ORIGINAL ARTICLE

Hemoptysis is a frightening and potentially life-threat-

ening symptom. However, most cases can be
approached effectively with conservative manage-
ment. Bronchial artery embolization should be
attempted when bleeding is refractory to medical ther-
apy, and surgery may be needed in severe hemorrhage.

Hemoptysis is the expectoration of blood or blood-

Hemoptysis: tinged sputum from the lower respiratory tract.
While it is usually a self-limiting process from a

Diagnosis and benign cause, the seriousness and the exact source
of the bleeding can rarely be determined from the
initial presentation and physical examination. Today

Management the acute, overall mortality of hemoptysis is rela-

tively low, while the underlying etiology remains
the most important determinant of long-term sur-
vival. We review the possible causes of hemoptysis,
ROBERTA LENNER, MD the diagnostic work-up and therapeutic options.
Director, Emergency Department
Associate Director of the Medical and Surgical ETIOLOGY
Intensive Care Unit According to the American Thoracic Society, there
Attending Physician, Pulmonary and Critical Care are more than 100 documented causes of hemopty-
Bronx VA Medical Center sis.1 The more common causes have changed over
Bronx, NY time. Before the widespread use of antimycobacter-
Attending Physician, Pulmonary and Critical Care ial chemotherapy and the rise in prevalence of ciga-
Mount Sinai—New York University Health rette smoking and related pulmonary malignancies,
New York, NY hemoptysis was nearly synonymous with pul-
Assistant Professor in Medicine monary tuberculosis. As exemplified by the Hippo-
The New York University— cratic aphorism, “The spitting of pus follows the
Mount Sinai School of Medicine spitting of blood and consumption follows the spit-
New York, NY ting of this and death follows consumption.”2 Epi-
GREGORY J. SCHILERO, MD demiological studies conducted between 1930 and
Director, Medical and Surgical Intensive Care Unit 1960 found that tuberculosis accounted for most
Attending Physician, Pulmonary and Critical Care cases of hemoptysis (5% to 46%), followed by
The Bronx VA Medical Center bronchiectasis (7% to 28%), and carcinoma (2% to
Bronx, NY 19%).3-9 Following the widespread use of antituber-
Attending Physician, Pulmonary and Critical Care culous drugs, antibiotics, and vaccination against
Mount Sinai—New York University Health whooping cough, the incidence of hemoptysis due
New York, NY to tuberculosis and bronchiectasis declined, while
Assistant Professor of Medicine that caused by bronchitis and bronchogenic carci-
The New York University— noma rose, presumably due to the increased inci-
Mount Sinai School of Medicine dence of smoking. More recent epidemiological
New York, NY studies10-14 reflect these changes. (Table 1) While
many different causes of hemoptysis are described
MARVIN LESSER, MD
in these reports, the majority of patients bleed from
Director, Department of Pulmonary Medicine
either infection, bronchogenic carcinoma, or
The Bronx VA Medical Center
bronchiectasis.
Bronx, NY
Associate Professor of Medicine
The New York University— REPRINTS
Roberta Lenner, MD, 515 E. 72nd Street, Apt. 10L, New York, NY 10021
Mount Sinai School of Medicine
New York, NY Submitted for publication: Apr. 25, 2001. Accepted: May 24, 2001

COMP THER. 2002; 28(1):7–14 7

 TABLE 1
The Changing Spectrum of Hemoptysis in Recent Decades
Etiology of Hemoptysis
No of
Study Year Patients Bronchitis Malignancy Pneumonia TB Bronchiectasis Unknown
[10] 1989 148 37% 19% 5% 7% 1% 3%

[13] 1991 264 23% 29% 11% 6% 0.5% 22%

[11] 1995 471 28% 18% 1.2% 3.2%

[12] 1997 208 18% 19% 16% 1% 20% 8%

[14] 1997 246 26% 23% 10% 8%

Causes of massive hemoptysis, on the other hand, same way whether the blood is coughed up from
have not changed over time and include tuberculo- the lungs, aspirated and then coughed up, or swal-
sis, bronchiectasis, lung abscess and lung cancer.15 lowed and subsequently vomited. The first step in
Table 2 contains a summary of the more frequent the diagnostic process, therefore, is to establish that
underlying etiologies of hemoptysis. the source of bleeding is the lower respiratory tract.
Inspection of the expectorated blood, together with
DIAGNOSTIC EVALUATION: some simple diagnostic tests may help determine
THE QUESTION OF URGENCY whether the source of bleeding is the lung or the
The most important factor shown to correlate with gastrointestinal tract. Hematemesis is characterized
mortality is the rate of blood loss,16-17 while both the by darker blood that may contain partially digested
amount and duration of bleeding are unreliable food with usually an acidic pH. History of frequent
indicators of underlying disease severity. For this nosebleeds or a tendency for hemoptysis to worsen
reason, hemoptysis is usually classified according to in the supine position and upon awakening may
the rate of bleeding. 10 Most authors consider point to a nasopharyngeal origin, a source of bleed-
hemoptysis to be mild if the amount of blood expec- ing in up to 10% of patients.11 Other possible causes
torated in 24 hours is less then 20 mL, moderate if of pseudohemoptysis include infection with Serratia
between 20 and 600 mL, and massive if more than marcescens which produces a red pigment, and the
600 mL. Others rely more on the magnitude of clini- use of isoetharine, an infrequently prescribed bron-
cal effect resulting from the bleeding, and define chodilator that may appear red when oxidized.
massive hemoptysis as the volume of expectorated Once the diagnosis of true hemoptysis is estab-
blood that is life-threatening by virtue of airway lished, the evaluation should begin with a thorough
obstruction, hypotension, or blood loss.15 In most investigation of the patient’s medical history for
series massive hemoptysis accounts for less then underlying pulmonary and cardiovascular diseases,
10% of all cases, but associated mortality may be as risk factors for bronchogenic carcinoma, bleeding
high as 85%.16-20 The assessment of hemoptysis is diathesis or anticoagulant therapy, recent trauma to
similar regardless of the rate of bleeding, but the the chest wall, and occupational exposure. Prior his-
urgency of the evaluation is related to the expected tory of cavitary or bullous disease such as tubercu-
mortality. Unfortunately, the rate of bleeding will losis, sarcoidosis, or fibrosis increases the risk of
not predict outcome accurately in all cases. In one aspergilloma formation. Patients with known pul-
study of 123 patients with hemoptysis, eight monary tuberculosis may bleed from Rasmussen
patients who had been stable while awaiting further aneurysm caused by erosion of blood vessels
work-up died of sudden, catastrophic hemorrhage.19 deprived of lateral support or by bronchopulmonary
anastomosis within the wall of old cavities. A histo-
DIAGNOSTIC EVALUATION: ry of congestive heart failure due to mitral stenosis,
INITIAL ASSESSMENT deep vein thrombosis, or foreign body aspiration
Hemoptysis is a frightening symptom for the may lead to a specific etiology. Travelers to Asia,
patient, who may describe the event in much the the Middle East, and South America may experi-

8 COMP THER. 2002; 28(1)

 TABLE 2
Common Causes of Hemoptysis
Infection Hematologic
• Bronchitis • Disorders of coagulation
• Necrotizing pneumonia • Disseminated intravascular coagulopathy
• Lung abscess • Thrombocytopenia
• Tuberculosis • Uremia
• Mycetoma • Platelet dysfunction
• Fungal infection
• Parasitic infection Traumatic
• Aortic aneurysm
Neoplastic • Ruptured bronchus
• Primary lung cancer • Chest injury
• Bronchial adenoma • Foreign body aspiration
• Metastatic lung cancer • Tracheal-innominate fistula

Cardiovascular Iatrogenic
• Pulmonary embolism • Bronchoscopy
• Mitral stenosis • Lung biopsy
• Left ventricular failure • Pulmonary artery catheterization
• Atrioventricular fistula • Endobronchial brachytherapy
• Pulmonary hypertension
Miscellaneous
Alveolar hemorrhage syndromes • Broncholithiasis
• Antiphospholipid syndrome • Bronchiectasis
• Bechet syndrome • Cystic fibrosis
• Goodpasture syndrome • Cryptogenic
• Henoch Schonlein purpura
• Systemic lupus erythematosus
• Wegener’s granulomatosis

ence hemoptysis due to parasitic infections such as rial blood gases, and urinalysis. If surgery is antici-
paragonimiasis and cystic hydatiform. pated, type and crossmatch should also be ordered
Physical examination should include careful together with bedside spirometry to assess the
inspection for signs of trauma, petechiae, ecchy- patient’s pulmonary reserve.
moses, and clubbing. A saddle nose with signs of
rhinitis and septal perforation may suggest Wegen- DIAGNOSTIC EVALUATION:
er’s granulomatosis. Stridor or wheezing should THE CHEST RADIOGRAPH
raise the suspicion of tracheolaryngeal obstruction, With few exceptions, a standard chest radiograph
foreign body aspiration, or endobronchial tumors. should be the first radiographic test ordered to evalu-
The diagnosis of pulmonary–renal syndromes such ate lung parenchyma, pulmonary vasculature, and
as Goodpasture disease should be pursued if blood the heart. A chest radiograph demonstrating a mass,
is detected in the urine. Oral or genital ulcerations, fibrocavitary disease, necrotizing pneumonia, or
uveitis, and cutaneous nodules may be the clinical interstitial disease may be of value diagnostically,
presentation of Bechet disease. although occasionally the abnormal area may not be
Routine laboratory and radiographic tests may the source of bleeding. A localized infiltrate sugges-
provide insight into the pathogenesis of the bleeding tive of aspirated blood may be visualized some dis-
and should include complete blood count, renal tance from the actual origin of hemoptysis because
function tests, coagulation profile, electrolytes, arte- of blood spillage from coughing and dependent

COMP THER. 2002; 28(1) 9

drainage. The chest radiograph may suggest unsus- that of computed tomography (CT).1,20,22,24 In a retro-
pected cardiac or pulmonary vascular disease spective study comparing the value of CT and
responsible for hemoptysis such as left atrial enlarge- fiberoptic bronchoscopy in 58 consecutive patients
ment (mitral stenosis) or focal oligemia (pulmonary presenting with hemoptysis,27 abnormalities involv-
emboli). Finally, approximately 20%–60% of patients ing the airways were depicted by CT in 28 cases
will have a normal or non-localizing chest radiograph (48%) compared to 18 cases (31%) by fiberoptic
(one showing chronic, bilateral, or unchanged abnor- bronchoscopy. Bronchiectasis was detected only by
malities) upon presentation.1,11,13,21-24 This does not CT in 10 patients, 8 of whom had a normal or non-
rule out true hemoptysis and should not end the localizing chest radiograph. Malignancy was diag-
search for an underlying condition. Many pulmonary nosed in 24 patients, in whom 6 of these tumors
or cardiovascular diseases may cause hemoptysis were not visualized by bronchoscopy. Set et al.24
without being radiographically apparent. Further studied 91 patients presenting with hemoptysis, 34
diagnostic studies may reveal bronchitis, bronchiec- of whom (37%) had carcinomas. Computed tomog-
tasis, occult interstitial lung disease, pulmonary raphy detected all of these malignancies but 7 were
hypertension, or pulmonary emboli. Finally, approxi- not diagnosed by bronchoscopy. Bronchiectasis was
mately 5% to 6% of patients with a normal chest present in 15% of the patients and the diagnosis
radiograph and bronchoscopic examination have was made by CT in all cases. The only diagnosis
lung cancer diagnosed by further investigation.25 made exclusively by bronchoscopy in this study
was that of bronchitis. In another prospective study
THE NEXT STEP: by McGuinness et al.,22 57 patients presenting with
BRONCHOSCOPY OR CHEST CT? hemoptysis underwent diagnostic evaluation by CT
Mild hemoptysis associated with an upper respirato- and bronchoscopy. The prevalence of malignancies
ry tract infection, especially in a nonsmoker, may was somewhat lower (12%); all cases were detected
not require further work-up. In most other patients by CT, while bronchoscopy missed one peripheral
bronchoscopy is the next step in the evaluation of tumor. The diagnostic sensitivity and specificity of
hemoptysis. The optimal timing of this procedure is CT were somewhat less favorable in the study by
a matter of debate. It has been demonstrated that Hirshberg and colleauges.12 Out of 18 patients with
the diagnostic yield increases if bronchoscopy is a normal CT scan, 7 had positive findings by bron-
performed within 48 hours of the bleeding choscopy (4 infectious, 3 malignant disease).
episode,1,8,18 but whether or not this translates into a It is a mistake, however, to compare the two pro-
survival advantage is not clear. The choice between cedures based solely upon their diagnostic yield.
rigid and flexible bronchoscopy in massive hemopt- Studies have consistently demonstrated the comple-
ysis is also a source of continuing debate. Fiberoptic mentary role of the two techniques in this popula-
bronchoscopy can be performed at the bedside tion. Chest CT will visualize most if not all
under local anesthesia, and it allows easy access to malignant lesions, while it may miss endobronchial
the upper lobes and more peripheral airways. Rigid disease and bronchitis. Fiberoptic bronchoscopy
bronchoscopy is usually performed in the operating will fail to visualize small parenchymal lesions,
room under general anesthesia; its advantages bronchiectasis or interstitial lung disease, but it
include better control of the airway and suctioning allows direct visualization of the airways, lateraliza-
capacity. In most institutions flexible bronchoscopy tion of the bleed, and collection of samples for his-
is used as the initial attempt to visualize and lateral- tology and microbiology. A preliminary chest CT
ize the bleeding site.26 Rigid bronchoscopy is usually might be useful for directing the bronchoscopist to
reserved for cases of continued brisk bleeding, mak- the area of abnormality, as well as staging, once
ing the successful visualization by fiberoptic bron- malignancy is confirmed by fiberoptic biopsies. The
choscopy less likely. The following bronchoscopic localization, or at least the lateralization of the
findings may provide clues to the cause of hemopty- bleeding site is imperative if isolation of the healthy
sis: mucosal abnormalities associated with bronchi- lung by positioning or double-lumen endotracheal
tis, tracheal erosions or endobronchial tumor, tube is needed, or if bronchial artery embolization
mechanical obstruction by foreign body or bron- or a surgical procedure is planned. Direct visualiza-
cholith causing inflammation or erosion, or serial tion by bronchoscopy is the most successful for
bloody bronchoalveolar lavage samples suggesting such purposes. In a study by Fernando et al. 28
alveolar hemorrhage.26 angiographic evidence of bleeding was present in
The overall diagnostic accuracy of bronchoscopy only 17 of 26 (65.4%) patients. Of these, bron-
in patients with hemoptysis (0%–60%) is lower than choscopy localized the bleeding site in 16. Finally,

10 COMP THER. 2002; 28(1)

therapeutic interventions may be performed via Large, prospective studies with long-term follow
bronchoscopy, such as the administration of topical up are needed to examine the true incidence and
vasoconstrictor agents, cold saline lavage, or occlu- prognosis of cryptogenic hemoptysis utilizing cur-
sion of the bleeding segment by balloon catheters. rently available technological advances including
Bronchoscopy alone was considered therapeutic in high resolution CT.
14 of 134 (10%) patients with hemoptysis in the
study by Hirshberg et al.12 THERAPY
In preliminary experiences “virtual bron- The current management of hemoptysis includes
choscopy” derived from helical CT scan data sets medical, surgical, endobronchial, or endovascular
has helped to characterize airway disease more interventions, or combinations of these modalities.
completely than regular CT.29 Whether this technol- The choice of treatment depends on the rate of
ogy will have a routine place in the diagnostic eval- bleeding, the patient’s underlying cardiopulmonary
uation of these patients requires further studies. reserve, as well as the treating physician’s experi-
ence and institutional resources. Mild hemoptysis
CRYPTOGENIC HEMOPTYSIS associated with an acute upper respiratory tract
The entity of cryptogenic hemoptysis formally infection may be treated with outpatient antibiotic
referred to patients with a normal or non-localizing therapy. Inhaled bronchodilators, antitussives, and
chest radiograph and nondiagnostic examination by bed rest may also be prescribed. Once acute inflam-
bronchoscopy. Today, it is necessary to include a mation and coughing is controlled, bleeding usually
normal CT in this definition since up to 50% of subsides spontaneously.
patients with a normal chest radiograph and bron- In most other cases, patients are hospitalized for
choscopy will have an abnormal CT that demon- further assessment, diagnostic work-up, and man-
strates the likely cause of bleeding.30 The incidence agement. Once the diagnosis of hemoptysis is estab-
of cryptogenic hemoptysis varies in the literature lished and the possibility of pseudohemoptysis
depending on the study population and methods of ruled out, the initial management should focus on
investigation. In the study by Set et al.,24 31 of 91 stabilizing the patient, protecting the airways, and
(34%) patients who presented with hemoptysis had assessing surgical candidacy in the event this option
a nondiagnostic CT and negative fiberoptic broncho- becomes necessary. Immediate intubation with a
scopic examination. In the study by Hirshberg and large bore endotracheal tube should be performed
coworkers,12 no source of bleeding was found in 17 in cases of life-threatening hemoptysis, hypov-
of 208 (8%) patients. In a retrospective analysis of a olemic shock, worsening oxygenation despite sup-
hospital registry in France, 2677 of 6349 (42.2%) plemental oxygen, or elevated carbon dioxide
cases of hemoptysis had no attached diagnostic concentration. A size 8 or larger endotracheal tube
codes at discharge, 31 and the authors described is needed to allow subsequent bronchoscopic evalu-
these cases as cryptogenic hemoptysis. The absence ation and adequate suctioning. In cases of moderate
of a uniform, systematic work-up including fiberop- to massive hemoptysis, every effort should be made
tic bronchoscopy and chest CT in these patients, to identify the bleeding site and isolate the healthy
however, may have led to overestimation of the lung. This may be achieved by placing the patient
incidence of true cryptogenic hemoptysis. with the diseased side down, or separating the lungs
The prognosis of patients with cryptogenic by insertion of either a double-lumen endotracheal
hemoptysis is generally good. In a study by Adel- tube or a regular endotracheal tube into the con-
man et al., 32 67 patients were followed for an tralateral main bronchus. Vital signs and oxygen
average of 3 years, and only one patient was diag- saturation should be continuously monitored,
nosed with carcinoma 20 months following the preferably in the intensive care unit unless the rate
initial episode of hemoptysis. In the majority of of bleeding is slow. Blood should be drawn for com-
patients (90%) the symptoms resolved within 6 plete blood count, arterial blood gases, coagulation
months of presentation. In contrast, in a study of profile, electrolytes, type and crossmatch, and for
106 elderly male patients with normal chest radi- assessment of renal and liver functions. The initial
ographs and negative fiberoptic bronchoscopy,33 management also includes volume resuscitation,
six malignant carcinomas were diagnosed during correction of any coagulopathy, supplemental oxy-
an average follow up of 32 months. Not all of gen, and cough suppression. Once the patient is sta-
these patients underwent chest CT examination, bilized, the next step is directed toward finding and
however, which may have detected some of these controlling the bleeding site. If adequate control of
malignancies earlier. the airways and sufficient gas exchange cannot be

COMP THER. 2002; 28(1) 11

maintained due to massive bleeding and incipient tion is the most common source of hemoptysis.
hypovolemic shock, surgery should be considered. Angiography of the bronchial arteries and emboliza-
If the bleeding is less severe and the patient is sta- tion of the bleeding vessel is a well-accepted proce-
ble hemodynamically, several non-surgical thera- dure for management of massive or recurrent
peutic interventions are available. hemoptysis either singly or in association with sur-
Bronchoscopic Therapy. Epinephrine instilla- gical or medical therapy. Angiographic findings of
tion at the bleeding site (1:20,000 topical solution) is localized hyperemia, shunt, pericavitary vascularity,
used universally to treat hemoptysis secondary to or the extravasation of contrast medium may guide
transbronchial biopsy, but its efficacy as a therapeu- the embolization to the feeder artery. Hyperosmolar
tic agent in massive hemoptysis is untested. 1,18 contrast material, absolute alcohol, bucrylate, steel
Lavage with iced saline may be effective in control- coils, and detachable balloons have all been used
ling pulmonary bleeding. Two retrospective studies successfully, although the most efficient embolizing
from the same institution described long-term con- material has been gelfoam particles. Immediate con-
trol of hemoptysis by this method.34,35 Presumably, trol of bleeding is achieved in up to 91% of patients
iced saline causes local vasoconstriction and pro- after bronchial artery embolization, with a relative-
motes hemostasis and local thrombosis of the bleed- ly low relapse rate of 16% to 21%. 37 The most
ing vessels. Fibrin precursors including topical severe complication of bronchial artery emboliza-
thrombin and thrombin-fibrinogen solutions have tion is spinal cord ischemia due to accidental
been used successfully to control bleeding.36 Fur- embolization of the spinal artery, but its reported
ther studies are needed, however, before these frequency is less than 1%.38 To minimize the risk of
agents can be recommended for widespread use in this serious complication selective bronchial angiog-
the treatment of hemoptysis. Tamponade may be raphy is performed prior to bronchial artery
accomplished by placing packing material directly embolization to define the anatomy of the bronchial
into the bleeding site when the bleeding is proximal circulation with special attention directed toward
and easily visualized. Another option is to isolate identifying the anterior spinal artery. A common
the bleeding segment using a balloon tamponade origin of this artery with the bronchial artery is a
catheter which is passed through the working chan- relative contraindication to bronchial artery
nel of the flexible bronchoscope.17,18 Once the affect- embolization. Other complications of this procedure
ed bronchus is identified, the balloon is inflated include fever, chest or back pain, dyspnea, dyspha-
proximal to the bleeding source, thus, isolating and gia, contrast medium allergy, and lower limb
tamponading the bleeding site. The inflated balloon ischemia or claudication due to backflow of
may be left in place for 24–48 hours; when no fur- embolization material.
ther bleeding is noted upon deflation, the catheter is Radiation Therapy. When surgical resection is
removed. Finally, coagulating laser phototherapy not feasible and bronchial artery embolization can-
may be used to control endotracheal or bronchial not be performed successfully, radiation therapy
bleeding if the bleeding site is successfully visual- may be used to treat massive hemoptysis. Although
ized by bronchoscopy.18 more frequently indicated for pulmonary malignan-
Systemic Pharmacological Therapy. Intra- cies, localized external beam radiation has been
venous vasopressin and pituitary extract were used used successfully in patients with aspergilloma.18
to treat massive hemoptysis in the 1940s and The mechanism by which radiation arrests bleeding
1950s.18 The mechanism by which these agents help is presumably by inducing necrosis of the vessels as
arrest bleeding is by causing bronchial arterial vaso- a result of thrombosis and compression from
constriction. Their efficacy, however, has never perivascular edema.
been assessed in a prospective manner, and both Surgery. With the availability of successful con-
drugs should be used with caution in patients with servative therapeutic options and the changing spec-
underlying hypertension or cardiovascular disease. trum of underlying etiologies, fewer patients require
Systemic corticosteroids and/or cytotoxic agents emergent surgery for hemoptysis.16 In the past, with
may be efficacious in cases of hemoptysis caused by tuberculosis accounting for most cases of hemopty-
alveolar hemorrhage associated with immune-medi- sis, the source was commonly a ruptured bronchial
ated diseases. Finally, hormonal therapy to control artery aneurysm leading to high pressure bleeding
endometriosis may be helpful in the long-term man- that required surgical intervention. Today, hemopty-
agement of catamenial hemoptysis. sis is more commonly associated with bronchitis
Angiography and Embolization. Of the dual and carcinoma, where bleeding is from the low
vascular supply of the lungs, the bronchial circula- pressure venous system and conservative measures

12 COMP THER. 2002; 28(1)

 (5–6):70.
are generally effective. There have been no prospec- 5. Jackson CL, Diamond S. Haemorrhage from the trachea,
tive, randomized studies comparing the effective- bronchi and lungs of nontuberculous origin. Am Rev Tuber-
ness of surgical and medical therapy, neither would cul. 1942;46:126.
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Med Soc. 1951;50:606.
surgical series were conducted prior to the birth of
7. Moersch HJ. Clinical significance of hemoptysis. JAMA.
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N Engl J Med. 1952;247:790.
Surgery is indicated for patients with adequate 10. Johnston H, Reisz G. Changing spectrum of hemoptysis.
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In most reported series surgical mortality ranges hemoptysis revisited: a review of the etiologies of hemopty-
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