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

Initial Workup for Hemoptysis

The initial workup for hemoptysis must immediately prioritize severity assessment and airway protection, followed by CT chest with IV contrast for stable patients or direct bronchial artery embolization for unstable patients with massive bleeding. 1

Immediate Assessment and Stabilization

Determine hemoptysis severity first, as this dictates the entire diagnostic and therapeutic pathway. Massive hemoptysis is defined as ≥200 mL in 24 hours or any amount causing respiratory compromise, with the rate of bleeding more closely associated with mortality than total volume. 1

For Massive/Life-Threatening Hemoptysis (Unstable Patients):

• Intubate immediately with a single-lumen cuffed endotracheal tube to allow bronchoscopic suctioning and clot removal. 1, 2
• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation and potential transfusion. 1, 2
• Administer high-flow oxygen to maintain adequate oxygenation. 1, 2
• Proceed directly to bronchial artery embolization (BAE) without delay—do not waste time on bronchoscopy or additional diagnostic procedures in unstable patients, as delaying BAE significantly increases mortality. 1, 3, 2
• BAE achieves immediate hemostasis in 73-99% of cases and is now first-line therapy for massive hemoptysis. 1, 2

Initial Laboratory Studies:

• Obtain complete blood count, PT/aPTT, fibrinogen (Clauss method, not derived), and type and cross-match. 1
• Stop all anticoagulants and NSAIDs immediately, as they worsen bleeding. 3
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy. 1

Diagnostic Imaging for Stable Patients

CT Chest with IV Contrast (Preferred Initial Test):

For clinically stable patients, CT chest with IV contrast is the preferred initial diagnostic test to identify the cause and location of bleeding. 4, 1, 3, 2

• CT demonstrates 77% diagnostic accuracy compared to only 8% for bronchoscopy in identifying the etiology of hemoptysis. 4, 3
• CT is superior to chest radiography—in patients with normal chest radiographs, subsequent CT provides a definitive cause in 39% of cases. 4
• CT angiography (CTA) has become the standard of care for arterial planning if BAE is being considered. 1
• CT identifies both the bleeding source and underlying pathology, particularly malignancy, which is a major cause in developed countries. 2

Chest Radiograph:

• A chest radiograph is reasonable as an initial choice when confirming benign causes like acute bronchitis or pneumonia. 1
• However, chest radiography has limited sensitivity and suggests the etiology in only 26% of cases. 1
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk. 1

Bronchoscopy

Timing and Indications:

• For stable patients with mild-to-moderate hemoptysis, perform bronchoscopy to identify the source of bleeding and obtain tissue diagnosis. 1
• Bronchoscopy provides valuable information on the anatomic site and side of bleeding. 1
• Do NOT perform bronchoscopy before BAE in unstable patients—this wastes valuable time and is not recommended. 1, 3

Bronchoscopic Interventions for Visible Central Airway Lesions:

• Tamponade with iced saline instillation and bronchial blockade balloons. 1
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh arrests hemoptysis in 98% of cases. 1
• Thermal ablation using argon plasma coagulation, Nd:YAG laser, or electrocautery for visible lesions, achieving 80-90% success rates. 1

Common Etiologies to Consider

The most common causes vary by geographic region and patient demographics:

• Bronchiectasis is the most common cause in many series. 1
• Lung cancer is a major cause in developed countries, particularly in patients >40 years old with >40 pack-year smoking history. 4, 2
• Active or sequelae from tuberculosis is common in endemic areas. 4
• Infectious and inflammatory airway diseases account for 25.8% of cases. 5

High-Risk Features for Malignancy:

• Heavy cigarette smokers with new onset cough or change in chronic cough characteristics. 4
• Hemoptysis with streaks of blood in a smoker. 4
• Age >40 years with >40 pack-year smoking history. 6
• Exposure to asbestos, radon, or other carcinogens. 4

Critical Pitfalls to Avoid

• Never delay BAE for bronchoscopy in unstable patients—this significantly increases mortality. 1, 3, 2
• Avoid BiPAP in massive hemoptysis, as positive pressure can worsen bleeding. 1
• Stop all airway clearance therapies immediately to allow clot formation. 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity. 1
• Do not use derived fibrinogen levels—they are misleading; use Clauss fibrinogen instead. 1
• Never delay airway protection in favor of diagnostic procedures when the patient has respiratory distress. 1

Follow-Up Considerations

• Recurrence of bleeding occurs in 10-55% of cases after BAE, requiring close follow-up. 1, 3
• Recurrence within 3 months is often due to incomplete embolization; after 3 months, it's typically due to vascular collateralization or recanalization. 1
• Repeat BAE shows no increased risk of morbidity or mortality for recurrent hemoptysis. 1
• For aspergillomas causing hemoptysis, definitive surgical treatment following initial BAE is recommended due to 55% recurrence rates. 1