When Is Coughing Up Blood an Emergency?

Coughing up blood, otherwise known as hemoptysis, can be very frightening. It can also be confusing at first. Is the blood truly coming from your lungs or could it be from a nosebleed, your esophagus, or from your stomach? While hemoptysis is the most specific symptom of lung cancer, it is more often due to a benign cause. Let's look at the possible causes, what may be done to diagnose the underlying problem, and the possible treatment options.

We will also discuss when coughing up blood can be an emergency, but coughing up even small amounts of blood can be dangerous.

Hemoptysis may occur when there is bleeding in the throat, the trachea, or in the large or small airways of the lungs (the bronchi or the bronchioles). Many people describe their symptoms as spitting up blood-streaked mucus. Blood that is coughed up is often mixed with phlegm and can have a bubbly appearance.

It is important to make a distinction between coughing up blood and blood that is brought up through your mouth from other regions of your body. “Pseudohemoptysis” is a term that describes spitting up blood that doesn’t come from your lungs or bronchial tubes. "Hematemesis" is a term that refers to blood that comes from your esophagus and stomach (throwing up blood).

If you cough up blood it doesn’t necessarily mean you have lung cancer. There are many conditions that can cause this symptom—and only one of these is lung cancer.

But since the outlook for lung cancer is better the earlier it's diagnosed, it is important to consult your doctor as soon as possible.

The most common causes of coughing up blood are irritation in the airways from coughing or an infection. Some possible causes of blood-streaked sputum include:

• Inflammation and irritation of the airways from repeated coughing
• Bronchitis
• Bronchiectasis
• Lung cancer: Roughly 20% of people with lung cancer will experience coughing up blood at some point in the course of their disease, and cancers in the chest (including lung cancer) are responsible for around 25% of cases of hemoptysis.
• Pneumonia
• Pulmonary edema
• Blood clots in the lungs (pulmonary embolus)—With pulmonary emboli, people often have pain, redness, or swelling in their calves due to deep vein thrombosis.
• Tuberculosis—This is the most common cause of coughing up blood worldwide, but less common in the United States.
• Inhalation of a foreign body
• Bleeding disorders—These can be inherited or due to medications or supplements that increase the time it takes for your blood to clot.

Coughing up blood can quickly become an emergency. Coughing up more than one teaspoon of blood is considered a medical emergency. Coughing up 100cc of blood—only 1/3 of a cup—is called massive hemoptysis and has a mortality (death) rate of over 50 percent. Don't try to drive yourself or have someone else drive you to the hospital—call 911.

If you cough up blood—even a very slight amount just once or even if you aren't sure that you truly coughed up blood—it is important to make an appointment to see your physician. If possible, bring a sample of what you have been coughing up to your doctor’s appointment. Wrapping the sample in plastic wrap or wax paper can preserve the sample better than wrapping it in tissue.

Your doctor will ask you several questions in addition to performing a careful physical exam. Some of these include:

• How long has this been happening?
• When did it begin?
• Did it occur while you were eating?
• How much blood did you cough up?
• Was the blood mixed with mucus?
• What other symptoms have you been experiencing? For example, a persistent cough, allergy symptoms, shortness of breath, hoarseness, wheezing, unexplained weight loss, or fatigue.
• Have you had any episodes of choking?
• Do you, or have you ever, smoked?
• What medications are you taking (including any herbal supplements or over-the-counter medications)?
• What other medical conditions do you have?
• Has anyone in your family had bronchitis, bleeding disorders, lung problems, or lung cancer?

Depending upon the amount of blood you are coughing up, your doctor will first want to make sure your airway is okay to prevent aspiration (breathing in the contents that are present in your mouth) and control any active bleeding. He/she will then recommend tests to determine the cause. Possible tests may include:

• Lab tests to check your blood counts and look for any reason for bleeding
• A chest X-ray to look for infection of any evidence of a tumor
• A CT scan of your chest
• A bronchoscopy to check for foreign bodies or evaluate your airways for a tumor (in a bronchoscopy, a flexible tube is inserted through your mouth and down into your bronchi)

It's important to be your own advocate and to keep asking questions if an answer is not found. Lung cancers are often missed on regular chest X-rays and further testing is needed, including a chest CT scan.

If you aren't getting answers, consider getting a second opinion.

Treatment will depend on the cause of your symptoms as well as the amount of blood you have been coughing up. Remember that if you only cough up blood once, and even if it is a small amount, it is still extremely important to see your doctor as soon as possible.

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

If your doctor is suspicious that you may have lung cancer, you can learn more about how lung cancer is diagnosed, what you may expect, and your possible risk factors for lung cancer (it goes far beyond smoking and 10% to 15 % of lung cancer diagnoses occur in never smokers).

Don't dismiss the chance that you could have lung cancer until the diagnosis has been ruled out. Lung cancer occurs in never-smokers. It occurs in young adults. And it is almost as common in women as in men. Unfortunately, the average time between the onset of symptoms and diagnosis of lung cancer is 12 months —a time during which treatment can often make a difference in the outcome of the disease.

An important step in addressing hemoptysis is to find and treatment the underlying cause, but sometimes the symptom 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 (inserting an endotracheal tube) may be necessary, especially with massive bleeding. When bleeding is mild, treatment may be focused on managing the underlying cause. Otherwise the following options may be considered.

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

• Endobronchial insertions: A number of substances can be inserted via endoscopy to attempt to stop bleeding topically. Some that have been used include iced saline, fibrinogen, and oxidized regenerative cellulose.
• Coagulation either with argon plasma coagulation or photocoagulation
• Electrocautery (endobronchial)
• Endobrochial stent placement (especially with lung cancer)

When bleeding is very significant (massive hemoptysis), bronchoscopic procedures are much less likely to be effective. At the current time, bronchial artery embolization is recommended first line for massive hemoptysis and can be quite effective (though the success rate is better when a diagnosis other than cancer is the cause).

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

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. Surgery may be done in a minimally invasive way (video-assisted thoracoscopic approach) or via an open procedure. A resection of a wedge of lung tissue in the region that is bleeding (sublobar resection) is most often done.

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.

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.