From the Guidelines
The initial workup for a patient presenting with hemoptysis should begin with a thorough history and physical examination, followed by chest imaging with a chest X-ray as the initial imaging study, and then a chest CT with IV contrast if necessary, as it has been shown to identify a cause of bleeding in an additional 20% of patients compared to chest radiographs alone 1.
Initial Assessment
First, assess the severity of bleeding, as massive hemoptysis (>100-200 mL in 24 hours) requires immediate stabilization and possible ICU admission.
- Obtain a detailed history including the amount and duration of bleeding, associated symptoms like fever or weight loss, smoking history, medication use (especially anticoagulants), and past medical conditions.
- Physical examination should focus on vital signs, respiratory status, and signs of underlying diseases.
Laboratory Tests and Imaging
- Order a chest X-ray as the initial imaging study, followed by chest CT with IV contrast if necessary for better visualization of bronchial arteries and parenchymal abnormalities, as studies have shown that CT with IV contrast can identify a cause of bleeding in a high percentage of cases 1.
- Laboratory tests should include:
- Complete blood count
- Coagulation studies (PT, PTT, INR)
- Renal function tests
- Arterial blood gases if respiratory compromise is suspected
- Sputum studies for cytology, culture, and acid-fast bacilli are important to rule out infection or malignancy.
Further Evaluation and Treatment
- Bronchoscopy may be necessary for direct visualization of the bleeding source, especially in moderate to severe cases or when the diagnosis remains unclear after initial testing.
- This systematic approach helps identify common causes of hemoptysis such as bronchitis, bronchiectasis, pneumonia, tuberculosis, lung cancer, or pulmonary embolism, allowing for appropriate targeted treatment.
- In cases of massive hemoptysis, consideration should be given to bronchial artery embolization (BAE) to temporize the bleeding, as it has been shown to be a safe and effective intervention for the treatment of massive hemoptysis 1.
From the Research
Initial Workup for Hemoptysis
The initial workup for a patient presenting with hemoptysis involves several diagnostic tests to determine the severity, origin, and cause of the bleeding.
- Chest X-ray (lateral and AP) is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology 2.
- Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray 2.
- Computed tomography (CT) and computed tomography angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding 3.
Diagnostic Procedures
Additional diagnostic procedures may be necessary to determine the cause of hemoptysis, including:
- Flexible bronchoscopy, which plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis 2.
- Bronchoscopy, which can be used to locate the source of the hemorrhage and is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis 2, 4.
- Multidetector CT angiography, which can pinpoint the presence, origin, number, and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding 2.
Management of Hemoptysis
The management of hemoptysis depends on the severity and cause of the bleeding.
- Mild hemoptysis often can be managed on an outpatient basis with dose monitoring 4.
- Massive hemoptysis requires urgent investigation and intervention, and bronchial artery embolization (BAE) is now considered to be the most effective procedure for the management of massive and recurrent hemoptysis 5.
- Surgery is reserved for patients whose medical treatment and embolization are not effective 3.