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)

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.
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 (Innovative Sport Medicine Calgary). His interests are in paediatrics, 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…..