Coughing Up Blood (Hemoptysis)

What hemoptysis is

Hemoptysis (from Greek, "blood spitting") is blood that comes from the lungs or the airways leading to them (the trachea and bronchi). It can look like:

• pink or red streaks in yellow, green or white phlegm
• rusty or brown sputum, typical of pneumonia
• frothy, pink sputum, typical of fluid in the lungs
• bright red blood or clots

Massive hemoptysis usually means more than about 100 to 600 ml (roughly half a cup to 2.5 cups) in 24 hours, though any amount that affects breathing is dangerous. The danger is less from blood loss and more from blood filling the airways.

Is it really from the lungs?

Blood in the mouth can come from three places, and the cause and tests differ.

If you are vomiting blood, see vomiting blood. Blood that drips down the back of the throat from a nosebleed can be coughed up and look like hemoptysis.

Causes of coughing up blood

Common causes

• Acute bronchitis and chest infections: the most common cause in the US. Inflamed airway lining bleeds easily during coughing, giving streaks of blood that clear as the infection settles.
• Pneumonia: rusty or blood-stained sputum with fever, chest pain and breathlessness.
• Bronchiectasis: permanently widened, scarred airways cause a daily productive cough and repeated episodes of bleeding.
• COPD flare-ups: inflamed airways in people with chronic bronchitis.
• Severe or prolonged coughing from any cause.

Serious causes

• Lung cancer: hemoptysis is one of its warning signs, especially in current or former smokers over 40. It may come with a persistent cough, weight loss, tiredness or chest pain. Cancers spreading to the lung can do the same.
• Pulmonary embolism: a clot in the lung arteries causes sudden breathlessness, sharp pain on breathing and sometimes blood in sputum.
• Tuberculosis: a long cough, fever, night sweats and weight loss, especially after travel to or living in areas where TB is common, or with HIV.
• Heart problems: heart failure and mitral stenosis can cause pink, frothy sputum.
• Vasculitis and autoimmune disease: granulomatosis with polyangiitis and Goodpasture syndrome cause bleeding in the lungs, often with kidney problems and blood in the urine.
• Lung abscess and fungal infections such as aspergilloma in old cavities.
• Blood thinners and bleeding disorders: these increase bleeding from any cause, so an underlying problem should still be looked for.
• Trauma: chest injury, a bruised lung or an inhaled foreign object (common in young children).
• Drugs: smoking cocaine can cause lung bleeding.

Can coughing up blood be a sign of internal bleeding?

Hemoptysis is a form of bleeding inside the body, from the lungs or airways. It does not usually mean bleeding elsewhere, such as in the abdomen. After an injury, though, coughing up blood can mean the lung itself is damaged, which is an emergency.

Coughing up blood with other symptoms

When to go to the ER with hemoptysis

Go to the ER or call 911 or your local emergency number if you cough up more than a few tablespoons of blood, have clots, or have blood with breathlessness, chest pain, dizziness or a fast heartbeat. While waiting, sit up and lean forward, or lie on the side you think is bleeding if you know it, so blood does not spill into the healthy lung.

If your dad, partner or another older relative is coughing up blood, even small amounts, especially if they smoke or used to smoke, book a prompt appointment within days. In the US and UK, unexplained hemoptysis in someone over 40 is a reason for an urgent chest X-ray to check for lung cancer.

How doctors find the cause

1. History: amount and appearance of blood, how long, smoking history, travel, TB exposure, weight loss, blood thinners and recent surgery or flights.
2. Examination: oxygen level, breath sounds, signs of a clot in the leg and the nose and mouth.
3. Blood tests: blood count, clotting, kidney function, and sometimes autoimmune tests.
4. Sputum tests: for bacteria, TB and sometimes cancer cells.
5. Chest X-ray: the first imaging test. A normal X-ray does not exclude cancer.
6. CT scan of the chest: the key test for tumors, bronchiectasis and, with contrast, pulmonary embolism.
7. Bronchoscopy: a camera passed into the airways to find and sometimes treat the bleeding source and take biopsies.

Treatment

Treatment depends on the cause and amount.

• Infections: most bronchitis is viral and settles on its own. Antibiotics are used for bacterial pneumonia, flare-ups of bronchiectasis and TB.
• Pulmonary embolism: blood thinners.
• Cancer: surgery, radiotherapy, chemotherapy or targeted treatment, depending on stage.
• Massive hemoptysis: protecting the airway, sometimes a breathing tube, and bronchial artery embolization, where a radiologist blocks the bleeding artery via a catheter. Bronchoscopy treatments and surgery are other options.

While you wait for assessment, avoid cough suppressants unless a doctor advises them, do not smoke, and do not stop prescribed blood thinners without medical advice.

Frequently asked questions

Should you go to the ER with hemoptysis?

Go to the ER if you cough up more than a few tablespoons of blood, pass clots, or have blood with shortness of breath, chest pain, dizziness or a racing heart. Small streaks during a chest cold are less urgent but should still be reported to your doctor, especially if you smoke.

Why do you cough up blood?

Blood comes from small vessels in the airways or lungs that are inflamed, damaged or under pressure. Infection, coughing hard, widened airways, tumors, blood clots in the lungs and heart failure can all make these vessels bleed. Blood thinners make bleeding more likely.

Is coughing up a little blood with a cold normal?

Small streaks of blood during a chest cold or bronchitis are fairly common and usually harmless, from irritated airways. They should clear as the cough improves. See a doctor if it keeps happening, is more than streaks, or you are over 40 or a smoker.

Can coughing up blood be cancer?

It can be. Hemoptysis is a warning sign of lung cancer, especially in current or former smokers over 40 and in people with weight loss or a cough lasting more than 3 weeks. Most coughed blood is not cancer, but these situations need a chest X-ray or CT scan.

What does blood in sputum look like?

It can appear as bright red streaks or spots in phlegm, pink frothy sputum, rusty-brown mucus, or clots of red blood. Dark, coffee-ground material that is vomited usually comes from the stomach rather than the lungs.

What should I do if my dad is coughing up blood?

If he is coughing up large amounts, struggling to breathe or has chest pain, call 911 or your local emergency number. If it is small amounts, arrange a doctor visit within a few days, particularly if he smokes or has smoked, has lost weight or has had a cough for weeks.