Last updated: September 11, 2023

CME information and disclosurestoggle arrow icon

To see contributor disclosures related to this article, hover over this reference: [1]

Physicians may earn CME/MOC credit by reading information in this article to address a clinical question, and then completing a brief evaluation, in which they will identify their question and report the impact of any information learned on their clinical practice.

AMBOSS designates this Internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only credit commensurate with the extent of their participation in the activity.

For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see "Tips and Links" at the bottom of this article.

Summarytoggle arrow icon

Hemoptysis is the expectoration of blood from the lower respiratory tract. It most commonly occurs as a result of a pulmonary infection; tuberculosis is the leading cause of hemoptysis worldwide. While lung cancer is the second most frequent cause of hemoptysis, bleeding from the respiratory tract only occurs in a minority of these patients. Typically, management of hemoptysis begins with the identification of the bleeding site using imaging or bronchoscopy. Definitive diagnostic evaluation is then guided by the location and appearance of the hemorrhagic site, patient symptoms, and patient risk factors for lung cancer. Treatment is directed at the underlying cause. Oral or inhaled tranexamic acid may be used for symptomatic relief. A minority of patients may present with massive hemoptysis, which can be life-threatening if not controlled emergently. In these patients, management begins with securing the airway and protecting the functioning lung. Bedside bronchoscopy and/or bronchial artery embolization are then used to control the hemorrhage. Definitive diagnosis and treatment follow respiratory and hemodynamic stabilization.

Definitiontoggle arrow icon

Epidemiologytoggle arrow icon

  • Hemoptysis is the presenting symptom in 0.1% of outpatient visits and hospitalizations. [6][7]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Source of bleeding [3][8][9][10]

Overview of common etiologies

Etiology of hemoptysis [6][11][12]

Diffuse alveolar hemorrhage is most commonly a result of immune-mediated vasculitis or connective tissue disease. Other causes include congestive heart failure, infection, coagulopathy, and trauma. [2]

Managementtoggle arrow icon

Approach [8][9]

See detailed further management of ”Nonmassive hemoptysis” and ”Massive and/or life-threatening hemoptysis” in their dedicated sections.

In cases of massive hemoptysis, stabilize the patient before obtaining further diagnostic studies.

Management priorities are resuscitation, protecting the nondiseased lung, and establishing respiratory and hemodynamic stability. Fatal hypoxia due to impaired gas exchange typically occurs before a hemodynamic change resulting from blood loss. [8][15]

Severity assessment [8]

Nonmassive hemoptysis requires respiratory and hemodynamic stability, a low volume and speed of blood loss, and no red flags for hemoptysis. Assume all other types of hemoptysis to be potentially life-threatening or have a high risk of progression to massive hemoptysis.

Red flags for hemoptysis [16]

The presence of any red flag feature is associated with an increased risk of mortality and the potential for rapid patient deterioration. [16]

Hemoptysis due to diffuse alveolar hemorrhage is frequently severe and life-threatening. [2]


Diagnosticstoggle arrow icon


  • Perform initial studies, including CXR and basic laboratory studies.
  • Locate the site of bleeding.
  • Continue with further investigations for the underlying cause once the patient is clinically stable.

Initial studies for hemoptysis

Chest x-ray is mandatory in all patients with hemoptysis as it may quickly indicate the location and underlying cause of the bleeding.

Studies to locate the source of bleeding

Bronchoscopy can accurately determine the site of bleeding but is much less sensitive than chest CT at determining the underlying cause of the hemoptysis. A combination of both studies is often required for optimal management. [19]

Workup for underlying causes

Consider further investigations as directed by clinical suspicion of underlying conditions. See “Etiology of hemoptysis”. [6][20]

Massive hemoptysis and life-threatening hemoptysistoggle arrow icon

Priorities for management are acute stabilization followed by definitive bleeding control. The underlying cause can be investigated and treated once patients have been stabilized.


  • Massive hemoptysis
    • A frequently used term with no universal definition
    • Commonly described using blood loss parameters, e.g., 100–1000 mL/24 hours or > 100 mL/hour [13]
    • Occurs in 5–15% of patients presenting with hemoptysis. [6][21]
  • Life-threatening hemoptysis consists of any volume of expectorated blood that causes any of the following: [22]

The effects of hemoptysis on a patient's airway patency, oxygenation, ventilation, and hemodynamic status are more important predictors of outcome and need for intervention than the absolute value or rate of blood loss. [8]

Acute stabilization

Follow ABCDE approach with simultaneous assessment and management.

Airway management and respiratory support

Avoid using a double-lumen endotracheal tube in the management of massive hemoptysis: The small lumen diameter impedes passage of a flexible bronchoscope and effective removal of large blood clots! [8]

Immediate hemodynamic support

Basic hemostatic measures

  • Reverse anticoagulants.
  • Consider the use of a hemostatic agent.
    • First line: tranexamic acid (TXA)
      • Has been shown to reduce mortality, interventional procedures, and length of hospital stay. [21][23][24][25]
      • Can be administered systemically, orally, or by nebulization. [23][26]
    • Consider desmopressin in patients with severe renal impairment. [27][28]

Bronchoscopic hemostasis [8]

Basic hemostatic measures alone rarely control the bleeding in massive hemoptysis; patients typically require local therapy via bronchoscopy.

Flexible fiberoptic bronchoscopy is the initial procedure of choice for the diagnosis and treatment of massive hemoptysis in an unstable patient. [8]

Definitive therapy

To prevent a recurrence, the majority of patients who have experienced massive hemoptysis undergo either bronchial artery embolization or surgery.

Bronchial artery embolization (BAE) [30]

  • BAE is the preferred treatment method for most patients with massive hemoptysis.
  • Bleeding sites or high-risk vascular abnormalities are detected on CTA or thoracic angiography.
  • Embolic material or coils are introduced to the suspected area under fluoroscopic guidance. [9][15]

BAE should be performed as soon as the patient has been stabilized. [9][31]

Because the aortic origins of the spinal arteries and the bronchial arteries are in close proximity, spinal arteries may be inadvertently occluded during BAE. Therefore, be alert for new neurological symptoms in patients who have recently undergone BAE. [9]

Surgery [9][13]

Management of diffuse alveolar hemorrhage [2][32]

Acute management checklist for massive and/or life-threatening hemoptysis

Nonmassive hemoptysistoggle arrow icon

Description [6][8]

Nonmassive hemoptysis has no universal definition. Commonly described parameters include all of the following:

Initial approach

Treat any patients who develop signs of hemodynamic instability, respiratory compromise, or red flags for hemoptysis as life-threatening hemoptysis!

Symptomatic therapy

  • In 90% of cases, hemoptysis resolves with treatment of the underlying cause. [8]
  • If the symptoms of hemoptysis are distressing for the patient, consider TXA. [23][26]

Management of underlying causes [6]

  • For patients with new opacity or signs of infection on CXR:
  • Obtain CT chest with IV contrast for patients with:
    • CXR showing a mass or evidence of lung disease (e.g., COPD).
    • Any of the following despite normal findings or new opacity on initial CXR:
      • Elevated cancer risk
      • Recurrent hemoptysis at any time
      • Persistent opacity on follow-up CXR
  • Consult pulmonology and consider bronchoscopy for patients with:
    • A mass or evidence of lung disease on imaging
    • Recurrent hemoptysis at any time
    • Elevated cancer risk despite normal imaging [10]

Even after extensive evaluation, up to 50% of patients with nonmassive hemoptysis have no definitive diagnosis. Though the likelihood of underlying malignancy is rare, educate patients on the symptoms of lung cancer and arrange regular follow-up for those with an elevated risk. [12]

Acute management checklist for nonmassive hemoptysis

  • Verify patient is stable, oxygenating well, and that the bleeding is not clinically significant.
  • Verify that bleeding is from the lower respiratory tract.
  • Obtain x-ray chest.
  • Obtain initial laboratory studies for hemoptysis, including cultures.
  • Determine the patient's cancer risk based on history and volume of hemoptysis.
  • CT chest if indicated by x-ray chest findings and cancer risk.
  • Pulmonary consultation for abnormal imaging, abnormal laboratory studies, or recurrent bleeding
  • Investigate and treat underlying causes.

Differential diagnosestoggle arrow icon

Distinguishing hemoptysis from pseudohemoptysis [6][10]
History Potential findings
  • Known pulmonary disease
  • Cough
Gastrointestinal bleeding
  • Known gastrointestinal disease or liver disease
  • Sequelae of liver disease may be present on examination.
  • Blood resembles coffee grounds
  • Food remnants may be visible.
  • Blood visible on gastric suctioning
  • Acidic blood pH
Upper respiratory tract bleeding

The differential diagnoses listed here are not exhaustive.

Prognosistoggle arrow icon

Referencestoggle arrow icon

  1. Earwood JS, Thompson TD. Hemoptysis: evaluation and management.. Am Fam Physician. 2015; 91 (4): p.243-9.
  2. Cordovilla R, Bollo de Miguel E, Nuñez Ares A, Cosano Povedano FJ, Herráez Ortega I, Jiménez Merchán R. Diagnosis and Treatment of Hemoptysis. Arch Bronconeumol. 2016; 52 (7): p.368-377.doi: 10.1016/j.arbres.2015.12.002 . | Open in Read by QxMD
  3. Larici AR, Franchi P, Occhipinti M, et al. Diagnosis and management of hemoptysis. Diagnostic and Interventional Radiology. 2014; 20 (4): p.299-309.doi: 10.5152/dir.2014.13426 . | Open in Read by QxMD
  4. Ketai LH, Mohammed T-LH, Kirsch J, et al. ACR Appropriateness Criteria® Hemoptysis. J Thorac Imaging. 2014; 29 (3): p.W19-W22.doi: 10.1097/rti.0000000000000084 . | Open in Read by QxMD
  5. Revel MP, Fournier LS, Hennebicque AS, et al. Can CT Replace Bronchoscopy in the Detection of the Site and Cause of Bleeding in Patients with Large or Massive Hemoptysis?. AJR Am J Roentgenol. 2002; 179 (5): p.1217-1224.doi: 10.2214/ajr.179.5.1791217 . | Open in Read by QxMD
  6. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. Journal of Thoracic Disease. 2017; 9 (S10): p.S1069-S1086.doi: 10.21037/jtd.2017.06.41 . | Open in Read by QxMD
  7. Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis.. Int J Mole Sci. 2021; 22 (2).doi: 10.3390/ijms22020793 . | Open in Read by QxMD
  8. Sakr L, Dutau H. Massive Hemoptysis: An Update on the Role of Bronchoscopy in Diagnosis and Management. Respiration. 2010; 80 (1): p.38-58.doi: 10.1159/000274492 . | Open in Read by QxMD
  9. Blasi F, Tarsia P. Oxford Textbook of Critical Care. Oxford University Press ; 2016
  10. Paul S, Andrews W, Nasar A, et al. Prevalence and Outcomes of Anatomic Lung Resection for Hemoptysis: An Analysis of the Nationwide Inpatient Sample Database. Ann Thorac Surg. 2013; 96 (2): p.391-398.doi: 10.1016/j.athoracsur.2013.03.097 . | Open in Read by QxMD
  11. Davidson K, Shojaee S. Managing Massive Hemoptysis. Chest. 2020; 157 (1): p.77-88.doi: 10.1016/j.chest.2019.07.012 . | Open in Read by QxMD
  12. Kathuria H, Hollingsworth HM, Vilvendhan R, Reardon C. Management of life-threatening hemoptysis. J of Int Care. 2020; 8 (1).doi: 10.1186/s40560-020-00441-8 . | Open in Read by QxMD
  13. Fartoukh M, Khoshnood B, Parrot A, et al. Early Prediction of In-Hospital Mortality of Patients with Hemoptysis: An Approach to Defining Severe Hemoptysis. Respiration. 2012; 83 (2): p.106-114.doi: 10.1159/000331501 . | Open in Read by QxMD
  14. Choi J, Baik JH, Kim CH, et al. Long-term outcomes and prognostic factors in patients with mild hemoptysis. Am J Emerg Med. 2018; 36 (7): p.1160-1165.doi: 10.1016/j.ajem.2017.11.053 . | Open in Read by QxMD
  15. Deshwal H, Sinha A, Mehta AC. Life-Threatening Hemoptysis. Semin Respir Crit Care Med. 2020; 42 (01): p.145-159.doi: 10.1055/s-0040-1714386 . | Open in Read by QxMD
  16. Gadre A, Stoller JK. Tranexamic Acid for Hemoptysis: A Review. Clinical Pulmonary Medicine. 2017; 24 (2): p.69-74.doi: 10.1097/cpm.0000000000000200 . | Open in Read by QxMD
  17. Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment. Chest. 2018; 154 (6): p.1379-1384.doi: 10.1016/j.chest.2018.09.026 . | Open in Read by QxMD
  18. Kinoshita T, Ohbe H, Matsui H, Fushimi K, Ogura H, Yasunaga H. Effect of tranexamic acid on mortality in patients with haemoptysis: a nationwide study. Critical Care. 2019; 23 (1).doi: 10.1186/s13054-019-2620-5 . | Open in Read by QxMD
  19. Alabdrabalnabi F, Alshahrani M, Ismail N. Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med. 2020; 13 (1).doi: 10.1186/s12245-020-00304-x . | Open in Read by QxMD
  20. Gershman E, Guthrie R, Swiatek K, Shojaee S. Management of hemoptysis in patients with lung cancer. Annals of Translational Medicine. 2019; 7 (15): p.358-358.doi: 10.21037/atm.2019.04.91 . | Open in Read by QxMD
  21. Pea L, Roda L, Boussaud V, Lonjon B. Desmopressin Therapy for Massive Hemoptysis Associated with Severe Leptospirosis. Am J Respir Crit Care Med. 2003; 167 (5): p.726-728.doi: 10.1164/rccm.200205-450cr . | Open in Read by QxMD
  22. Conlan AA, Hurwitz SS. Management of massive haemoptysis with the rigid bronchoscope and cold saline lavage.. Thorax. 1980; 35 (12): p.901-904.doi: 10.1136/thx.35.12.901 . | Open in Read by QxMD
  23. Gagnon S, Quigley N, Dutau H, Delage A, Fortin M. Approach to Hemoptysis in the Modern Era.. Can Respir J. 2017; 2017: p.1565030.doi: 10.1155/2017/1565030 . | Open in Read by QxMD
  24. Lorenz J, Patel J, Sheth D. Bronchial Artery Embolization. Seminars in Interventional Radiology. 2012; 29 (03): p.155-160.doi: 10.1055/s-0032-1326923 . | Open in Read by QxMD
  25. Lowrance WT, Breau RH, Chou R, et al. Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline PART I. J Urol. 2021; 205 (1): p.14-21.doi: 10.1097/ju.0000000000001375 . | Open in Read by QxMD
  26. Desai H, Smith J, Williams MD. Diffuse Alveolar Hemorrhage. Springer International Publishing ; 2020: p. 253-257
  27. Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. Dtsch Arztebl Intl. 2017.doi: 10.3238/arztebl.2017.0371 . | Open in Read by QxMD
  28. Buchwald Z, Amrita V. Hemoptysis Due to Diffuse Alveolar Hemorrhage. J of Education and Teaching in Emergency Medicine. 2020.doi: 10.21980/J8ZP86 . | Open in Read by QxMD
  29. Ta R, Celli R, West AB. Diffuse Alveolar Hemorrhage in Systemic Lupus Erythematosus: Histopathologic Features and Clinical Correlations. Case Reports in Pathology. 2017; 2017: p.1-6.doi: 10.1155/2017/1936282 . | Open in Read by QxMD
  30. Collard HR, Schwarz MI. Diffuse alveolar hemorrhage. Clin Chest Med. 2004; 25 (3): p.583-592.doi: 10.1016/j.ccm.2004.04.007 . | Open in Read by QxMD
  31. Afonso M, Alfaro TM, Fernandes V, Cemlyn-Jones J. Diffuse alveolar hemorrhage - review of an interstitial lung disease clinic. Eur Resp J. 2017.doi: 10.1183/1393003.congress-2017.pa3862 . | Open in Read by QxMD
  32. $Contributor Disclosures - Hemoptysis. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer