Coughing up blood — called hemoptysis (hem-OP-tih-sis, from the Greek words for “blood” and “spitting”) — can be alarming. While it does
occur in BE, it is less common than many people fear: roughly 1 in 5 patients with bronchiectasis will experience it over their lifetime. That said, when it does happen, the amount matters and knowing how to respond can make all the difference.
Hemoptysis happens because the chronically inflamed, damaged airways of bronchiectasis can weaken the blood vessels lining the lungs, making them more prone to bleeding, especially during infections or exacerbations. Not all blood that appears to come from the airway actually originates in the lungs. Nosebleeds, heart conditions, blood clots in the lungs, and other causes can all produce a bloody cough, which is why your provider will want to investigate the source carefully.
Certain medications may increase the risk for hemoptysis occurring. Non-steroidal anti-inflammatory drugs (Aspirin, Ibuprofen, Naproxen, etc) and blood thinners (Xarelto, Eliquis, warfarin, Plavix) should be taken into account when investigating hemoptysis.
How Much Blood? Why It Matters
The single most important factor in evaluating hemoptysis is how much blood is involved. Providers often use a practical benchmark: think in terms of a standard coffee mug, which holds about 250 milliliters (mL) or roughly one cup. Coughing up 500 mL — about two full mugs — over 24 hours is considered a significant amount, though any episode that concerns you deserves attention.
It can be very helpful to take a photo of what you coughed up and share it with your care team. This gives your provider a much clearer picture than a verbal description alone.
Hemoptysis is generally thought of in three levels of severity:
Mild (streaking or small flecks of blood) Blood appears as streaks mixed into mucus, or as very small flecks. The bleeding is self-limited, meaning it stops on its own, and you otherwise feel okay.
Moderate (more than streaking, or anything that worries you) If the amount of blood concerns you — or concerns your provider when you describe or show it — treat it as moderate. This category also includes bleeding that is ongoing or comes and goes repeatedly.
Severe / Massive (large amounts, not stopping) Coughing up large amounts of blood that is not stopping is a medical emergency. Do not wait to see if it resolves.
What To Do
For mild hemoptysis:
• Call your provider or care team to report what happened and share a photo if possible.
• You may be able to continue airway clearance cautiously, but check with your provider first. If you are very anxious or unsure, it is reasonable to hold airway clearance for 24 hours and then resume once things have settled.
• Watch for other signs of a flare-up: increased cough, more sputum, change in sputum color, increased shortness of breath, or loss of appetite. If these accompany the bleeding, your provider may want to treat you with antibiotics. A single self-limited episode of hemoptysis in a patient who otherwise feels fine does not automatically require antibiotics.
For moderate hemoptysis:
• Stop airway clearance and contact your care team promptly. Your provider will likely want to evaluate you in person.
• Make sure you let your doctor know about NSAID or blood thinner use.
• Do not resume airway clearance until you have been bleeding-free for at least 24 hours and your provider has given the go-ahead.
For severe / massive hemoptysis:
• Call 911 or go to the emergency room immediately. This is not a situation for a message to your doctor — get emergency help right away!
• If someone is with you, ask them to stay close and help guide you.
• If you have a sense of which side of your chest the bleeding is coming from, try lying with that side down to help protect the other lung.
• Emergency care may include IV fluids and medications, imaging, and in some cases placement on a ventilator to protect the airway.
Other Warning Signs: When To Call 911
Go to the emergency room or call 911 immediately if you experience any of the following, regardless of how much blood you see:
• Severe shortness of breath or chest pain
• Feeling faint or dizzy
• A bluish tint to your lips or fingertips
• A rapid or pounding heartbeat
These can indicate that bleeding is affecting your ability to breathe, which is the most serious risk.
How Hemoptysis Is Treated
Once you are in the care of a medical team, the approach depends on the severity of bleeding and what is causing it.
Reversing contributing factors. If you are on blood thinners or antiplatelet medications, your team will carefully weigh whether to pause
them or even reverse their blood-thinning effects with special medicines. Infections will be treated with antibiotics. Any problems with blood clotting will be addressed.
Tranexamic acid (TXA). This medication — pronounced tran-EX-am-ik AS-id — is a “clot stabilizer.” It works by preventing the body from breaking down clots too quickly, which helps stop or slow bleeding. For patients hospitalized with significant but non-massive bleeding, inhaled TXA has become an increasingly common and generally well-tolerated treatment. An oral form is also available by prescription for outpatients with recurrent low-grade bleeding. Side effects are uncommon but can include vision changes or allergic reaction.
Bronchial artery embolization (BAE). For significant or recurrent hemoptysis, the first-line procedure is bronchial artery embolization.
A radiologist threads a thin catheter into the blood vessel that is bleeding and uses coils or other agents to seal it off. Because the lungs have abundant redundant circulation, blocking one vessel is generally safe and can stop bleeding effectively. As with any procedure, there are small risks which radiologists are specifically trained to watch for.
Surgery. In rare cases where embolization cannot control the bleeding, surgical removal of the affected portion of the lung may be necessary.
This is considered a last resort for life-threatening situations, but it can be lifesaving when other options have been exhausted.
Vitamin K and Blood Clotting
Vitamin K is essential for blood clotting. It is directly responsible for producing and activating specific clotting factors in the liver. Without
sufficient vitamin K, these coagulation proteins cannot bind calcium, resulting in impaired blood clotting, excessive bleeding, and bruising.
If blood clotting is abnormal, your provider may administer vitamin K to help restore proper clotting function, particularly in patients who are not on blood thinners but may have vitamin K deficiency due to liver disease or poor nutrition.
Rifampin and Vitamin K — An Important Interaction for NTM Patients
Patients being treated for NTM with rifampin should be aware of an important interaction: rifampin can lower vitamin K levels, which may cause a rare but serious vitamin K deficiency leading to a bleeding disorder. If you are on rifampin and experience unusual bruising, prolonged bleeding, or hemoptysis, alert your care team promptly so your clotting function can be checked.
Make a Plan Before It Happens
The most important step you can take is to talk with your provider now, before any bleeding episode occurs, so that you have a personal action plan ready. Know who to call, when to go to the emergency room, and what to do about your airway clearance routine. Having that plan in place and sharing it with a family member or caregiver means you will not have to make difficult decisions in a stressful moment.