Coughing Up Blood

Coughing up blood (blood expectoration) is a symptom that present in many diseases causing bleeding into respiratory tract. Blood expectoration may be tightly related to upper GI (gastrointestinal) bleeding and blood vomiting. Blood from respiratory tract may be swallowed, digested followed by black, tarry, foul-smelling melena occurrence like in GI bleeding and on the contrary blood from GI tract may be aspirated and coughed up.


Bleeding from respiratory tract is usually not massive; there is often only a small stripe of blood in sputum. On the other hand, bigger cases of bleeding may be dangerous, because when blood flows into lung alveoli, the affected person can suffocate by “drowning in own blood”.


Respiratory tract infections

Respiratory infections can cause irritation of mucosa and bleeding. Blood expectoration may follow infections of both upper (common cold, sinusitis, laryngitis) and lower respiratory tract (windpipe infection, bronchitis, pneumonia).


Advanced stages of tuberculosis were associated with coughing up blood in the past. In developed countries this is, however, less common and tuberculosis manifests rather by systemic symptoms like night sweats, periods of elevated temperature and fatigue. Bleeding is usually caused by damage done to a blood vessel by growth of tuberculosis process.


Lung cancer is the most feared and yet common cause of blood expectoration. Bleeding is not usually massive; there is rather a trace of blood in sputum. This seemingly subtle symptom is very serious and should not be underestimated. Any finding of blood in the expectorated sputum should be further investigated, at least by a chest X-ray. Other anatomically close cancers like tongue cancer or laryngeal cancer may also cause bleeding and coughing up blood, but these malignant diseases are less usual than lung tumors.

Disorders of blood circulation in the lungs

Accumulation of blood in the pulmonary blood vessels is associated with increased lung blood pressure. This situation may cause filtering blood fluid into alveoli followed by expectoration of pinkish liquid. It accompanies cases of heart failure and acute pulmonary embolism.

Coagulation disorders

Blood clotting disorders can cause bleeding from mucous membranes in the whole body including the respiratory system. Inherited blood clotting disorders are rare (e.g. hemophilia), acquired disorders are more usual. This problem is typical in patients using anticoagulant agents.

Diagnostic approach

It is necessary to determine the source of bleeding. Medical history and physical examination should be the first. Chest X-ray and X-ray of nasal sinuses are important to exclude pneumonia, sinusitis and lung cancer. If there is an unclear finding in chest X-ray, we can follow by computed tomography. Upper respiratory tract is accessible to otolaryngological examination. When there is a suspicion of lung pathology, bronchoscopy is performed. This is an endoscopic examination using tubular apparatus with camera and light source. It can help to detect the source of bleeding in lung bronchi, to obtain a tissue sample and, if need, to stop the bleeding.


Heart function is examinable by echocardiography; pulmonary embolism can be ruled out by evaluating D-dimers levels from standard blood tests followed by lung scintigraphy or CT angiography.


If there is massive bleeding, it is important to stabilize the patient and his or her vital life functions and stop the bleeding as soon as possible. Some haemostyptic drugs are used and bleeding from respiratory tract often stops spontaneously. Otherwise, more invasive approach is needed. Bleeding from upper airways may be stopped by an otolaryngologist; lower respiratory tract must be usually treated by bronchoscopy.

Jiri Stefanek, MD  Author of texts: Jiri Stefanek, MD
 Sources: basic text sources