Cough and haemoptysis in advanced disease

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Cough can protect the airway or become exhausting and non-productive. Ask whether sputum is present, whether swallowing or position triggers episodes, and whether cough causes vomiting, pain, syncope, bleeding, insomnia or inability to speak. Examine upper airway, chest, fluid status and swallowing. A suppressive medicine is hazardous when the person needs cough to clear a large secretion burden.

Haemoptysis ranges from streaking to airway-threatening haemorrhage. Description of tablespoons is unreliable; urgency follows rate, airway effect, gas exchange and haemodynamics. Establish lower-respiratory origin by asking about nausea, retching, epistaxis and oral bleeding. Review tumour location, cavitation, recent procedures or radiotherapy, infection, platelet count and anticoagulant or antiplatelet treatment.

Investigate proportionately. Chest radiography identifies infection, collapse and tumour change; CT with contrast or angiographic technique localises parenchymal and vascular disease in a stable patient. Bronchoscopy can inspect and sometimes treat central bleeding. Full blood count, coagulation, renal function and group-and-save support planning. In catastrophic active bleeding, resuscitation and airway action precede complete imaging.

Cause-directed treatment depends on the source and goals. Antibiotics treat infection, bronchodilators reduce bronchospasm, drainage relieves effusion, and reflux or aspiration strategies address cough triggers. Bronchial-artery embolisation can control significant recurrent bleeding. Endobronchial intervention or palliative radiotherapy can reduce tumour bleeding. Review anticoagulants individually, balancing current bleeding against thrombosis and the reason treatment was started.

For a dry distressing cough without a readily reversible cause, simple linctus, honey where appropriate or low-dose opioid may help. Codeine is variably metabolised and problematic in renal impairment; a person already receiving morphine may need adjustment of the existing regimen rather than another opioid. Productive cough needs hydration, physiotherapy, mucolytic or suction strategy selected by secretion burden, swallowing and ability to expectorate.

Foreseeable catastrophic bleeding requires a short rehearsed plan. Explain the possibility only in a manner and level the patient wants, prepare dark towels, identify the likely bleeding side, write one rapid-route anxiolytic and make the emergency or comfort ceiling visible. If massive bleeding occurs, stay close, use simple words and avoid abandoning the person to draw up medication. Support witnesses immediately afterward.

Key points

Ask whether blood truly came from the lower respiratory tract, then assess airway, breathing, circulation and trajectory rather than relying on volume alone.
First-line cough assessment defines dry or productive, triggers, timing, aspiration, reflux, medicines, infection, obstruction and impact on sleep, speech and eating.
Treat the cause when useful: antibiotic, bronchodilator, reflux care, drainage, airway clearance, bronchoscopy, embolisation, radiotherapy or anticoagulant review may outperform cough suppression.
Simple measures include upright position, hydration or mouth care, avoiding triggers, honey where safe, humidification or saline for selected thick secretion and speech-therapy techniques.
For dry distressing cough, an opioid antitussive can be tried at a low dose after current opioid exposure and respiratory safety are reviewed.
For recurrent haemoptysis, CT angiography, bronchoscopy and bronchial-artery embolisation are considered according to stability, source and goals.
Palliative radiotherapy can control tumour-related haemoptysis; benefit, timing and attendance burden require oncology assessment.
Catastrophic planning prioritises staying with the person, dark absorbent towels, known-side-down positioning and a simple call route; medicine may not act before death.
The gold-standard record separates minor bleed treatment from catastrophic response and states anticoagulant decisions, escalation ceiling, rescue route and family communication.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Tumour and vascular erosion

Endobronchial tumour, cavitation and invasion of bronchial or pulmonary vessels cause cough, minor bleeding or catastrophic haemorrhage.

Infection and inflammation

Pneumonia, bronchitis, fungal disease, bronchiectasis and treatment pneumonitis inflame airway mucosa and increase secretion and friability.

Thromboembolic and cardiac disease

Pulmonary embolism, infarction, pulmonary hypertension and oedema can produce cough or blood-streaked sputum in advanced illness.

Medication and treatment effects

Anticoagulants, antiplatelets, radiotherapy, ACE inhibitors and immune or systemic treatments can provoke cough or increase bleeding severity.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Cough-reflex activation
Mechanical, chemical and inflammatory receptors in larynx and airways signal through vagal pathways to a coordinated expiratory motor response.
2
Airway hypersensitivity
Chronic inflammation or nerve injury lowers the cough threshold so speech, cold air, smell and minor secretion trigger repeated episodes.
3
Bronchial arterial bleeding
High-pressure systemic bronchial vessels supply many tumours and bronchiectatic areas, making their rupture a common source of major haemoptysis.
4
Airway flooding
Death in catastrophic pulmonary haemorrhage often results from obstruction and loss of gas exchange before exsanguination.
5
Antifibrinolytic action
Tranexamic acid blocks plasminogen activation and stabilises fibrin, potentially reducing bleeding while increasing clot persistence and thrombotic concern.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Dry tumour cough

Persistent non-productive cough, localised wheeze, hoarseness or postural change may reflect endobronchial irritation or airway compression.

Productive infective pattern

Purulent sputum, fever, focal crackles, pleuritic pain and systemic deterioration supports infection or abscess.

Aspiration-associated cough

Cough during meals, wet voice, regurgitation, recurrent basal infection or impaired swallow points to aspiration.

Sentinel bleed

A new small bleed in a high-risk central tumour may precede major vessel erosion and warrants urgent anticipatory review.

Airway-threatening haemorrhageRed flag

Rapid blood flow, inability to clear clot, falling oxygenation or respiratory distress defines a life-threatening event regardless of volume.

Antitussive over-sedation

Drowsiness, slowed breathing and retained sputum after opioid or sedative addition requires immediate medicine and airway review.

Red flags requiring action

Any haemoptysis with airway compromise, hypoxaemia, haemodynamic instability or rapidly accumulating blood is an emergency regardless of measured volume.
A small sentinel bleed in central lung tumour, cavitation, prior radiotherapy or vascular invasion may precede catastrophic haemorrhage.
New pleuritic pain, tachycardia, syncope or leg swelling suggests pulmonary embolism and requires urgent goal-concordant investigation.
Fever, purulent sputum, focal signs or neutropenia suggests infection and can worsen both cough and bleeding.
Stridor, monophonic wheeze, postural cough or recurrent collapse suggests central obstruction, fistula or aspiration needing specialist airway assessment.
Tranexamic acid can increase thrombosis risk and requires renal reduction; visible urinary-tract bleeding raises concern for ureteric clot obstruction.
Sedating antitussives combined with opioids, benzodiazepines or respiratory failure can impair ventilation and secretion clearance.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line source and stability assessmentFirst stepFirst line
Why
Confirm likely respiratory blood, quantify rate and recurrence and assess airway, ventilation, oxygenation, circulation and known bleeding risk.
Interpretation and limitations
Instability or airway flooding triggers emergency management; even small sentinel bleeding can be high risk in central disease.
02
Chest radiograph
Why
Identify infection, collapse, effusion, cavitation, mass or other change that can guide immediate treatment.
Interpretation and limitations
A normal film does not exclude endobronchial tumour, embolism or vascular source and should not falsely reassure after significant bleeding.
03
Contrast CT or CT angiography
Why
Define tumour, vessel, embolic, cavitary and parenchymal anatomy and plan embolisation or intervention in a stable patient.
Interpretation and limitations
Select protocol with radiology and renal function; active instability may require airway and interventional action before scanning.
04
Bronchoscopy
Why
Localise central airway bleeding, remove clot, obtain samples and permit selected local haemostatic or stenting procedures.
Interpretation and limitations
Its value depends on stability, airway access and treatment goal; sedation and transfer burden may outweigh benefit near death.
05
Blood count, haemostasis and kidney tests
Why
Assess anaemia, platelets, coagulopathy, renal clearance and suitability for antifibrinolytic, contrast, transfusion or intervention.
Interpretation and limitations
Correct reversible abnormalities when proportionate and review anticoagulant timing; normal tests do not remove tumour-vessel risk.
06
Swallow and cough-effectiveness assessment
Why
Identify aspiration, laryngeal dysfunction, secretion retention and whether suppressing cough would compromise airway clearance.
Interpretation and limitations
Speech and language or physiotherapy strategies may be safer than an antitussive for a productive protective cough.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Pseudohaemoptysis

Blood from nose, mouth or pharynx may be coughed out but lacks a lower-respiratory source and requires targeted examination.

Haematemesis

Nausea, dark altered blood, food material and melaena suggests gastrointestinal bleeding, although swallowed pulmonary blood can confuse the history.

Infective cough

Fever, purulent sputum, focal chest signs and inflammatory change suggests pneumonia, abscess or an acute bronchiectasis exacerbation.

Mechanical obstruction

Localised wheeze, atelectasis, postural symptoms or recurrent infection suggests tumour, foreign material, clot or mucus plug.

Drug-related cough

ACE inhibition, pneumonitis, reflux-promoting medicines and inhaled-treatment irritation can maintain persistent cough without malignant airway progression.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Cough managementTreat mechanism before suppressing reflexFirst stepCough is distressing, persistent or interfering with sleep, speech, eating or treatment.

1Characterise dry or productive pattern, aspiration, reflux, medicines, airway and infection and identify red flags or protective clearance need.
2Treat the cause and use position, hydration, airflow, swallow and physiotherapy measures before selecting a low-dose antitussive for a dry refractory cough.
3Review frequency, sleep, sputum clearance, alertness and breathing and stop suppression that causes retention or no meaningful benefit.

02Non-massive haemoptysisLocalise bleeding and reduce recurrenceHaemoptysis is currently limited but recurrent or arises in a high-risk disease context.

1Assess stability and true source, review tumour anatomy, infection, blood count, coagulation, renal function and antithrombotic medicines.
2Arrange CT, bronchoscopy, embolisation, radiotherapy or infection treatment according to likely source, trajectory and the patient's goals.
3Document what should trigger emergency action, prepare catastrophic supplies when risk is credible and review the balance of anticoagulation separately.

03Catastrophic bleedStay, position and reduce terrorPulmonary bleeding is rapidly flooding the airway or causing collapse and a catastrophic plan is applicable.

1Call the agreed help, stay with the patient, position the known bleeding side down when feasible, use dark towels and clear visible oral blood without blind deep suction.
2Give the prepared rapid-route midazolam only when immediately available and time allows, while maintaining calm voice, touch and airway comfort.
3Support witnesses, document the event and medicines and provide immediate debrief and bereavement contact after death or stabilisation.

04Anticoagulant reviewBalance bleed and thrombosis explicitlyThe patient with haemoptysis is receiving anticoagulant or antiplatelet treatment.

1Identify indication, last dose, renal function, bleeding severity, thrombotic risk, reversal options and the patient's current treatment goals.
2Hold, reverse, restart or discontinue through the relevant acute and specialist protocol rather than making a blanket palliative decision.
3Record the benefit-burden reasoning, monitoring and future bleeding action and communicate it to every prescriber and service.

Key medicines and prescribing safety4 treatments · regimens, roles and cautions

Suppresses severe dry cough and may also reduce associated breathlessness when cause-directed and simple measures are insufficient.

Immediate-release morphine for refractory dry cough

In an opioid-naive adult, a specialist palliative protocol may use 2.5 mg oral immediate-release morphine as needed or at a defined interval and titrate cautiously; calculate from current exposure when already opioid treated and use a renal-appropriate alternative when needed.

Monitor sedation, breathing, secretion retention, nausea and constipation; avoid stacking with codeine or other opioids and seek advice in renal or hepatic impairment.

May reduce a dry distressing cough when a strong opioid is not already being used and metabolism and clearance are suitable.

Codeine for selected dry cough

A typical adult antitussive dose is 15 to 30 mg orally every 4 to 6 hours as required under the BNF, with the lowest effective exposure and a short response review.

CYP2D6 response is variable; constipation, sedation, dependence and respiratory depression occur, and renal impairment or concurrent opioid therapy makes it a poor choice.

Stabilises clot and may reduce recurrent non-catastrophic tumour or airway bleeding while definitive haemostatic treatment is considered.

Tranexamic acid for selected haemoptysis

Specialist protocols may use 1 g orally three times daily for a short course, with dose reduction in renal impairment; route, duration and indication must be confirmed by oncology, respiratory or palliative guidance for the individual bleed.

Review active or previous thrombosis, haematuria, seizure risk and renal function; it cannot control airway flooding and must not delay embolisation, bronchoscopy or radiotherapy.

May reduce overwhelming fear and awareness during a catastrophic bleed if it can be given without delaying human presence.

Midazolam for catastrophic haemorrhage distress

Prepare one rapid-route adult dose, commonly 10 mg buccally, intranasally or intramuscularly under the local catastrophic-bleed protocol, selected for the route carers or staff can deliver immediately and lawfully.

Bleeding may cause death before medicine works; stay with the patient first, avoid complex preparation, and monitor respiratory depression if the event stabilises.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Asphyxiation

Blood, clot and secretion obstruct conducting airways and prevent ventilation, producing rapid terror, hypoxia and death.

Haemodynamic collapse

High-volume bleeding causes acute anaemia, hypotension, myocardial ischaemia, tissue hypoperfusion and profound shock alongside respiratory compromise.

Aspiration and infection

Retained blood and impaired cough promote distal airway blockage, aspiration pneumonitis, impaired gas exchange and subsequent infection.

Antitussive toxicity

Opioid or sedative escalation can cause constipation, delirium, secretion retention and respiratory depression without correcting the cough mechanism.

Traumatic family experience

Unprepared witnesses may experience panic and persistent intrusive memories, making advance explanation, dark towels and bereavement support important.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Track cough frequency, sleep, vomiting, pain, sputum clearance and the patient's most important functional effect after treatment.
Record every haemoptysis episode by timing, approximate rate, associated distress and physiological effect rather than imprecise volume alone.
Review haemoglobin, platelets, coagulation, renal function and anticoagulant exposure when results can change intervention or medicine safety.
During opioid or codeine trials monitor alertness, respiratory rate, constipation and retained secretion.
During tranexamic acid review ongoing bleeding, thrombosis symptoms, urinary bleeding, seizures and renal dose suitability.
Confirm dark towels, rescue medicine, route, expiry, emergency contact and bleeding-side instruction remain available where catastrophic risk exists.
After any sentinel bleed, update oncology, respiratory, community and ambulance plans and offer patient and family another information discussion.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Volume is hard to estimate

Airway compromise and bleeding rate predict danger more reliably than a witness's comparison with cups or teaspoons.

Minor bleeding can be sentinel

A small new haemoptysis episode in a cavitating central tumour may be the only warning before vessel rupture.

Position protects the other lung

Placing the known bleeding side down can reduce contamination of the better-ventilated lung during major haemoptysis.

Dark towels reduce visual trauma

They do not change physiology but can reduce the overwhelming visual impact for the patient and witnesses.

Presence outranks injection

Catastrophic bleeding may progress in seconds, so a patient should not be left alone while someone searches for medication.

A useful cough is protected

Suppressing a productive reflex without a clearance plan can worsen plugging, infection and breathlessness.

11Common pitfallsFrequent interpretation and management errors.

01
Judging haemoptysis severity only by reported volume.
02
Missing a sentinel bleed in high-risk central tumour.
03
Calling haematemesis or nasal bleeding haemoptysis without examination.
04
Suppressing a productive cough that is maintaining airway clearance.
05
Adding codeine to an existing strong opioid without reconciliation.
06
Using tranexamic acid without renal, thrombotic and haematuria review.
07
Treating catastrophic bleeding as a complex medicine-administration exercise.
08
Using white towels that intensify visual distress when dark supplies are available.
09
Leaving the patient alone to obtain rescue medication.
10
Failing to support relatives and staff after a witnessed catastrophic event.