From the Guidelines
The workup for hemoptysis begins with a thorough history and physical examination to determine the severity and potential causes, followed by chest imaging with a chest X-ray and chest CT with contrast if necessary, as recommended by the American College of Radiology 1, 2, 3, 4, 5, 6, 7, 8. Initial evaluation should include vital signs, oxygen saturation, and assessment of respiratory distress. Laboratory tests should include:
- Complete blood count
- Coagulation studies
- Renal function tests
- Urinalysis Chest imaging is essential, starting with a chest X-ray, followed by chest CT with contrast if the X-ray is non-diagnostic or if bronchiectasis, malignancy, or vascular abnormalities are suspected. Bronchoscopy is indicated for moderate to severe hemoptysis, localization of bleeding, or when imaging fails to identify a cause. For massive hemoptysis (>100-200 mL in 24 hours), immediate stabilization and consideration for bronchial artery embolization or surgical intervention may be necessary, as supported by recent studies 3, 6, 7. Additional tests may include:
- Sputum studies for infection
- Autoimmune markers if vasculitis is suspected
- Echocardiography for cardiac causes The workup should be tailored to the clinical presentation, with consideration of common causes such as bronchitis, bronchiectasis, lung cancer, tuberculosis, and pulmonary embolism. Prompt evaluation is crucial as hemoptysis can indicate serious underlying pathology and may be life-threatening if massive, highlighting the importance of a thorough and timely workup 1, 2, 3, 4, 5, 6, 7, 8.
From the Research
Initial Evaluation
- The initial evaluation of hemoptysis includes determining the severity of bleeding and stability of the patient 9, 10.
- A history and physical examination can assist in identifying an etiology, but diagnostic testing is often required 9, 11.
- Chest radiography is a good initial test, but it has limited sensitivity for determining the site and etiology of the bleeding 9, 12, 13.
Diagnostic Testing
- Computed tomography (CT) and CT angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding 9, 12, 13, 10.
- Bronchoscopy may also be needed to determine the etiology of bleeding and to protect the airway 9, 12, 11, 10.
- Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray 12.
- MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding 12.
Management
- The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause 11.
- Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with dose monitoring 11.
- Bronchial arterial embolization is used to treat massive hemoptysis, particularly when an involved artery is noted on computed tomography angiography 9, 12, 10.
- Surgery is reserved for patients whose medical treatment and embolization are not effective 9, 12, 10.
- Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis 12.