Snapshot A 58-year-old man presents to an urgent care clinical after coughing up blood and experiencing shortness of breath. The patient reports that he has been coughing recently and decided to cut back on his cigarette use. He notes a 25-lb unintentional weight loss over the course of 6 months, along with night sweats and generalized malaise. On physical exam, the patient has blood in his sputum and no notable source of bleeding in his oropharynx. A chest radiograph is performed, which demonstrates a bronchial mass. (Lung cancer) Introduction Definition expectoration of blood from the lower respiratory tract hemoptysis is said to be massive when there is ≥ 500 mL of blood over 24 hours or ≥ 100 mL/hour ETIOLOGY Types airway diseases bronchitis bronchogenic carcinoma bronchiectasis pulmonary parenchymal diseases tuberculosis abscess rheumatic diseases amyloid anti-glomerular basement membrane disease (Goodpasture disease) treat with steroids, plasmapheresis, and cyclophosphamide for acute flares granulomatosis with polyangiitis (Wegener disease) and other vasculitides systemic lupus erythematosus pulmonary vascular diseases pulmonary embolism pulmonary arteriovenous malformation heart failure coagulation disorders disseminated intravascular coagulation anticoagulant and antiplatelet medications iatrogenic bronchoscopy other cocaine use catamenial hemoptysis due to thoracic endometriosis Pathoanatomy blood comes from 2 sources pulmonary arteries bronchial arteries (most common source of massive hemoptysis) Presentation Symptoms hemoptysis Physical exam blood can range from a streak of blood to gross blood Imaging Chest radiograph indication initial imaging study in the evaluation of hemoptysis CT of the chest indication considered in patients with an abnormal chest radiograph, risk factors for malignancy, or recurrent hemoptysis risk factors for malignancy include > 40 years of age substantial smoking history Bronchoscopy indication confirms hemoptysis and localizes the bleeding Differential Hematemesis differentiating factors source of bleeding is noted on endoscopy diagnosis Diagnostic approach based on an extensive history and physical and chest imaging it is important to differentiate hemoptysis from hematemesis or from the upper respiratory and gastrointestinal tract laboratory testing is dependent on clinical suspicion e.g., a patient comes from a tuberculosis-endemic region presenting with hemoptysis should get sputum acid-fast bacilli testing Treatment Conservative patient positioning indication in cases of severe hemoptysis position patient on the side of the involved lung and intubate the normal lung if necessary e.g., if the source of the bleed is from the right lung, position the patient on the right side Procedural therapeutic bronchoscopy indication recommended in life-threatening cases bronchovascular artery embolization indication first-line for massive, recurrent, or malignant hemoptysis emergency thoracotomy indicated for massive hemoptysis that does not respond to initial measures (such as bronchoscopy) Complications Asphyxiation Exsanguination