Haemoptysis: Causes, Symptoms, Diagnosis, Prevention & Treatment
What is Haemoptysis?
Haemoptysis refers to the expectoration of blood or blood-stained sputum from the lungs, bronchi, trachea or larynx. The blood originates below the vocal cords (i.e., from the respiratory tract and not the upper airway or gastrointestinal tract).
It is classified as:
• Mild (< 20 mL/24 h)
• Moderate (20–100 mL/24 h)
• Massive/Life–threatening (> 100–600 mL in 24 h, exact volume definition varies)
Even small amounts of bright red or pink frothy sputum should never be ignored.
How Common is Haemoptysis?
Worldwide, haemoptysis accounts for 10–15% of all pulmonary consultations. In India and Southeast Asia, tuberculosis remains the leading cause, while in Western countries bronchitis, lung cancer and bronchiectasis dominate.
Causes of Haemoptysis (Most to Least Common Globally – 2025 Data)
Rank Cause Approximate % of Cases Notes
1 Acute bronchitis / respiratory infuntions 25–40% Usually self-limiting
2 Tuberculosis (TB) 20–30% (high in endemic areas) Still #1 in India, Africa, parts of Asia
3 Bronchiectasis 15–20% Common in cystic fibrosis & post-TB
4 Lung cancer (primary or metastatic) 15–20% Leading cause in smokers >50 years
5 Pneumonia (bacterial, viral, fungal 5–10% Especially necrotising organisms
6 Pulmonary embolism (infarction) 3–7% Often misdiagnosed initially
7 Congestive cardiac failure 3–5% Pink frothy sputum
8 Aspergilloma mycetoma 2–5% “Fungus ball” in old cavities
9 Autoimmune (GPA, SLE, Goodpasture) < 2% Diffuse alveolar haemorrhage
10 Iatrogenic (biopsy, catheter) < 2% Increasing with procedures Cryptogenic (no cause found) 10–25% Even after full workup
Rare but important causes
• Dieulafoy’s vascular malformation Pulmonary arteriovenous malformation (AVM)
• Inhaled foreign body (children)
• Factitious / pseudohaemoptysis (ENT or GI source)
Signs and Symptoms – When to Worry
Symptom Indicates Severity / Urgency
Small streaks of blood in sputum Usually benign (bronchitis)Repeated blood-stained sputum >1 week Needs evaluation
>30 mL bright red blood at once Emergency
Associated chest pain, weight loss, night sweats Suggests TB or cancer
Frothy pink sputum + breathlessness Cardiac failure pulmonary oedema
Fever + foul-smelling sputum Lung abscess necrotising pneumonia
Sudden onset + leg swelling/pain Possible PE
Haemoptysis + epistaxis + haematuria Vasculitis (GPA)
Red-flag symptoms requiring immediate hospital admission
• Haemodynamic instability
• >100 mL in 24 h or inability to maintain airway
• Respiratory failure
• Bilateral infiltrates on imaging (diffuse alveolar haemorrhage)
Differential Diagnosis: Haemoptysis vs Pseudohaemoptysis vs Hematemesis
Feature Haemoptysis Hematemesis Pseudohaemoptysis (ENT source)
Source Below vocal cords Stomach / duodenum Nose, sinuses, pharynx
Preceding symptom Cough Nausea / vomiting Throat irritation / nose bleed
Appearance Bright red, frothy, alkaline Dark red/coffee-ground, acidic Mixed with clear saliva
pH (if tested) Alkaline Acidic Neutral
Food particles Absent May be present Absent
Diagnostic Approach (Step-by-Step 2025 Guidelines)
Step 1 – History & Examination
• Smoking history & pack-years
• TB exposure, previous TB, BCG status
• Weight loss, night sweats, fever
• Recent travel / immigration from TB-endemic area
• Anticoagulant or antiplatelet use
• Family history of hereditary haemorrhagic telangiectasia (HHT)
Step 2 – Initial Investigations
• Complete blood count (anaemia, thrombocytopenia)
• Coagulation profile & INR
• Renal function & urine routine (vasculitis screen)
• Sputum for AFB (smear + GeneXpert MTB/RIF Ultra)
• Sputum Gram stain & culture
• Chest X-ray (PA view)
Step 3 – Advanced Imaging
CT chest with contrast (gold standard)
• HRCT for bronchiectasis
• CTPA if pulmonary embolism suspected
• CT pulmonary angiography for vascular anomalies
Step 4 – Bronchoscopy
• Fibre-optic bronchoscopy (most useful in active bleeding)
• Identifies site in >85% of massive haemoptysis
• Allows biopsy, lavage, and therapeutic interventions
Step 5 – Special Tests (when indicated)
• ANA, ANCA (c-ANCA, p-ANCA), anti-GBM
• D-dimer (if low probability of PE)
• Echocardiography (heart failure, mitral stenosis)
• V/Q scan or CTPA for PE
Management of Massive / Life-Threatening Haemoptysis (2025 Protocol)
1.ABC stabilisation
• Place patient in lateral decubitus position with bleeding side down (if side known)
• High-flow oxygen, IV access, blood grouping & cross-match
2. Correct coagulopathy immediately
3.Medical stabilisation
• Tranexamic acid 1 g IV bolus → 1 g infusion over 8 h (strong evidence)
• Nebulised adrenaline or tranexamic acid (emerging data
4. Bronchoscopic interventions
• Cold saline / adrenaline instillation
• Balloon tamponade
• Endobronchial blockers
5. Definitive treatment
• Bronchial artery embolisation (BAE) – first-line in most centres (success 85–95%)
• Surgery (lobectomy / pneumonectomy) – if embolisation fails or cancer
Treatment of Common Underlying Causes
Cause First-Line Treatment
Acute bronchitis Supportive, ntibiotics only if bacterial
Active pulmonary TB ATT (2HRZE + 4HR) + corticosteroids if airway threat Bronchiectasis Chest physiotherapy, mucolytics, rotating antibiotics
Lung cancer Oncology referral – surgery, chemo, immunotherapy, SBRT
Pulmonary embolism Anticoagulation ± thrombolysis
Cardiac failure Diuretics, ACEi/ARB, beta-blockers
Aspergilloma Surgical resection (preferred) or long-term azoles
GPA /vasculitis High-dose steroids + rituximab or cyclophosphamide |
Prevention of Haemoptysis
1.Smoking cessation – single most effective measure to reduce lung cancer & COPD-related haemoptysis
2. TB control– BCG vaccination, early case detection, contact tracing
3. Vaccination – annual influenza & pneumococcal vaccines reduce severe LRTIs
4.Control of cardiovascular risk factors – hypertension, AF (reduces heart-failure related haemoptysis)
5. Occupational lung disease screening– silica, asbestos exposure
6. Cystic fibrosis & bronchiectasis management – airway clearance, DNase, CFTR modulators
Prognosis
• Benign causes (bronchitis): excellent
• Tuberculosis: >95% cure with proper ATT
• Lung cancer presenting with haemoptysis: often stage III–IV → 5-yr survival <20%
• Massive haemoptysis: mortality 10–50% even with modern care (highest if aspiration occurs)
Frequently Asked Questions (FAQs)
Q1. Is coughing up blood always cancer?
No. In non-smokers <40 years, cancer causes <5% of cases. Bronchitis and infections are far more common.
Q2. Can haemoptysis be the only symptom of tuberculosis?
Yes, especially in primary or endobronchial TB.
Q3. When should I go to emergency?
• Coughing >30–50 mL blood at once
• Feeling faint or short of breath
• Continuous bleeding >1 hour
Q4. Is CT scan always needed?
Yes in recurrent or unexplained haemoptysis. Chest X-ray misses 30–50% of causes.
Q5. Can haemoptysis happen after COVID-19?
Yes – post-COVID bronchiectasis, organising pneumonia and secondary fungal infections (mucormycosis, aspergillosis) are emerging causes in 2024–2025.
Q6. Is bronchial artery embolisation safe?
Success rate >90%, major complication (spinal cord infarction) <0.5% in experienced centres.
Q7. Can haemoptysis occur in children?
Yes – foreign body aspiration, congenital malformations, infections. Always urgent evaluation.
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Writer: Vandita Singh, Lucknow (GS India Nursing Group)