II. Definitions

  1. Hemoptysis
    1. Blood expectorated from the lung parenchyma or airways (trachea, Bronchi, Bronchioles)
  2. Massive Hemoptysis
    1. Expectoration of >100 ml of blood per 24 hours (or 50 ml in a single cough)
    2. Various volume criteria have been used ranging from 100 to 600 ml per 24 hours
  3. Life-Threatening Hemoptysis
    1. Hemoptysis AND
    2. Hemodynamic instability, abnormal gas exchange or need for urgent Resuscitation

III. Precautions

  1. Even small volumes of bright red blood (not simply blood tinged Sputum) may herald Massive Hemoptysis
  2. Evaluate carefully and consider early Endotracheal Intubation in high risk cases
  3. Patients with Hemoptysis die of asphyxiation, not Hemorrhage

IV. Epidemiology

  1. Incidence: 1 in 1000 patients per year
  2. Only 5-15% of hempotysis cases meet criteria for Massive Hemoptysis

VI. Findings: Symptoms and signs

  1. Hemoptysis
    1. Frothy Sputum with bright red blood, and alkaline pH
    2. Contrast with Hematemesis

VII. Imaging

  1. Chest XRay
    1. First-line in most cases
    2. Test Sensitivity for identifying bleeding site: 33%-82% (and identifies cause in 35% of cases)
  2. Chest CT with contrast indications
    1. Test Sensitivity for detecting bleeding site
      1. Standard Chest CT: 70-88% (and identifies the cause in 60-77% of cases)
      2. Multidetector Chest CT: 100% for Bronchial arteries (62% for non-Bronchial arteries)
    2. Identify source of Hemoptysis to direct Intervention Radiology or surgery (Massive Hemoptysis)
    3. Mass lesion on Chest XRay
    4. Lung Cancer risk factors (e.g. Tobacco Abuse)
    5. Failed resolution of Pulmonary Infiltrate on Chest XRay
    6. Suspected Pulmonary Embolism
    7. Persistent symptoms despite negative Chest XRay
  3. Bronchoscopy indications
    1. Test Sensitivity for identifying bleeding site: 73-93% (and identifies cause in <8% of cases)
    2. CT chest non-diagnostic
    3. Mass lesion on Chest XRay
    4. Recurrent Hemoptysis
  4. Bronchial artery arteriography
    1. Used in some cases when Intervention Radiology is planned for embolization

VIII. Differential Diagnosis

  1. See Hemoptysis Causes
  2. Distinguish from Pseudohemoptysis (e.g. upper respiratory or gastrointestinal source)

IX. Evaluation: Non-Massive Hemoptysis

  1. See labs below
  2. Step 1: Consider non-lower respiratory cause (Pseudohemoptysis)
    1. Upper respiratory source (e.g. Sinusitis)
    2. Upper Gastrointestinal Bleeding (Hematemesis)
      1. Coffee grounds with acidic pH
  3. Step 2: Imaging
    1. See imaging as above
  4. Step 3: Bronchoscopy Indications
    1. See imaging above

X. Labs: Massive Hemoptysis

  1. First-line studies
    1. Complete Blood Count with Platelets and differential
    2. ProTime (PT, INR)
    3. Partial Thromboplastin Time (aPTT)
    4. Blood Type and cross-match
    5. Renal Function tests
    6. Sputum Gram Stain and culture (including acid-fast bacilli, Fungal Culture, cytology)
  2. Other studies to consider
    1. D-Dimer
    2. HIV Test
    3. Arterial Blood Gas
    4. Quantiferon-TB (or PPD)
      1. Does not replace Sputum testing when acute symptoms are present

XI. Management: Massive Hemoptysis

  1. See ABC Management
  2. Position patient with bleeding lung side down (if known source, e.g. Lung Lesion)
  3. Patient alert, not hypoxic and able to clear their own airway
    1. Supplemental Oxygen
    2. Avoid BIPAP or other positive pressure that interferes with airway clearance of blood
    3. Observe closely for decompensation
      1. Bronchial tree will completely fill with 150-200 cc of blood
  4. Advanced Airway (patient decompensating, hypoxic)
    1. Attempt awake intubation under Ketamine
      1. Allows for visualization of cords as patient coughs and clears airway
    2. Large bore suction or suction via Endotracheal Tube attached to meconium aspirator
    3. Place as large a bore Endotracheal Tube as possible (e.g. >7.5 up to 8.5)
    4. Emergency Cricothyrotomy if unable to intubate
  5. Lung isolation
    1. Best performed by bronchoscopy if skilled operator available (e.g. pulmonology, thoracic surgery)
    2. Suspected source of Massive Hemorrhage is on the LEFT
      1. Pass the Endotracheal Tube into the right mainstem Bronchus (bleeding should stop)
    3. Suspected source of Massive Hemorrhage is on the RIGHT
      1. Pull ET Tube back to glottis (but still below Vocal Cords)
      2. Pass bougie (or bronchoscope) through ET Tube and rotate bougie 90 degrees left
      3. Pass ET Tube over the bougie and assess bleeding and position (auscultation, Chest XRay)
  6. Emergent Consultation
    1. Pulmonology Consultation for bronchoscopy
    2. Intervention Radiology for directed Bronchial artery embolization
    3. Cardiothoracic surgery Consultation
    4. ECMO may be needed
  7. Manage Coagulopathy
    1. See Coagulation Bleeding Disorders
    2. See Emergent Reversal of Anticoagulation
  8. References
    1. Swaminathan and Weingart in Herbert (2019) EM:Rap 19(3): 10-11

XII. Management: Indications for ICU Admission or Tertiary Care Transfer

  1. Lesions at the highest risk of bleeding (e.g. Aspergillus infection, pulmonary artery involved)
  2. Respiratory distress or Hypoxia
    1. Respiratory Rate >30 per minute
    2. Oxygen Saturation <88% on room air
    3. Requiring High Flow Oxygen at >8 L/min or Mechanical Ventilation
  3. Hemodynamic instability
    1. Hemoglobin < 8 g/dl or more than 2 g/dl drop from baseline
    2. Disseminated Intravascular Coagulation (DIC) or other consumptive Coagulopathy
    3. Hypotension requiring intervention (fluid bolus, transfusion, Vasopressors)
  4. Massive Hemoptysis
    1. Hemoptysis >200 ml per 24 hours OR
    2. Hemoptysis >50 ml per 24 hours in a patient with COPD
  5. Serious comorbidity
    1. Previous pneumonectomy
    2. Chronic Obstructive Pulmonary Disease (COPD)
    3. Cystic Fibrosis
    4. Ischemic Heart Disease
  6. References
    1. Fartoukh (2010) Rev Mal Respir 27(10): 1243-53 +PMID:21163400 [PubMed]

XIII. Management: Non-Massive Hemoptysis

  1. See Evaluation above
  2. Consider antibiotic course if symptoms or signs of lower respiratory infection
  3. Serially re-evaluate
  4. Consider CT Chest
  5. Consider pulmonology Consultation for bronchoscopy

XIV. Prognosis: Calculation

  1. Criteria
    1. Score 1: Admit Chest XRay with involvement of 2 or more lung quadrants
    2. Score 1: Chronic Alcoholism
    3. Score 1: Pulmonary artery involvement
    4. Score 2: Aspergillosis
    5. Score 2: Malignancy
    6. Score 2: Mechanical Ventilation required
  2. Interpretation
    1. Admit to ICU for score >2 (see other indications above)
    2. Consider urgent Intervention Radiology for score >5
  3. Mortality: In-Hospital
    1. Total 0: Mortality 1%
    2. Total 1: Mortality 2%
    3. Total 2: Mortality 6%
    4. Total 3: Mortality 16%
    5. Total 4: Mortality 34%
    6. Total 5: Mortality 58%
    7. Total 6: Mortality 79%
    8. Total 7: Mortality 91%
  4. References
    1. Fartoukh (2012) Respiration 83(2): 106-14 +PMID:22025193 [PubMed]

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Related Studies

Ontology: Hemoptysis (C0019079)

Definition (MSH) Expectoration or spitting of blood originating from any part of the RESPIRATORY TRACT, usually from hemorrhage in the lung parenchyma (PULMONARY ALVEOLI) and the BRONCHIAL ARTERIES.
Definition (NCI_NCI-GLOSS) Coughing or spitting up blood from the respiratory tract.
Definition (NCI) Coughing up blood from the respiratory tract.
Concepts Sign or Symptom (T184)
MSH D006469
ICD9 786.3, 786.30
ICD10 R04.2
SnomedCT 207068006, 207071003, 66857006, 31741006, 6686005, 139191001, 161936004, 267035006, 158387000, 158384007
English Hemoptyses, Hemoptysis, COUGHING BLOOD, HAEMOPTYSIS, SPUTUM BLOODY, Haemoptysis NOS, [D]Hemoptysis (context-dependent category), [D]Hemoptysis NOS (context-dependent category), [D]Haemoptysis, [D]Haemoptysis NOS, [D]Hemoptysis, [D]Hemoptysis NOS, Hemoptysis (finding), Hemoptysis (disorder), Blood in sputum - haemoptysis, Blood in sputum - hemoptysis, Expectoration of hemorrhagic sputum, Expectoration of blood streaked sputum, coughing up blood-streaked sputum (symptom), coughing up blood, coughing up blood (hemoptysis), coughing up blood-streaked sputum, hemoptysis, coughing up blood (symptom), Coughing up Blood, Coughing blood, Sputum bloody, Hemoptysis [Disease/Finding], Hemoptysis NOS, Hemoptysis, unspecified, bloody sputum, Coughing;blood, Spitting (up);blood, coughing blood, blood coughed, blood streaked sputum, cough up blood, blood spitting up, spitting (up) blood, spit up blood, blood spit up, hemoptyses, Blood in sputum - hemoptysis [& symptom], Blood in sputum - haemoptysis [& symptom], [D]Hemoptysis NOS (situation), Haemoptysis - symptom, Blood in sputum - haemoptysis (finding), [D]Haemoptysis NOS (situation), Blood in sputum - symptom, Sputum + blood-symptom, Blood in sputum - haemoptysis [& symptom] (finding), Blood in sputum-symptom, Blood in sputum - hemoptysis (finding), Expectoration of bloody sputum, [D]Haemoptysis (situation), [D]Hemoptysis (situation), Hemoptysis - symptom, Coughing and spitting blood, HEMOPTYSIS, Coughing up blood, Haemoptysis, Blood streaked sputum, Blood streaked sputum (finding), spitting up blood, haemoptysis
French HEMOPTYSIE, Toux avec expectorations sanguines, Expectoration hémoptoïque, Crachats à traces de sang, EXPECTORATION SANGLANTE, HEMORR LORS D'EFFORTS DE TOUX, Hémoptysie
Portuguese HEMOPTISE, Expectoração com laivos de sangue, Tossir sangue, Expectoração sanguinolenta, EXPECTORACAO COM SANGUE, EXPECTORACAO HEMOPTOICA, Hemoptise
Spanish HEMOPTISIS, Esputo con estrias de sangre, Sangre al toser, Esputo sanguinolento, hemoptisis (trastorno), [D]hemoptisis, SAI (categoría dependiente del contexto), [D]hemoptisis (categoría dependiente del contexto), hemoptisis (hallazgo), ESPUTO SANGUINOLENTO, TOS HEMOPTOICA, [D]hemoptisis, [D]hemoptisis, SAI, expectoración de esputo hemorrágico, expectoración de esputo hemorrágico (concepto no activo), [D]hemoptisis, SAI (situación), [D]hemoptisis (situación), expectoración de esputo sanguinolento, expectoración con sangre, expectoración de esputo con vestigios de sangre (hallazgo), expectoración de esputo con vestigios de sangre, expectoración de esputo veteado de sangre, hemoptisis, Hemoptisis
Dutch bloed ophoesten, bloedstreepjes bevattend sputum, sputum bloederig, Haemoptoe, haemoptysis, Hemoptoe, Hemoptysis
German Sputum mit Blutspuren, Husten von Blut, Sputum, blutig, BLUTHUSTEN, HAEMOPTOE, SPUTUM BLUTIG, Haemoptoe, Bluthusten, Blutspucken, Hämoptyse
Italian Escreato striato di sangue, Espettorato striato di sangue, Tosse ematica, Emottisi
Japanese 喀血, 血痕痰, 血痰, カッケツ, ケッタン, ケッコンタン
Swedish Blodupphostning
Czech hemoptýza, Krvavé sputum, Sputum s příměsí krve, Vykašlávání krve, Hemoptýza
Finnish Veriyskä
Korean 객혈
Polish Krwioplucie
Hungarian Haemoptoe, Haemoptysis, Vércsíkos köpet, Vérköhögés, Véres köpet
Norwegian Opphosting av blod, Blodhoste, Blodig oppspytt, Hemoptyse, Blodig hoste

Ontology: Pulmonary hemorrhage (C0151701)

Definition (NCI) Bleeding from the lung parenchyma.
Concepts Pathologic Function (T046)
ICD10 R04.89
SnomedCT 274252009, 207070002, 158386009, 78144005
English PULMONARY HAEMORRHAGE, PULMONARY HEMORRHAGE, Pulmonary haemorrhage NOS, [D]Pulmonary hemorrhage (context-dependent category), [D]Pulmonary hemorrhage NOS (context-dependent category), [D]Pulmonary haemorrhage NOS, [D]Pulmonary hemorrhage NOS, Pulmonary haemorrhage [D], Pulmonary hemorrhage [D], Pulmonary hemorrhage, pulmonary hemorrhage (diagnosis), pulmonary hemorrhage, Hemorrhage lung, Lung hemorrhage, Hemorrhage pulmonary, Pulmonary Hemorrhage, hemorrhage lung, hemorrhagic lung, lung hemorrhagic, hemorrhagic lungs, pulmonary haemorrhage, lung haemorrhage, lung hemorrhage, Pulmonary hemorrhage NOS, Pulmonary bleeding, [D]Pulmonary haemorrhage, [D]Pulmonary hemorrhage NOS (situation), [D]Pulmonary hemorrhage (situation), Haemorrhage pulmonary, Lung haemorrhage, Haemorrhage lung, [D]Pulmonary hemorrhage, Pulmonary haemorrhage [D] (situation), Pulmonary haemorrhage, Haemorrhagic lung, Hemorrhagic lung, Pulmonary hemorrhage (disorder), hemorrhage; lung, hemorrhage; pulmonary, lung; hemorrhage, pulmonary; hemorrhage, Pulmonary hemorrhage [D] (disorder)
Italian Emorragia del polmone, Emorragia polmonare, Sanguinamento polmonare
Dutch hemorragie long, hemorragie pulmonaal, bloeding long, pulmonale bloeding, bloeding; long, bloeding; pulmonaal, long; bloeding, pulmonaal; bloeding, longbloeding
French Hémorragie du poumon, HEMORRAGIE PULMONAIRE, Saignement pulmonaire, Hémorragie pulmonaire
German Blutung pulmonal, Blutung der Lunge, LUNGENBLUTUNG, Bluten der Lungen, Lungenblutung
Spanish Hemorragia de pulmón, [D]hemorragia pulmonar, SAI (categoría dependiente del contexto), hemorragia pulmonar [D] (categoría dependiente del contexto), HEMORRAGIA PULMONAR, Sangrado pulmonar, [D]hemorragia pulmonar, SAI, hemorragia pulmonar [D], [D]hemorragia pulmonar, SAI (situación), hemorragia pulmonar [D] (situación), hemorragia pulmonar (trastorno), hemorragia pulmonar [D] (trastorno), hemorragia pulmonar, Hemorragia pulmonar
Japanese 肺出血, ハイシュッケツ
Portuguese HEMORRAGIA PULMONAR, Sangramento pulmonar, Hemorragia pulmonar
Czech Hemoragie plicní, Pulmonální hemoragie, Plicní hemoragie, Krvácení pulmonální, Hemoragie pulmonální, Plicní krvácení, Krvácení plicní, Pulmonální krvácení
Hungarian Pulmonalis haemorrhagia, Pulmonalis vérzés, Tüdővérzés, Tüdő vérzés, Tüdő vérzése

Ontology: coughing up massive amount of blood (C2138228)

Concepts Finding (T033)
English massive hemoptysis, coughing up massive amount of blood, coughing up massive amount of blood (symptom)