What is the initial workup for a patient presenting with hemoptysis (cough with blood)?

Initial Workup for Hemoptysis

Begin with chest radiography (posteroanterior and lateral views) as the first-line imaging study, followed immediately by CT chest with IV contrast for all patients with frank hemoptysis, hemoptoic sputum, or risk factors for malignancy. 1, 2, 3

Immediate Assessment

Quantify the severity of bleeding to guide management urgency:

• Massive hemoptysis (life-threatening): ≥200 mL in 24 hours or any amount placing the patient at risk for asphyxiation—requires immediate airway protection and resuscitation 1, 2, 4
• Mild-to-moderate hemoptysis: >5 mL but not life-threatening—allows for systematic outpatient evaluation 1, 5
• Scant hemoptysis: <5 mL—typically managed conservatively unless first episode or persistent 1

The rate of bleeding correlates more closely with mortality than total volume. 1, 2 Two or more opacified lung quadrants on chest radiograph indicate increased mortality risk. 2, 4

Diagnostic Algorithm

Step 1: Chest Radiography (PA and Lateral)

Obtain chest X-ray as the initial imaging study in all patients. 1, 2, 5 This detects causative abnormalities in 35-86% of cases, though sensitivity is limited. 1, 2 A normal chest radiograph does not rule out malignancy—up to 16% of patients with endobronchial lung cancers have normal chest X-rays. 2

Step 2: CT Chest with IV Contrast

Proceed directly to CT chest with IV contrast (or CTA) for:

• All patients with frank hemoptysis or hemoptoic sputum 1, 2, 3
• Any patient with risk factors for lung cancer (age >40 years, smoking history) 1, 2, 6
• Abnormal or nonlocalizing chest radiograph 1, 2
• Persistent or recurrent hemoptysis even if initial chest X-ray was normal 2

CT with IV contrast is superior to chest radiography, identifying the etiology and location of bleeding in up to 91% of cases. 1, 2 Modern CT scanners can reconstruct high-resolution images, making separate HRCT protocols rarely necessary. 1, 2

Use CTA (rather than standard CT with contrast) if bronchial artery embolization is being considered, as it provides better vascular mapping for procedural planning. 1, 2 Patients who undergo BAE without contrast-enhanced imaging have significantly higher rates of emergent surgical resection (10% vs 4.5%). 2

Non-contrast CT should only be used in patients with severe renal dysfunction or life-threatening contrast allergy, recognizing its lower diagnostic yield. 2

Step 3: Bronchoscopy

Perform flexible bronchoscopy in:

• Patients with risk factors for lung cancer (smokers, age >40) even with normal chest X-ray 2, 6
• Persistent or recurrent hemoptysis after initial evaluation 2, 5
• When CT is non-diagnostic or shows suspicious findings 2, 3
• Massive hemoptysis requiring immediate airway clearance and localization 3, 7

The combined use of bronchoscopy and chest CT has the highest diagnostic yield (93%) for evaluating hemoptysis. 8 However, do not delay bronchial artery embolization to perform bronchoscopy in clinically unstable patients with massive hemoptysis—this wastes critical time and increases mortality. 9, 4

Additional Workup Considerations

Obtain complete blood count, coagulation studies (PT/INR, aPTT), and renal function tests to assess for bleeding diathesis and guide contrast administration. 5, 7

In high TB prevalence settings or high-risk patients (HIV-positive, incarcerated, close TB contacts), evaluate for pulmonary tuberculosis with sputum testing (Xpert MTB/RIF preferred over microscopy) even with short cough duration. 1 Consider chest X-ray in all TB suspects when resources allow. 1

Stop NSAIDs and anticoagulants immediately in patients with mild-to-moderate or massive hemoptysis, as these worsen bleeding. 1, 9

Common Pitfalls to Avoid

• Do not assume a normal chest X-ray excludes serious pathology—proceed to CT with contrast in patients with risk factors or persistent symptoms 2, 5
• Do not order HRCT as a separate study—modern CT protocols provide equivalent resolution when reformatted 1, 2
• Do not perform CT without IV contrast unless contraindicated—contrast significantly improves diagnostic accuracy and procedural planning 1, 2
• Do not delay definitive treatment (BAE) in massive hemoptysis to complete diagnostic workup—stabilization and hemorrhage control take priority 9, 4
• Do not dismiss scant hemoptysis in smokers with COPD—persistent blood-streaked sputum may indicate endobronchial tumor requiring evaluation 1

Most Common Etiologies by Population

In adults, the leading causes are:

• Bronchiectasis (20%) 8
• Lung cancer/malignancy (17-19%) 1, 5, 8
• Bronchitis (18%) 5, 8
• Pneumonia (16%) 5, 8
• No identifiable cause in 20-50% of cases 5, 6

In children, consider lower respiratory tract infection and foreign body aspiration as primary causes. 6