What are the causes, signs, and symptoms of hemoptysis (coughing up blood), how to differentiate between lung and gastrointestinal (GI) causes, and what are the treatment options and differential diagnoses (ddx) for a patient with a history of lung disease, such as chronic obstructive pulmonary disease (COPD) or cancer, and GI conditions like gastroesophageal reflux disease (GERD) or ulcers?

Hemoptysis: Causes, Clinical Features, Differentiation, and Management

Definition and Key Clinical Features

Hemoptysis is the expectoration of blood from the lung alveoli or airways of the lower respiratory tract, and must be distinguished from hematemesis (GI bleeding) through specific clinical characteristics. 1

Distinguishing Pulmonary from GI Bleeding

Blood from the lungs is typically bright red, frothy, alkaline pH, and mixed with sputum, while GI blood is dark, coffee-ground appearance, acidic pH, and mixed with food particles. 2, 3

Key differentiating features include:

• Pulmonary source: Preceded by throat tickling or urge to cough, frothy appearance, bright red color, alkaline pH on testing 2, 3
• GI source: Preceded by nausea/vomiting, dark or coffee-ground appearance, acidic pH, mixed with food particles 2, 3
• Associated symptoms for lung: Dyspnea, chest pain, fever, weight loss 3, 4
• Associated symptoms for GI: Abdominal pain, melena, history of liver disease or GERD 3

Common Causes by Clinical Setting

Primary Care/Outpatient Setting

The most common causes are acute respiratory tract infections, COPD, malignancy, and bronchiectasis. 1

• Acute bronchitis and pneumonia: Most frequent in primary care 1, 3, 4
• COPD exacerbations: Common in patients with known disease 1
• Bronchiectasis: Leading cause in tertiary centers in North America/Europe 1
• Lung cancer: Present in 7-10% as initial symptom, 25% at presentation 5

Tertiary Care/Hospital Setting

Bronchiectasis, respiratory infections, and lung carcinomas predominate in referral centers. 1

Geographic Considerations

Tuberculosis and its sequelae remain the most prevalent cause in developing countries and should be considered in endemic regions or high-risk populations (homeless, foreign-born). 1, 4

Additional Important Causes

• Autoimmune diseases: Causing capillaritis or cavitation 1
• Coagulopathies: Medication-related or intrinsic 1
• Vascular causes: Pulmonary arteriovenous malformations, pseudoaneurysms, pulmonary artery aneurysms 1
• Pulmonary embolus: Uncommon cause, rarely primary etiology 1
• Cryptogenic hemoptysis: 20% of cases despite complete investigation with CT and bronchoscopy 1

Signs and Symptoms

Clinical Presentation Patterns

Hemoptysis severity ranges from scant (<5 mL/24h) to massive (>100-240 mL/24h or causing respiratory compromise), with the rate of bleeding more predictive of mortality than total volume. 1, 6, 7

Key clinical features to assess:

• Volume and rate of bleeding: Critical for risk stratification 1, 6, 7
• Respiratory distress: Indicates high-risk massive hemoptysis 6, 7
• Hemodynamic instability: Hypotension suggests massive bleeding 1
• Associated symptoms: Fever (infection), weight loss (malignancy), dyspnea (multiple causes) 3, 4

Red Flags for Malignancy

Finger clubbing with pleural effusion or lobar collapse is almost pathognomonic for bronchogenic carcinoma. 5

• Constitutional symptoms: Fatigue, decreased appetite, unintentional weight loss (OR 2.1 for lung cancer) 5
• Hoarseness: Suggests recurrent laryngeal nerve involvement from mediastinal disease 5
• Risk factors: Heavy smoking (90% of lung cancers), occupational exposures (asbestos, radon), 25-year high-risk occupation 5

Differential Diagnosis

Pulmonary Causes (>90% of cases)

Over 90% of massive hemoptysis originates from bronchial arteries (systemic circulation), not pulmonary arteries. 6, 7

• Infectious: Bronchitis, pneumonia, tuberculosis, aspergilloma 1, 3, 4
• Structural: Bronchiectasis, COPD 1
• Neoplastic: Lung cancer (primary or metastatic) 1, 5
• Vascular: AVM, pseudoaneurysm, pulmonary embolus 1
• Autoimmune: Vasculitis, Goodpasture syndrome 1

Non-Pulmonary Mimics

• Upper airway: Epistaxis with posterior drainage 2, 3
• GI tract: Hematemesis from esophageal varices, peptic ulcer, Mallory-Weiss tear 2, 3
• Pseudohemoptysis: Oral/pharyngeal bleeding 3, 4

Treatment Approach

Severity-Based Algorithm

Massive Hemoptysis (Life-Threatening)

For clinically unstable patients with massive hemoptysis, proceed directly to bronchial artery embolization (BAE) without delay, as delaying BAE significantly increases mortality. 6, 7

Immediate airway management:

• Intubate with single-lumen cuffed endotracheal tube (NOT double-lumen) to allow bronchoscopic suctioning and clot removal 6, 7
• Avoid BiPAP entirely as positive pressure worsens bleeding 6, 7
• Consider selective mainstem intubation to protect non-bleeding lung if side identified 6, 7
• Establish large-bore IV access (ideally 8-Fr central line) for resuscitation 6, 7

Critical interventions:

• Stop all NSAIDs and anticoagulants immediately due to platelet dysfunction and worsening bleeding 6, 7
• Stop all airway clearance therapies to allow clot formation 6, 7
• Stop aerosolized hypertonic saline as it exacerbates bleeding 6
• Actively warm patient and all transfused fluids to prevent hypothermia-induced coagulopathy 6, 7

Definitive management:

• BAE achieves immediate hemostasis in 73-99% of cases and is first-line therapy 6, 7
• Do NOT perform bronchoscopy before BAE in unstable patients as this delay significantly increases mortality 6, 7
• Bronchoscopy is reserved for airway clearance and temporizing measures (tamponade, iced saline, bronchial blockade balloons) 6, 7

Mild-to-Moderate Hemoptysis (≥5 mL/24h)

For clinically stable patients, CT chest with IV contrast is the preferred initial diagnostic test with 77-80% diagnostic accuracy, superior to bronchoscopy for identifying cause and location. 6, 7

Management steps:

• Admit to hospital for monitoring any hemoptysis ≥5 mL 6
• Administer antibiotics as bleeding may represent pulmonary exacerbation or bacterial infection 6, 7
• Stop all NSAIDs immediately due to platelet dysfunction 6, 7
• Chest radiograph is reasonable initial imaging when confirming benign causes (bronchitis, pneumonia), though sensitivity is limited (26% diagnostic yield) 6
• Bronchoscopy provides 70-80% diagnostic yield for identifying anatomic site and therapeutic options 6, 7

Bronchoscopic interventions for visible central lesions:

• Argon plasma coagulation, Nd:YAG laser, electrocautery achieve 80-90% success rates 6
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh arrests bleeding in 98% 6, 7
• Tamponade, iced saline instillation, bronchial blockade balloons for temporizing control 6, 7

Scant Hemoptysis (<5 mL/24h)

Scant hemoptysis may not require hospital admission but warrants outpatient evaluation. 6

• Continue aerosol therapies (except hypertonic saline) 6
• Continue airway clearance with least concerning techniques (active cycle of breathing, autogenic drainage) 6
• Chest radiograph as initial diagnostic test 5, 3, 4

Cause-Specific Management

Malignancy

BAE for malignancy is typically palliative or temporizing prior to definitive surgery. 6

• External beam radiation therapy (EBRT) provides 81-86% hemoptysis relief for unresectable tumors 6
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone 6
• Surgery for resectable tumors in stable patients achieves 50-70% survival but carries 16% mortality for massive hemoptysis 6

Aspergilloma

Definitive surgical treatment following initial BAE is recommended due to 55% recurrence rate. 6

Recurrent Hemoptysis

Repeat BAE is the primary therapeutic option with no increased risk of morbidity or mortality for repeat interventions. 6, 7

• Recurrence occurs in 10-55% of cases after initial BAE 6, 7
• Higher recurrence rates with aspergillomas (55%), malignancy, sarcoidosis 6
• Early recurrence (<3 months): Incomplete/missed embolization 6
• Late recurrence (>3 months): Vascular collateralization or recanalization 6
• Perform CTA or CT with IV contrast before repeat BAE for arterial mapping 6

Intensive Care Management

Admit all patients with massive hemoptysis to ICU for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding. 6, 7

• Start venous thromboprophylaxis as soon as bleeding controlled 6, 7
• Obtain baseline labs: CBC, PT/aPTT, Clauss fibrinogen (NOT derived), type and cross-match 6
• Do not rely on single hematocrit as isolated marker for bleeding severity 6

Common Pitfalls and Caveats

Critical Errors to Avoid

• Never delay airway protection for diagnostic procedures when respiratory distress present 6, 7
• Never use double-lumen endotracheal tubes as they prevent therapeutic bronchoscopy and are difficult to place 7
• Never delay BAE for CT or bronchoscopy in unstable patients as this significantly increases mortality 6, 7
• Do not instill vasoactive agents (epinephrine) if bleeding is brisk as they are unlikely to help 7
• Do not use derived fibrinogen levels as they are misleading; use Clauss method 6
• Avoid hyperventilation and excessive PEEP in hypovolemic patients as this worsens hemodynamics 6

Diagnostic Pitfalls

• Normal chest radiograph does not rule out malignancy or other pathology; proceed to CT if clinical suspicion high 5, 8, 3, 4
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 6
• CTA is standard of care for arterial planning before BAE, detecting aberrant bronchial arteries in 36% and pulmonary artery pseudoaneurysms missed on conventional arteriography 6
• Pulmonary artery bleeding accounts for ~10% of massive hemoptysis; pulmonary artery embolization achieves 88-90% success 6

Risk Stratification Considerations

• Rate of bleeding correlates more closely with mortality than total volume 1, 6, 7
• Massive hemoptysis mortality is 59-100% if untreated 6
• Fatal massive hemoptysis results from asphyxiation more commonly than exsanguination 1
• Concomitant hypotension is independent factor determining massive hemoptysis 1