What is the next step in managing a patient with hemoptysis (coughing up blood) and a normal upper gastrointestinal (GI) endoscopy?

Management of Hemoptysis with Normal Upper GI Endoscopy

The next step is to perform chest imaging with CT angiography (CTA) of the chest to identify the source and cause of bleeding from the lower respiratory tract, followed by bronchoscopy if needed for diagnosis and potential therapeutic intervention. 1, 2

Confirming True Hemoptysis vs. Pseudohemoptysis

Since upper GI endoscopy is normal, this effectively rules out an upper gastrointestinal source of bleeding. 3 The key now is to confirm true hemoptysis (blood from the tracheobronchial tree) rather than pseudohemoptysis from nasopharyngeal sources, which should be clinically apparent. 4

Initial Diagnostic Approach

Chest Radiography

• Obtain lateral and AP chest X-ray as the initial imaging study, though a normal chest X-ray does not rule out malignancy or other underlying pathology. 2
• Chest radiography has limited sensitivity for determining the site and etiology of bleeding but serves as a reasonable first step. 4

CT Angiography of the Chest

• Perform multidetector CT (MDCT) angiography of the chest with intravenous contrast in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis, risk factors for lung cancer, or signs of pathology on chest X-ray. 2, 4
• MDCT angiography is the preferred modality to determine the etiology of bleeding and can identify the presence, origin, number, and course of systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources. 2
• This non-invasive technique has replaced conventional arteriography for identifying bleeding arteries. 2

Bronchoscopy

• Flexible bronchoscopy plays a pivotal role in diagnosis and can be performed rapidly, even at the bedside. 2
• Bronchoscopy is effective in locating the source of hemorrhage and can provide immediate control of bleeding at bronchoscopically accessible sites. 1, 2
• This procedure is particularly important when CT findings are inconclusive or when tissue diagnosis is needed. 4

Severity Assessment and Management Strategy

Mild Hemoptysis (>90% of cases)

• Self-limited in 90% of cases with good prognosis. 4
• Proceed with diagnostic workup as outlined above to identify underlying cause. 4
• Treatment should target the underlying etiology to prevent recurrence. 4

Massive Hemoptysis (life-threatening)

• Ensure adequate oxygenation through oxygen administration, positioning patient with bleeding side down (if known), and temporary intubation if necessary. 1
• In hemodynamically unstable patients, flexible bronchoscopy is the first-line procedure for immediate bleeding control. 2
• Bronchial arterial embolization is the first-line treatment for hemorrhage from the pulmonary periphery, providing successful hemostasis in 75-98% of cases. 1, 5
• Embolization is indicated in all patients with life-threatening or recurrent hemoptysis when MDCT angiography shows arterial disease. 2

Common Etiologies to Consider

The most common causes include:

• Infectious and inflammatory airway diseases (25.8%). 1
• Cancer (17.4%). 1
• Bronchiectasis. 2, 4
• Chronic obstructive pulmonary disease. 4
• The cause remains unknown in 20-50% of cases despite thorough evaluation. 1, 4

Surgical Intervention

Surgery is reserved for specific indications:

• Failed bronchial artery embolization. 1
• Traumatic or iatrogenic pulmonary/vascular injury. 1
• Refractory aspergilloma. 1
• Surgery in hemodynamically unstable patients with life-threatening hemoptysis carries extremely high mortality and should be avoided when possible. 2

Key Pitfalls to Avoid

• Do not assume the bleeding is from the GI tract simply because blood is being expectorated; the normal upper GI endoscopy confirms this is respiratory in origin. 3
• Do not delay CT angiography in favor of chest X-ray alone, as chest X-ray has limited sensitivity. 2, 4
• Do not proceed directly to surgery in unstable patients; bronchial artery embolization should be attempted first. 1, 2