Why Am I Coughing Up Blood?

Coughing up blood, otherwise known as hemoptysis, can be 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 (non-cancerous) cause. These include causes like bronchitis, pneumonia, and the use of blood thinners.

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

What Causes You to Cough Up Blood?

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. 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 in adults. The most common causes are respiratory infections, such as pneumonia, bronchitis, and tuberculosis. Underlying heart disease is the second most common cause in children.

Roughly one-third of hemoptysis cases in children are idiopathic (meaning of unknown origin) with symptoms resolving without ever determining the cause.

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%.

If coughing up large amounts of blood, do not drive yourself to the hospital or have someone else drive you—call 911. Coughing up blood in these volumes can cause airway obstruction and infiltration of the blood into your lungs, leading to suffocation and death.

Testing for Causes of Hemoptysis

If you cough up blood—even a very small amount—it is important 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 it better than wrapping it in tissue.

The diagnosis will involve a review of your medical history and a physical exam. 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. This may include:

• Lab tests to check your blood count and blood oxygen levels
• Chest X-ray to look for infection, obstruction, trauma, or a tumor
• Computed tomography (CT), which composites multiple X-ray images to get a 3-D image of the lungs and airways
• Bronchoscopy, in which a flexible scope is inserted through the mouth to view the airways

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

A timely diagnosis is essential when you have hemoptysis. While the cause may ultimately be benign or treatable, an early diagnosis almost invariably leads to better outcomes irrespective of the cause.

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

How Is Hemoptysis Treated?

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.

Bronchoscopy

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

Options include:

• Endobronchial insertions: These are substances that are delivered through the bronchoscope to stop bleeding, such as iced saline, cellulose, and an organic fiber known as fibrinogen.
• Argon photocoagulation: This is a technique used to form blood clots locally.
• Electrocautery: This involves electricity to burn tissues to stop a bleed.
• Endobronchial stent placement: This involves the insertion of a tube into blood vessels to redirect circulation after the bleeding has been stopped.

Bronchial Artery Embolization

When the bleeding is massive, bronchial artery embolization is typically the first-line treatment. In this procedure, a tube called a catheter is inserted into an artery in the upper thigh and threaded to the lung to the site of the bleeding.

Once in place, various substances are injected through the catheter to embolize (create a clot) in the artery. Options include a gelatin sponge, PVC particles, or a metallic coil.

Surgery

Surgery is needed less often in the past for hemoptysis but may still be used in situations where there is massive hemoptysis due to trauma.

This may include a type of surgery called a wedge resection in which a wedge of lung tissue is removed and the cut ends are sewn together. This may be performed with traditional open surgery or minimally invasive video-assisted thoracoscopic surgery.

Summary

Coughing up blood (hemoptysis) can be caused by many different things, from violent coughing and chronic lung disease to respiratory infection and lung cancer. There is no way to tell what is involved without an evaluation by a healthcare provider.

Coughing up any amount of blood warrants a medical business, but coughing up more than a teaspoon is considered a medical emergency. Massive hemoptysis (coughing up a 1/3 cup of blood or more) correlates with a high risk of death.

While the underlying cause of hemoptysis needs to be addressed, other interventions may be needed to stop the bleeding. This includes substances that cause clotting at the site of the bleeding or tools that use heat (cautery) to seal ruptured vessels. Surgery may be needed in cases of trauma.