Synopsis
Assess cough and haemoptysis by mechanism and bleeding risk, treat reversible causes, use proportionate antitussive and tumour-directed therapy, and prepare a simple presence-led plan for foreseeable catastrophic pulmonary haemorrhage.
- 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.
Key red flags
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.
Rapid blood flow, inability to clear clot, falling oxygenation or respiratory distress defines a life-threatening event regardless of volume.
Investigation priorities
Confirm likely respiratory blood, quantify rate and recurrence and assess airway, ventilation, oxygenation, circulation and known bleeding risk.
Management branches
Cough is distressing, persistent or interfering with sleep, speech, eating or treatment.
- Characterise dry or productive pattern, aspiration, reflux, medicines, airway and infection and identify red flags or protective clearance need.
- Treat the cause and use position, hydration, airflow, swallow and physiotherapy measures before selecting a low-dose antitussive for a dry refractory cough.
- Review frequency, sleep, sputum clearance, alertness and breathing and stop suppression that causes retention or no meaningful benefit.