From the Guidelines
For acute hemoptysis, the recommended initial diagnostic tests include a chest X-ray and computed tomography (CT) of the chest with contrast, as these tests can help identify potential causes and locate the bleeding source, according to the American College of Radiology Appropriateness Criteria 1. The diagnostic approach should be tailored to the severity of bleeding, patient's clinical status, and suspected underlying cause.
- A chest X-ray is the initial imaging study to identify potential causes such as pneumonia, tuberculosis, or lung cancer.
- Computed tomography (CT) of the chest, preferably with contrast, provides detailed imaging of the lungs and vasculature to locate the bleeding source.
- Bronchoscopy may be necessary for direct visualization of the airways and to localize the bleeding site, especially in moderate to severe cases.
- In selected cases, CT angiography or pulmonary angiography might be needed to identify vascular abnormalities.
- Complete blood count and coagulation studies (PT, PTT, INR) are important to rule out bleeding disorders or anemia.
- Sputum analysis including culture, cytology, and AFB testing helps identify infectious causes or malignancy. These tests are essential because hemoptysis can result from various conditions ranging from benign to life-threatening, including bronchitis, pneumonia, tuberculosis, lung cancer, pulmonary embolism, or bronchiectasis, as supported by recent studies 1. In cases of massive hemoptysis, bronchial artery embolization may be considered as a treatment option, in addition to supportive care and stabilization of the patient 1.
From the Research
Diagnostic Tests for Acute Hemoptysis
The following tests are commonly ordered for acute hemoptysis:
- Chest radiograph: recommended as the initial diagnostic test for hemodynamically stable patients with hemoptysis 2, 3, 4, 5, 6
- Computed tomography (CT) scan: recommended for patients with massive hemoptysis, those with abnormal radiographic findings, and those with risk factors for malignancy despite normal radiographic findings 2, 3, 4, 6
- Bronchoscopy: recommended for patients with massive hemoptysis, those with abnormal radiographic findings, and those with risk factors for malignancy despite normal radiographic findings 2, 3, 4, 5, 6
- Contrast-enhanced multidetector CT: recommended before embolization or surgery to define the source of hemoptysis 2
- Computed tomography angiography of the chest with intravenous contrast: recommended to determine the etiology of bleeding 4
Indications for Each Test
- Chest radiograph: initial evaluation of patients with hemoptysis, especially those who are hemodynamically stable 2, 3, 4, 5, 6
- CT scan: patients with massive hemoptysis, those with abnormal radiographic findings, and those with risk factors for malignancy despite normal radiographic findings 2, 3, 4, 6
- Bronchoscopy: patients with massive hemoptysis, those with abnormal radiographic findings, and those with risk factors for malignancy despite normal radiographic findings 2, 3, 4, 5, 6
- Contrast-enhanced multidetector CT: patients with massive hemoptysis who require embolization or surgery 2
- Computed tomography angiography of the chest with intravenous contrast: patients with hemoptysis who require determination of the etiology of bleeding 4
Special Considerations
- Patients at high risk for malignancy (>40 y old, >40 pack-year smoking history) with negative chest radiograph, CT scan, and bronchoscopy can be followed with observation for the following 3 years 2
- Massive hemoptysis can be effectively treated with either surgery or percutaneous embolization 2, 3, 4
- Bronchial arterial embolization is the first line of treatment for hemorrhage from the pulmonary periphery 3, 4