This visually arresting photo shows a medical anomaly — a huge blood clot that took the shape of the bronchial tree. This was a terminal patient so this was not coughed up, it was removed from the end of the breathing tube after death. You basically could not cough up a clot this large or well formed, at least not when intubated. You wouldn't be able to take a breath deep enough to get the air to cough it up because the airway is obstructed. Also if the patient is intubated with an endotracheal tube, they will not be able to cough well (or at all if they are sufficiently sedated). The other issue to think about is why is blood entering the space of the bronchioles where air should be? This is a sign that the lungs and bronchi were so severely damaged from infection that the patient was bleeding into their airways and then the blood clotted in those spaces. Even intubated, if there is blood/liquid in those airway spaces no air exchange can happen and death will occur. It is worth noting that clots like that are very rare. It's considered a medical anomaly. There are news articles on it from back in 2018 where a man coughed one up, and it was in the near-perfect shape of his right bronchial tree, similar to this patient.