Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Overview of massive hemoptysis

David H Ingbar, MD
Section Editor
Praveen N Mathur, MB;BS
Deputy Editor
Geraldine Finlay, MD


When a patient presents with massive hemoptysis, the initial steps are to correctly position the patient, establish a patent airway, insure adequate gas exchange and cardiovascular function, and control the bleeding [1]. The source of massive hemoptysis may be identified either during the initial efforts to control the bleeding or later during a diagnostic evaluation once the patient has been stabilized. It is important to identify the cause of the massive hemoptysis even if the bleeding has ceased, since the cause determines the appropriate definitive treatment and the risk of recurrence. It also will help in early management of major re-bleeding.

The definition, diagnostic evaluation, and definitive treatment of massive hemoptysis are reviewed here. The initial management of massive hemoptysis (ie, positioning, airway control, controlling the bleeding) and the causes of massive hemoptysis are discussed separately. (See "Massive hemoptysis: Initial management" and "Massive hemoptysis: Causes".)


Massive hemoptysis is generally used to describe the expectoration of a large amount of blood and/or a rapid rate of bleeding, although the precise thresholds that constitute massive hemoptysis are controversial [2]. Thresholds of 100 mL [3], 200 mL [4], 240 mL [5], 500 mL [6], 600 mL [7], and 1000 mL [8] over 24 hours have been proposed, but none has been universally accepted. Some clinicians argue that a large volume of expectorated blood alone should not define massive hemoptysis, but rather, that abnormal gas exchange and hemodynamic instability should also be present [2]. 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.


The volume of blood expectorated has traditionally been used by clinicians to determine the severity of the hemoptysis. However, the identification of other risk factors may also be helpful in characterizing the severity of the hemoptysis. The physiologic impact and threat to the patient who presents with massive hemoptysis are greatly affected by the degree of underlying lung and heart disease. If a patient has little cardiopulmonary reserve, smaller amounts of bleeding may be life-threatening. For example if a patient has poor lung reserve for gas exchange, a relatively small amount of alveolar bleeding in this area may make it impossible to oxygenate the patient, even with high intubation and effective ventilation with high fractions of inspired oxygen. A retrospective cohort study of 1087 consecutive patients admitted to an intensive care unit (ICU) over a 14-year period found that independent risk factors for in-hospital mortality included mechanical ventilation, lung densities involving two or more quadrants on an admission chest radiograph, bleeding from the pulmonary artery, cancer, aspergillosis, and alcoholism [9].


There are numerous causes of bleeding from the lower respiratory tract, as listed in the table (table 1). This list is not comprehensive as there are many diseases that can rarely cause hemoptysis, including massive hemoptysis. These etiologies are described in detail separately. (See "Massive hemoptysis: Causes".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 29, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28:1642.
  2. Ibrahim WH. Massive haemoptysis: the definition should be revised. Eur Respir J 2008; 32:1131.
  3. Amirana M, Frater R, Tirschwell P, et al. An aggressive surgical approach to significant hemoptysis in patients with pulmonary tuberculosis. Am Rev Respir Dis 1968; 97:187.
  4. Knott-Craig CJ, Oostuizen JG, Rossouw G, et al. Management and prognosis of massive hemoptysis. Recent experience with 120 patients. J Thorac Cardiovasc Surg 1993; 105:394.
  5. Brinson GM, Noone PG, Mauro MA, et al. Bronchial artery embolization for the treatment of hemoptysis in patients with cystic fibrosis. Am J Respir Crit Care Med 1998; 157:1951.
  6. Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997; 112:440.
  7. Crocco JA, Rooney JJ, Fankushen DS, et al. Massive hemoptysis. Arch Intern Med 1968; 121:495.
  8. Corey R, Hla KM. Major and massive hemoptysis: reassessment of conservative management. Am J Med Sci 1987; 294:301.
  9. Fartoukh M, Khoshnood B, Parrot A, et al. Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis. Respiration 2012; 83:106.
  10. Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15:147.
  11. Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration 2010; 80:38.
  12. Hsiao EI, Kirsch CM, Kagawa FT, et al. Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. AJR Am J Roentgenol 2001; 177:861.
  13. Haponik EF, Chin R. Hemoptysis: clinicians' perspectives. Chest 1990; 97:469.
  14. Revel MP, Fournier LS, Hennebicque AS, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol 2002; 179:1217.
  15. Haponik EF, Britt EJ, Smith PL, Bleecker ER. Computed chest tomography in the evaluation of hemoptysis. Impact on diagnosis and treatment. Chest 1987; 91:80.
  16. Naidich DP, Funt S, Ettenger NA, Arranda C. Hemoptysis: CT-bronchoscopic correlations in 58 cases. Radiology 1990; 177:357.
  17. McGuinness G, Beacher JR, Harkin TJ, et al. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest 1994; 105:1155.
  18. Jeudy J, Khan AR, Mohammed TL, et al. ACR Appropriateness Criteria hemoptysis. J Thorac Imaging 2010; 25:W67.
  19. Yoon W, Kim YH, Kim JK, et al. Massive hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT. Radiology 2003; 227:232.
  20. Müller NL. Hemoptysis: high-resolution CT vs bronchoscopy. Chest 1994; 105:982.