Next Investigation: Chest Radiograph Followed by CT Chest
A 50-year-old patient with chronic cough and hemoptysis requires an immediate chest radiograph as the initial investigation, followed by CT chest if the radiograph is abnormal or if risk factors for malignancy are present. 1, 2
Initial Imaging Approach
Chest radiography is the mandatory first-line test recommended by the American College of Chest Physicians (ACCP), American College of Radiology (ACR), and multiple pulmonary societies for evaluating chronic cough with hemoptysis 1, 2
The combination of chronic cough with hemoptysis in a 50-year-old represents a red flag that warrants urgent evaluation, particularly if the patient has smoking history or other risk factors for lung cancer 2
Chest X-ray should be obtained immediately when a patient with cough has risk factors for lung cancer or hemoptysis 1
When to Proceed to CT Imaging
If the chest radiograph shows any abnormality, proceed directly to high-resolution CT (HRCT) chest without delay. 1, 3
CT chest is indicated even with normal chest radiography in patients with hemoptysis and smoking history >45 years, as central airway tumors can be bronchoscopically visible but radiographically occult in 16% of cases 1
HRCT detects bronchiectasis and other pathology missed in 34-42% of cases with "normal" chest radiographs 3
The most common CT findings in chronic cough include bronchiectasis (28%) and bronchial wall thickening (21%) 2
Role of Bronchoscopy
Bronchoscopy is indicated when there is suspicion of airway involvement by malignancy, especially in smokers with hemoptysis, even when chest radiograph findings are normal. 1
For a smoker with both cough and hemoptysis that persist after antimicrobial treatment, bronchoscopy is indicated regardless of chest radiograph findings 1
Bronchoscopy should be considered for patients with localized disease on CT to rule out endobronchial lesion or foreign body 1
Studies show completely obstructing lung cancers in central airways were found in 44% of endobronchial lesions with no radiographic signs of obstruction 1
Additional Investigations to Consider
Send three separate sputum samples for acid-fast bacilli (AFB) smear and culture if tuberculosis is suspected based on clinical features or CT findings 3
Sputum cytology may provide definitive diagnosis of lung cancer, though bronchoscopy is usually needed 1
Baseline laboratory tests including complete blood count to assess for infection or systemic disease 3
Critical Pitfalls to Avoid
Do not rely solely on chest X-ray in a patient with hemoptysis - proceed to CT if clinical suspicion remains high despite normal radiograph 3
Do not assume consolidation equals simple pneumonia - persistent consolidation after appropriate antibiotics mandates bronchoscopy to exclude malignancy 3
Do not delay bronchoscopy in smokers with hemoptysis even with normal chest radiograph, as this combination has high pretest probability for malignancy 1
In adults, the major causes of hemoptysis include bronchitis, bronchogenic carcinoma, pneumonia, and bronchiectasis 4, 5