| Category | Volume | Urgency |
|---|---|---|
| Non-massive (most common) | < 500 mL/24h, hemodynamically stable | Workup: CT chest, bronchoscopy if no source on CT. Outpatient if stable. |
| Massive | > 500 mL/24h (or > 100 mL/hr), or any amount causing hemodynamic instability or respiratory compromise [Crocco Classification, 1968 | EMERGENCY. Airway protection โ bronchoscopy โ IR embolization or surgery. |
| Category | Examples |
|---|---|
| Airway (most common) | Bronchitis (#1 cause overall), bronchiectasis, lung cancer |
| Parenchymal | Pneumonia, TB (cavitary), lung abscess, fungal (aspergilloma) |
| Vascular | PE, AV malformations, Dieulafoy lesion (bronchial artery), mitral stenosis |
| Diffuse alveolar hemorrhage (DAH) | Vasculitis (GPA, anti-GBM), SLE, coagulopathy. Bilateral GGOs on CT + dropping Hgb + hemoptysis. |
| Iatrogenic | Anticoagulation (unmasks underlying lesion), post-biopsy, PA catheter |
Patient: 58M with known bronchiectasis (chronic MAC infection). Sudden onset coughing up bright red blood, estimated 400 mL in 2 hours. HR 118, BP 100/62, SpOโ 88% on room air.
Key findings: Massive hemoptysis (> 300 mL/24h or > 100 mL/hr). Bronchiectasis causes hypertrophied bronchial arteries prone to rupture. Life-threatening, death is from asphyxiation (drowning in blood), not exsanguination.
Management:
Teaching point: In massive hemoptysis, positioning is critical: bleeding lung DOWN prevents blood from flooding the contralateral lung. The cause of death is airway obstruction, not hemorrhagic shock, protecting the unaffected lung is the priority.
Patient: 67M, 40-pack-year smoker. Blood-streaked sputum ร 3 weeks, 10 lb weight loss. CXR: right hilar mass. CT: 4 cm central RUL mass encasing bronchus.
Key findings: Central lung mass in a heavy smoker, squamous cell carcinoma until proven otherwise (central location, endobronchial involvement). Hemoptysis from tumor erosion into bronchial vessels.
Management:
Teaching point: Hemoptysis in a smoker > 40 is lung cancer until proven otherwise. Even mild hemoptysis in a high-risk patient requires CT chest and bronchoscopy, the amount of hemoptysis does not correlate with cancer severity.
Patient: 35M with hemoptysis, dyspnea, Hgb dropping 12 โ 7 over 48h. CXR: bilateral diffuse infiltrates. BAL: sequential aliquots increasingly bloody (confirms DAH). Cr 4.2 (rising). c-ANCA/PR3 positive.
Key findings: DAH + RPGN = pulmonary-renal syndrome. c-ANCA positive โ GPA (granulomatosis with polyangiitis). DAH confirmed by progressively bloodier BAL aliquots. Can also see hemosiderin-laden macrophages.
Management:
Teaching point: DAH is diagnosed by progressively bloodier BAL returns, not by hemoptysis (1/3 of DAH patients have no hemoptysis). The triad of bilateral infiltrates + dropping Hgb + rising Cr should prompt immediate evaluation for pulmonary-renal syndrome.
See the Overview and Management tabs for the hemoptysis workup algorithm (massive vs non-massive triage, CXR โ CT โ bronchoscopy, and DAH evaluation).
Medication details (TXA, reversal agents, antibiotics for infectious causes, cyclophosphamide/rituximab for DAH vasculitis) are in the Management tab with evidence-based dosing and trial citations.