Standard Workup for Hemoptysis
The standard workup for hemoptysis should begin with chest radiography followed by CT chest with IV contrast, as these imaging studies are essential for identifying the cause and location of bleeding in patients with hemoptysis. 1, 2
Initial Assessment
History
- Quantify bleeding volume (>100 mL/24 hours indicates massive hemoptysis)
- Determine bleeding rate and duration
- Assess respiratory symptoms (dyspnea, cough, wheezing, chest pain)
- Document smoking history (pack-years, current/former status)
- Inquire about risk factors for specific etiologies:
- Tuberculosis exposure
- Cancer risk factors
- History of bronchiectasis
- COPD
- Recent respiratory infections
Physical Examination
- Vital signs (hypotension may indicate massive hemoptysis)
- Respiratory assessment (breath sounds, respiratory distress)
- Signs of hemodynamic instability
- Evidence of respiratory compromise
Laboratory Studies
- Complete blood count with platelet count
- Coagulation studies
- Renal function tests
- Sputum examination for acid-fast bacilli
Diagnostic Imaging
Step 1: Chest Radiography (Frontal and Lateral)
- Initial imaging test for all patients with hemoptysis
- Can detect abnormalities in up to 90% of cases
- However, radiographs are suggestive of etiology in only 26-35% of cases 1
- Helps direct further evaluation
Step 2: CT Chest with IV Contrast
- Superior to chest radiography and bronchoscopy for identifying etiology
- Studies show CT identifies cause in 77-94% of cases 1
- Provides information on:
- Parenchymal abnormalities
- Bronchial and pulmonary vascular abnormalities
- Potential malignancies
- Bronchiectasis
Additional Diagnostic Procedures
Bronchoscopy
- Indicated when:
- CT findings are inconclusive
- Malignancy is suspected
- Localization of bleeding site is needed for intervention
- Massive hemoptysis requires airway management
- Can localize bleeding site in approximately 67% of cases 3
- Allows for therapeutic interventions (bronchial washing, biopsy)
CT Angiography
- Particularly useful for planning bronchial artery embolization
- Helps identify abnormal bronchial or pulmonary vessels
- Shows high concordance with conventional arteriography findings 1
Management Based on Severity
Massive Hemoptysis (>100 mL/24 hours)
- Requires immediate stabilization
- Airway protection (may need intubation)
- Hemodynamic support
- Bronchial artery embolization (BAE) is highly effective with success rates of 75-100% 1, 4
- Surgical intervention if BAE fails or is contraindicated
Non-Massive Hemoptysis
- Can often be managed conservatively
- Treat underlying cause (antibiotics for infection, etc.)
- Consider BAE for recurrent episodes or when medical therapy fails
- Follow-up imaging for patients with risk factors for malignancy
Common Pitfalls to Avoid
- Failing to differentiate true hemoptysis from pseudohemoptysis (blood from upper airway or GI tract)
- Overlooking cryptogenic hemoptysis (no identifiable cause in 20-50% of cases) 5
- Delaying imaging in patients with risk factors for malignancy
- Underestimating mild hemoptysis, which may precede massive episodes
- Neglecting to follow up patients with recurrent hemoptysis even after initial negative workup
The diagnostic yield of the workup is significantly enhanced when combining multiple modalities. CT with IV contrast has largely replaced bronchoscopy as the initial diagnostic tool of choice after chest radiography, but both may be necessary in complex cases.