What is the diagnostic approach for a patient presenting with haemoptysis (coughing up blood), considering their age, medical history, and clinical presentation?

Diagnostic Approach for Hemoptysis

Initial Severity Assessment and Stabilization

For patients presenting with hemoptysis, immediately classify the bleeding as massive (life-threatening) or non-massive, as this determines the entire diagnostic and management pathway. 1

Massive Hemoptysis (Life-Threatening)

• Defined as hemoptysis placing the patient at high risk for asphyxiation or exsanguination, typically >100-200 mL in 24 hours 1, 2
• Immediate priorities are airway protection, resuscitation, and bronchoscopy for clot clearance and bleeding site tamponade 1, 2
• Obtain portable chest radiograph to assess extent of blood aspiration—two or more opacified lung quadrants correlate with increased mortality risk 1, 2
• Morbidity and mortality correlate more with the rate of bleeding than total volume 1, 2

Non-Massive Hemoptysis

• Comprises >90% of cases with generally good prognosis 3
• Can be evaluated in a more systematic, stepwise manner 3
• Patients with mild-to-moderate hemoptysis (>5 mL) should contact their healthcare provider 1

Imaging Algorithm

Step 1: Chest Radiography

Obtain chest radiograph as the initial imaging study for all hemoptysis patients 2, 3

• Detects causative abnormalities in only 35-86% of cases, with some studies showing as low as 35% diagnostic yield 2
• A normal chest radiograph does NOT rule out significant pathology, including malignancy (up to 16% of endobronchial lung cancers have normal chest X-rays) 2
• Despite limited sensitivity, chest radiography remains appropriate for initial assessment and can guide subsequent testing 1, 2

Step 2: CT Chest with IV Contrast

CT chest with IV contrast is the primary diagnostic modality for determining hemoptysis etiology and should be performed in all patients with frank hemoptysis, hemoptoic sputum, or risk factors for lung cancer 1, 2

Key advantages:

• Accurately localizes bleeding site in up to 91% of cases 2
• Superior to bronchoscopy and arteriography for identifying the cause of hemoptysis 1
• Identifies malignancies not visible on chest radiograph 2
• Provides critical vascular mapping if bronchial artery embolization becomes necessary 2
• Modern CT scanners can reconstruct high-resolution images from routine contrast studies, eliminating need for separate HRCT protocols 2

Important nuances:

• CT without IV contrast is ONLY warranted in patients with poor renal function or life-threatening contrast allergy 1, 2
• Patients who undergo CT without contrast before bronchial artery embolization have worse outcomes, with higher rates of emergent surgical resection (10% vs 4.5%) 2
• There is NO added value to performing both non-contrast and contrast-enhanced acquisitions in the same study 1

Step 3: CTA Chest (When Intervention Anticipated)

Consider CTA chest instead of standard CT with contrast if bronchial artery embolization may be needed 2

• CTA has effectively replaced conventional aortography for arterial mapping prior to embolization 1, 2
• Provides superior vascular mapping for procedural planning 2
• Particularly important in patients with massive hemoptysis or recurrent bleeding 1

Bronchoscopy Indications

Flexible bronchoscopy plays a pivotal role but timing depends on clinical scenario 4

Immediate bronchoscopy indicated for:

• Massive hemoptysis requiring airway clearance and bleeding control 1, 2, 4
• Hemodynamically unstable patients where control of bleeding is vital 4

Elective bronchoscopy indicated for:

• Risk factors for lung cancer (smokers, age >40) even with normal chest radiograph 2
• Persistent or recurrent hemoptysis after initial evaluation 2
• CT findings suspicious for malignancy 3, 4
• Hemoptoic sputum or frank hemoptysis requiring tissue diagnosis 4

Important caveat: CT with IV contrast is superior to bronchoscopy for identifying the etiology of hemoptysis (77% vs 8% in massive hemoptysis) 1

Age and Risk Factor Considerations

Pediatric patients:

• Most common causes are lower respiratory tract infections and foreign body aspiration 5

Adult patients:

• Primary care setting: Acute respiratory infections, chronic obstructive pulmonary disease, malignancy, and bronchiectasis 1, 5
• Tertiary referral centers (North America/Europe): Bronchiectasis, respiratory infections, and lung carcinomas 1
• Endemic regions: Tuberculosis and its sequelae remain the most prevalent cause 1, 4

High-risk populations requiring aggressive workup:

• Smokers with hemoptysis (higher diagnostic yield on bronchoscopy) 2
• Age >40 years 2
• History of malignancy 3
• Chronic lung disease (bronchiectasis, COPD) 1

Common Causes by Frequency

The most common etiologies vary by clinical setting but include: 1

• Bronchiectasis (34% in some series) 1
• Acute respiratory infections/bronchitis 1, 5
• Lung malignancy 1
• Tuberculosis (in endemic areas) 1
• Nontuberculous mycobacterium (24% in some series) 1

Cryptogenic hemoptysis (no identifiable cause despite thorough investigation) accounts for approximately 20% of cases 1

Critical Pitfalls to Avoid

• Do not rely on chest radiography alone—it misses the bleeding source in 54-65% of cases and fails to detect important vascular abnormalities 2
• Do not skip IV contrast in CT imaging unless absolutely contraindicated—non-contrast CT significantly reduces diagnostic yield and worsens outcomes if embolization is needed 2
• Do not dismiss non-massive hemoptysis as benign—it may be the harbinger of future massive hemoptysis, especially in patients with underlying lung disease 1
• Do not assume normal chest X-ray excludes malignancy—up to 16% of endobronchial cancers have normal radiographs 2
• Do not delay bronchoscopy in massive hemoptysis—airway protection takes priority over imaging 1, 2, 4

Practical Clinical Algorithm

1. Classify severity: Massive vs non-massive hemoptysis 1, 2
2. Massive hemoptysis: Immediate stabilization → bronchoscopy → portable chest X-ray → CT with IV contrast or CTA → bronchial artery embolization if needed 1, 2
3. Non-massive hemoptysis: Chest radiograph → CT chest with IV contrast → bronchoscopy if risk factors for malignancy or persistent bleeding 1, 2, 3
4. Consider CTA instead of standard CT if intervention likely 2
5. Recurrent or persistent hemoptysis warrants repeat evaluation even if initial workup was negative 2, 3