CRACKCast E024 – Hemoptysis

In CRACKCast, Podcast by Adam Thomas1 Comment

This episode of CRACKCast covers Rosen’s Chapter 24, Hemoptysis. Hemoptysis has a host of causes ranging from benign to life threatening. This action packed episode covers it all, and will help you manage these potentially intimidating patients on your next shift.

Shownotes – PDF here

Rosen’s in Perspective

  • Expectoration of blood arising from the respiratory tract below the cords
  • Most cases this is a small amount of blood tinged sputum, due to bronchitis
  • 1-5% of patients have massive hemoptysis:
    • >100-600mL of blood in 24 hours (Rosen’s)
    • Can lead to shock, impaired gas exchange, with mortality >80%

Uptodate: “In our clinical practice, we define massive hemoptysis as either ≥500 mL of expectorated blood over a 24 hour period or bleeding at a rate ≥100 mL/hour, regardless of whether abnormal gas exchange or hemodynamic instability exists.”


Caused by a vascular disruption within the trachea

  • Involving bronchi, small, airways, and/or lung parenchyma
  • Vascular structures involved include capillary beds, bronchial arteries and/or the pulmonary arteries

Related Anatomy

  1. Trace Hemoptysis (capillary beds)
  2. Massive Hemoptysis (bronchial or pulmonary arteries)

Bronchial arteries:

  • Direct branches from the thoracic aorta
    • Supply oxygenated blood to the lung parenchyma
    • They are smaller in caliber, but are HIGH PRESSURE
  • Disruptions due to arteritis, trauma, bronchiectasis, or malignant erosion results in sudden, massive hemorrhage
  • They are the culprit vessels in 90% of hemoptysis requiring embolization

Pulmonary arteries

  • Transmit large volumes of blood, but at lower pressures
  • LESS likely to be the cause of hemoptysis

Describe the management of massive hemoptysis

Rapid assessment and stabilization:

  • Most lethal sequelae is hypoxia (V/Q mismatch)

Identify Massive Hemoptysis


ABC – IV – O2 – MONITORS – Advanced Airway to Bedside

  • Need to identify massive hemoptysis
  • Attempt to recognize which lung is the source of bleeding
  • Seriously consider early intubation

Initial Steps:

  1. Affected lung in down position to maximize gas exchange
  2. Large bore0 ETT into “good” lung
  • Attempt right mainstem intubation if left lung is bleeding using 90 degree twist to the right
  • Double lumen ETT
  • If unable to oxygenate patient, for lung isolation ventilation

Get them to CT Scan once airway is secured

List 12 causes of hemoptysis


  • Structural
    • Neoplasm
    • Trauma
    • Foreign body
  • Pulmonary
    • Bronchitis, bronchiectasis, tuberculosis,
    • Pneumonia, lung abscess, fungal infection
  • Iatrogenic
    • Post-lung core biopsy
    • Aorto-tracheal fistula post aneurysm repair
  • Thrombosis
    • Pulmonary embolism
    • Coagulopathy from cirrhosis or warfarin
    • DIC
    • Platelet dysfunction
    • Thrombocytopenia
  • Systemic
    • Congenital heart disease (kids)
    • Valvular heart disease
    • SLE, vasculitis, goodpastures syndrome

In essence the causes are vessel injury due to:

  • Acute and chronic inflammation (bronchitis / arteritis)
  • Local infection (lung abscesses, TB, aspergillosis)
  • Trauma
  • Malignant invasion
  • Infarction – pulmonary embolus
  • Fistula formation

Some Key Etiologies to Remember

  • Bronchiectasis
    • Chronic necrotizing infection
      • This leads to bronchial wall inflammation and dilation
      • One of the most common causes of massive hemoptysis
      • Can complicate necrotizing pneumonia, TB, CF
    • Hemorrhage control requires SURGERY
  • Iatrogenic hemoptysis
    • Complicates 2-10% of procedures, especially lung biopsies
  • Diffuse alveolar hemorrhage
    • Can be seen with autoimmune vasculitides
      • Wegener’s, SLE, Goodpasture’s syndrome
    • Uncommon causes:
      • Catamenial hemoptysis – ectopic endometrial tissue within the lung leads to episodes of bleeding

Another recap:

  • Most cases are due to:
    • Tuberculosis (TB)*
    • Bronchiectasis * or bronchitis
    • Cancer
    • Cystic fibrosis
    • AV malformations
    • Post-procedural complications

How do you tease out other hemoptysis mimics?

Differential considerations:

  • Must inquire about:

1) Nasal, oral, hypopharyngeal bleeding

  • Mimickers of hemoptysis
    • Requires a thorough inspection of those tissues for potential contribution to hemoptysis

2) Gastric or duodenal bleeding (GI)

  • Can be differentiated based on:
    • pH testing
    • Inspection:
      • Acidification of blood in the stomach – results in fragmentation: brown and black material “coffee grounds”
  • Pulmonary blood:
    • Is bright red
    • Slightly darker clots

This post was edited and uploaded by Ross Prager (@ross_prager)

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Adam Thomas

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Adam Thomas
- 14 hours ago
Chris Lipp
Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine. His interests are in endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's brewing a coffee or dreaming up an adventure…..