Hemoptysis is the expectoration of blood from the lower respiratory tract. It most commonly occurs as a result of a pulmonary infection; tuberculosis is the leading cause of hemoptysis worldwide. While lung cancer is the second most frequent cause of hemoptysis, bleeding from the respiratory tract only occurs in a minority of these patients. Typically, management of hemoptysis begins with the identification of the bleeding site using imaging or bronchoscopy. Definitive diagnostic evaluation is then guided by the location and appearance of the hemorrhagic site, patient symptoms, and patient risk factors for lung cancer. Treatment is directed at the underlying cause. Oral or inhaled tranexamic acid may be used for symptomatic relief. A minority of patients may present with massive hemoptysis, which can be life-threatening if not controlled emergently. In these patients, management begins with securing the airway and protecting the functioning lung. Bedside bronchoscopy and/or bronchial artery embolization are then used to control the hemorrhage. Definitive diagnosis and treatment follow respiratory and hemodynamic stabilization.
- Hemoptysis: expectoration of blood from the
- Diffuse alveolar hemorrhage (DAH): hemorrhage arising from the pulmonary microcirculation (e.g., alveolar capillaries, arterioles, and/or venules) that manifests clinically with hypoxemia, alveolar infiltrates on imaging, and possible hemoptysis. 
- Hemoptysis is the presenting symptom in 0.1% of outpatient visits and hospitalizations. 
Epidemiological data refers to the US, unless otherwise specified.
Source of bleeding 
- Bronchial arteries (90% of cases)
- Pulmonary arteries (5% of cases)
- Systemic arteries (5% of cases)
- Diffuse alveolar hemorrhage (0.2% of cases) 
Overview of common etiologies
|Etiology of hemoptysis |
Diffuse alveolar hemorrhage is most commonly a result of immune-mediated vasculitis or connective tissue disease. Other causes include congestive heart failure, infection, coagulopathy, and trauma. 
See detailed further management of ”” and ” ” in their dedicated sections.
- All patients: Initially assume that even a small volume of hemoptysis is life-threatening until proven otherwise.
- Begin acute stabilization and urgently consult pulmonology or thoracic surgery.
- Localize bleeding based on stability.
- Evaluate for definitive therapy: e.g., BAE) or surgery. (
In cases of , stabilize the patient before obtaining further diagnostic studies.
Management priorities are resuscitation, protecting the nondiseased lung, and establishing respiratory and hemodynamic stability. Fatal hypoxia due to impaired gas exchange typically occurs before a hemodynamic change resulting from blood loss. 
Severity assessment 
- Estimate volume and speed of blood loss: See “Massive hemoptysis” and “Nonmassive hemoptysis.”
- Evaluate the effect of hemoptysis on airway patency, gas exchange, and hemodynamics: See “Life-threatening hemoptysis” and “Nonmassive hemoptysis.”
- Identify any .
massive hemoptysis. requires respiratory and hemodynamic stability, a low volume and speed of blood loss, and no . Assume all other types of hemoptysis to be potentially life-threatening or have a high risk of progression to
Red flags for hemoptysis 
The presence of anyis associated with an increased risk of mortality and the potential for rapid patient deterioration. 
- Need for mechanical ventilation on admission
- History of:
- Pulmonary artery involvement
- CXR findings show involvement of more than one quadrant.
Hemoptysis due to is frequently severe and life-threatening. 
- Admit all patients with massive hemoptysis and life-threatening hemoptysis to hospital.
- Select patients with nonmassive hemoptysis may be managed as outpatients after initial workup and observation.
- Consider ICU admission for patients with any of the following: 
- Perform initial studies, including CXR and basic laboratory studies.
- Locate the site of bleeding.
- Continue with further investigations for the underlying cause once the patient is clinically stable.
Initial studies for hemoptysis
- Laboratory studies 
Chest x-ray is mandatory in all patients with hemoptysis as it may quickly indicate the location and underlying cause of the bleeding.
Studies to locate the source of bleeding
CT chest with IV contrast 
- Indications (see also “Nonmassive hemoptysis”)
- Potential findings 
- Potential findings
- Next steps: See “ .”
- Angiography: CTA chest or selective catheter angiography may be indicated to help guide , depending on the bleeding source identified on CT chest.
Bronchoscopy can accurately determine the site of bleeding but is much less sensitive than chest CT at determining the underlying cause of the hemoptysis. A combination of both studies is often required for optimal management. 
Workup for underlying causes
Consider further investigations as directed by clinical suspicion of underlying conditions. See “Etiology of hemoptysis”. 
- CT imaging: e.g., CTPA for PE or other pulmonary arterial abnormalities, CT chest/abdomen/pelvis for malignancy screening
- Laboratory studies
- Tests of cardiac and pulmonary function: e.g., echocardiography and CHF and valvular heart disease, spirometry for COPD
Priorities for management are acute stabilization followed by definitive bleeding control. The underlying cause can be investigated and treated once patients have been stabilized.
- A frequently used term with no universal definition
- Commonly described using blood loss parameters, e.g., 100–1000 mL/24 hours or > 100 mL/hour 
- Occurs in 5–15% of patients presenting with hemoptysis. 
- Life-threatening hemoptysis consists of any volume of expectorated blood that causes any of the following: 
The effects of hemoptysis on a patient's airway patency, oxygenation, ventilation, and hemodynamic status are more important predictors of outcome and need for intervention than the absolute value or rate of blood loss. 
Followwith simultaneous assessment and management.
- Secure the airway if are present, ideally via with a large ETT (internal diameter ≥ 8.5 mm). 
- Begin or as needed.
- Consider lung from lung still participating in gas exchange. : the physical separation of the bleeding
Avoid using a massive hemoptysis: The small lumen diameter impedes passage of a flexible bronchoscope and effective removal of large blood clots!  in the management of
- Establish large-bore IV access and obtain and for blood products
- Start and begin emergency blood transfusion as indicated.
- Consider the use of a hemostatic agent.
Bronchoscopic hemostasis 
- First-line modality: flexible fiberoptic bronchoscopy
- Alternative modality: rigid bronchoscopy
Bronchial artery embolization (BAE) 
- BAE is the preferred treatment method for most patients with massive hemoptysis.
- Bleeding sites or high-risk vascular abnormalities are detected on CTA or thoracic angiography.
- Embolic material or coils are introduced to the suspected area under fluoroscopic guidance. 
BAE should be performed as soon as the patient has been stabilized. 
Because the aortic origins of the spinal arteries and the bronchial arteries are in close proximity, spinal arteries may be inadvertently occluded during BAE. Therefore, be alert for new neurological symptoms in patients who have recently undergone BAE. 
- Ideally, surgery is only performed once hemostasis has been achieved via other methods because of the high mortality rate in actively bleeding patients. 
- Emergency surgical intervention typically involves lobectomy or pneumonectomy.
- Indications for surgery
- Iatrogenic pulmonary artery rupture or pulmonary artery aneurysm (e.g., Rasmussen aneurysm)
- Hemoptysis secondary to chest trauma
- Ongoing massive hemoptysis after attempted BAE
- Patients with hemoptysis secondary to aspergilloma, TB, or resectable lung tumor that is considered to have a high rebleeding risk
Management of diffuse alveolar hemorrhage 
- Acute stabilization and basic hemostasis measures as for other types of hemoptysis.
- Consider mechanical ventilation with high PEEP.
- If the etiology is immune-mediated, consult a specialist and consider immune suppression (e.g., high-dose corticosteroids, rituximab) and/or plasmapheresis.
Acute management checklist for massive and/or life-threatening hemoptysis
- Perform ABCDE survey.
- Place the patient in lateral decubitus position with the bleeding side down.
- Establish a secure airway with an 8.5-mm ID endotracheal tube if air exchange is compromised.
- Obtain urgent pulmonary medicine consult.
- Secure IV access and start resuscitation with fluid or blood products.
- Obtain x-ray chest.
- Send initial studies for hemoptysis.
- Reverse known anticoagulants.
- Consider TXA.
Nonmassive hemoptysis has no universal definition. Commonly described parameters include all of the following:
- < 100 mL of blood volume lost 
- No signs of respiratory distress or hemodynamic instability
- No other
- Rule out .
- Examine for signs of infectious disease.
- Identify features of elevated cancer risk, i.e., age > 40 years, smoking history ≥ 30 pack years, or hemoptysis volume ≥ 30 mL.
- Review CXR and other to determine further management.
Treat any patients who develop signs of hemodynamic instability, respiratory compromise, or as !
- In 90% of cases, hemoptysis resolves with treatment of the underlying cause. 
- If the symptoms of hemoptysis are distressing for the patient, consider TXA. 
Management of underlying causes 
- For patients with new opacity or signs of infection on CXR:
- Obtain CT chest with IV contrast for patients with:
- Consult pulmonology and consider bronchoscopy for patients with:
- A mass or evidence of lung disease on imaging
- Recurrent hemoptysis at any time
- Elevated cancer risk despite normal imaging 
Even after extensive evaluation, up to 50% of patients with nonmassive hemoptysis have no definitive diagnosis. Though the likelihood of underlying malignancy is rare, educate patients on the symptoms of lung cancer and arrange regular follow-up for those with an elevated risk. 
Acute management checklist for nonmassive hemoptysis
- Verify patient is stable, oxygenating well, and that the bleeding is not clinically significant.
- Verify that bleeding is from the lower respiratory tract.
- Obtain x-ray chest.
- Obtain initial laboratory studies for hemoptysis, including cultures.
- Determine the patient's cancer risk based on history and volume of hemoptysis.
- CT chest if indicated by x-ray chest findings and cancer risk.
- Pulmonary consultation for abnormal imaging, abnormal laboratory studies, or recurrent bleeding
- Investigate and treat underlying causes.
- Pseudohemoptysis: expectorated blood arising from the upper respiratory tract, oropharynx, or gastrointestinal tract
|Distinguishing hemoptysis from pseudohemoptysis |
|Gastrointestinal bleeding|| |
|Upper respiratory tract bleeding|
The differential diagnoses listed here are not exhaustive.