Coughing up blood from lower respiratory tract, often producing blood-streaked sputum

  • Can be from Pulmonary or Bronchial circulations with bleeding from Bronchial circulation more massive because of higher arterial pressures
  • Must differentiate from bleeding originating higher in airway or from GI tract
    • Hemoptysis blood bright red or rust color, alkaline pH
    • Hematemesis blood  coffee-ground color, mixed with food particles, acidic pH
  • Rare to see in children under 6 y/o who tend to swallow sputum


Top Etiologies in Children:

  • Infection
    • Pneumonia and tracheobronchitis most common
    • Others: bacterial (TB, lung abscess), fungal (histoplasmosis, coccidioidiomycosis), viral (HIV, influenza)
  • Bronchiectasis
    • Most common when associated with CF (60%) – possible contribution from coagulopathy secondary to Vitamin K malabsorption
    • Incidence 10-15% for bronchiectasis secondary to other causes
  • Foreign Body Aspiration


Other Etiologies:

  • Neoplasms
  • Coagulopathies (von Willebrand’s Disease, thrombocytopenia, anticoagulants)
  • Immune/Vasculitis (Henoch-Shonlein Purpura, Wegener’s, Goodpasture’s, SLE)
  • Pulmonary Vasculature Disorder (PE, AVM, telangiectasia)
  • Increased pulmonary pressures from cardiac disorder
  • Medications (amiodarone, PTU, penicillamine)
  • Inhaled Irritants (nitrogen dioxide, pesticides)
  • Airway Trauma
  • Idiopathic Pulmonary Hemosiderosis



  • Amount of blood produced (frank blood vs. blood-tinged sputum)
  • Symptoms of infection (fever, chills, etc.)
  • Associated symptoms (hematuria, easy bruising, etc.)
  • History of choking
  • New environmental exposures or travel
  • Trauma
  • PMH (chronic lung diseases, cardiac diseases)
  • Medications


Physical Exam:

  • Directed exam focused on oral and nasopharynx, heart, lung, skin



  • Direct based on H&P
    • Labs (CBC, Electrolytes, Coagulopathy workup, LFTs, UA, ABG)
    • Imaging (CXR, CT)
    • Flexible or Rigid Bronchoscopy +/- BAL
    • Sweat Test



  • Tailor to severity of bleeding (subjective measure)
    • Mild (streaks) – may observe for recurrence, work-up as outpatient if recurrent
    • Moderate – work-up as above, +/- admission for observation
    • Severe – admit for hemodynamic monitoring
  • All patients: ABCs, correction of clotting abnormality, cough suppression, lie with bleeding side down to prevent flow to contralateral lung
  • If bleeding continues, flexible or rigid bronchoscopy may be used to identify bleeding source and to  control bleeding (physical tamponade, epinephrine injection, embolotherapy)
  • Final resort is pulmonary resection, given patient has adequate pulmonary reserve to tolerate procedure



  1. Coss-Bu J.A.  Hemoptysis: A 10 Year Retrospective Study. Pediatrics 1997
  2. Batra P.S. and Holinger L.D.  Etiology and management of pediatric hemoptysis.  Archives Otolaryngology Head and Neck Surgery 2001
  3. Godfrey Simon. Pulmonary Hemorrhage/Hemoptysis in Children.  Pediatric Pulmonology 2004 37:476-484
  4. Bidwell J.L. and Pachner R.W. Hemoptysis: diagnosis and management. American Family Physician. 2005
  5. Sim J. et al. Etiology of hemoptysis in children: a single institutional series of 40 cases. Allergy Asthma Immunol Res. 2009