When Is Coughing up Blood an Emergency?

Coughing up blood, otherwise known as hemoptysis, can be very frightening. But, it can also be confusing because you may not know where the blood is coming from. Is it coming from the nasal passages, the esophagus (feeding tube), the trachea (windpipe), the lungs, or your stomach?

While hemoptysis is a tell-tale sign of lung cancer, it is more often due to a benign cause. Some causes of coughing up blood include bronchitis, pneumonia, and using blood thinners.

This article looks at the possible causes and symptoms of hemoptysis as well as how the condition is diagnosed and treated. It also describes when coughing up blood can be a medical emergency.

Symptoms

By definition, hemoptysis is bleeding specifically from the trachea or the large or small airways of the lungs (called the bronchi and bronchioles).

Many people describe the symptom as "spitting up blood" or having blood-streaked mucus. Blood that is coughed with phlegm will often have a bubbly appearance.

Depending on the underlying cause, there may also be accompanying symptoms like:

• Chest pain
• Fever
• Shortness of breath
• Dizziness or lightheadedness

Causes

There are many different reasons why you may be coughing up blood. Some are more serious than others, but there is generally no way to tell by just looking at it or assessing how it feels. Coughing up blood in any amount should be taken seriously.

Some possible causes of hemoptysis include:

• Excessive, violent coughing
• Bronchitis (inflammation of the bronchi)
• Bronchiectasis (damage to the airways)
• Bronchoscopy and other invasive procedures
• Chest trauma
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Complications of lupus (an autoimmune disease)
• Cystic fibrosis (CF)
• Hemophilia and other bleeding disorders
• Inhaled foreign objects
  
• Pneumonia
• Pulmonary edema (build-up of fluid in the lungs)
• Pulmonary embolism (blood clot in the lungs)
• Tuberculosis (TB)
• Use of anticoagulants (blood thinners)
• Vasculitis (blood vessel inflammation) of the lungs
• Lung cancer
  

Causes in Children

Coughing up blood in children tends to have different causes than the same symptom in adults. The most common causes are infections, such as pneumonia, bronchitis, and tuberculosis.

Roughly a third of the time a cause cannot be determined and the symptom goes away without finding a cause (something referred to as "idiopathic."

Underlying heart disease is the second most common cause of hemoptysis in children.

When to Go to the Hospital

Coughing up blood can quickly become an emergency. Coughing up more than one teaspoon of blood is considered a medical emergency.

Coughing up 100 cubic centimeters (cc) of blood—1/3 of a cup—is called massive hemoptysis and has a mortality (death) rate of 30% to 50%. Don't try to drive yourself or have someone else drive you to the hospital—call 911.

The issue is that coughing up blood can quickly cause airway obstruction and infiltration of the blood into your lungs, leading to suffocation and death.

Diagnosis

If you cough up blood—even a very small amount—it is important to make an appointment to see your healthcare provider.

If possible, bring a sample of what you have been coughing up to your appointment. Wrapping the sample in plastic wrap can preserve the sample better than wrapping it in tissue.

The diagnosis will involve a review of your medical history and a physical examination. The healthcare provider will not only examine your mouth and throat but listen for lung sounds using a stethoscope.

Based on the findings, your healthcare provider will recommend tests to help determine the cause. Possible tests may include:

• Lab tests to check your blood count and blood oxygen levels
• A chest X-ray to look for infection, obstruction, trauma, or a tumor
• A computed tomography (CT) scan of your chest
• A bronchoscopy (a flexible scope is inserted through the mouth and into the bronchi)

If you are actively bleeding, a CT scan is usually the imaging test of choice to evaluate bleeding.

This is important given that the average time between the onset of symptoms and diagnosis of lung cancer is 12 months. This is a span of time during which treatment can make a big difference in the outcome of the disease.

Treatment

While it is important to find the underlying cause of hemoptysis, the symptom sometimes needs to be treated directly (and immediately) even if the cause is not entirely clear.

The first step in managing hemoptysis is to make sure the airway is protected. Intubation (the insertion of a breathing tube) may be necessary, especially with massive bleeding.

When the bleeding is mild, treatment may be focused on managing the underlying cause. Otherwise, the following options may be considered.

Bronchoscopic Options

There are several techniques that can be used during a bronchoscopy to manage the bleeding, but these are most effective when the bleeding is mild or moderate.

Options include:

• Endobronchial insertions: These are substances delivered via endoscopy to stop bleeding topically. Options include iced saline, cellulose, and a liver fiber known as fibrinogen.
• Argon photocoagulation: This is a technique used to form blood clots locally.
• Electrocautery: This is using electricity to burn tissues in order to seal a bleed.
• Endobronchial stent placement: This may be used to redirect blood flow after a bleed has been stopped.

Bronchial Artery Embolization

When the bleeding is very significant, bronchoscopic procedures are much less likely to be effective. At the current time, bronchial artery embolization is recommended as the first-line treatment of massive hemoptysis.

In this procedure, a catheter is inserted into an artery in the upper thigh and threaded up to the pulmonary artery in the lung. Various substances then may be used to embolize (cause a clot) in the artery, such as a gelatin sponge, PVC particles, or a metallic coil.

Surgery

Surgery is needed less often than in the past for hemoptysis but is often still used in settings such as massive hemoptysis due to trauma.

A wedge resection (in which a wedge of lung tissue is removed and the cut ends are sewn together) is a common approach to treating massive hemoptysis. This may involve minimally invasive video-assisted thoracoscopic surgery or open surgery.

A Word From Verywell

Coughing up blood can be a frightening symptom, and the causes can be as mild as airway irritation from coughing, to as serious as lung cancer or a blood clot in the lungs. Even small amounts of bleeding into the lungs can be dangerous, due to the risk of aspiration (and asphyxiation). Coughing up only a teaspoon of blood is considered a medical emergency.

While frightening, even with active bleeding there is much that can be done. Bronchial artery embolization is often very effective in what could otherwise be a life-threatening situation.

While coughing up blood is the first symptom in only 7% of lung cancers, it's important to rule out this possibility in adults regardless of risk factors. As with other cancers, the earlier a lung cancer is diagnosed, the greater the chance of a cure.