Continuous bleeding