What are the appropriate steps for a patient coughing up blood, considering potential underlying conditions like respiratory infections or lung cancer, and a history of smoking?

Management of Hemoptysis (Coughing Up Blood)

Any patient coughing up blood requires immediate chest radiography and specialist referral for bronchoscopy, particularly when there is significant hemoptysis or risk factors for lung cancer such as smoking history. 1, 2

Immediate Assessment Priorities

Determine Hemodynamic Stability First

• Assess vital signs, oxygen saturation, and work of breathing to determine if urgent airway intervention is needed before diagnostic workup 2, 3
• Quantify the volume and rate of bleeding—the rate correlates more closely with mortality than total volume 2
• Massive hemoptysis (any amount compromising respiratory status) is a medical emergency requiring immediate airway protection 4

Critical History Elements in Smokers

• Calculate pack-years precisely, as smoking causes 90% of primary lung cancers and heavy smokers with new hemoptysis warrant immediate cancer evaluation 1, 2
• Document new onset cough or change in characteristics of preexisting cough, which strongly suggests malignancy 1, 2
• Ask about constitutional symptoms (weight loss, night sweats, fatigue) indicating possible advanced cancer 2
• Assess for occupational exposures (asbestos, radon) and family history of lung cancer, which are independent risk factors 1, 2

Mandatory Initial Diagnostic Testing

Chest Radiography Is Required

• Obtain PA and lateral chest X-ray as the mandatory first imaging study when hemoptysis occurs with lung cancer risk factors 2, 3
• However, normal chest radiograph findings do not exclude cancer—central airway tumors may not be visible on plain films 1, 2
• Abnormalities typical for neoplasm should place cancer at the top of the differential diagnosis 1

CT Chest with IV Contrast Is Preferred

• CT chest with IV contrast is the preferred initial diagnostic test for clinically stable patients, with 80-90% diagnostic accuracy 2, 3
• CT is superior to bronchoscopy for identifying the etiology and anatomic site of bleeding 2
• CT angiography has become standard of care if bronchial artery embolization is being considered 2

Bronchoscopy Indications

• Specialist referral for bronchoscopy is mandatory with significant hemoptysis or possible lung cancer 1
• Bronchoscopy should be performed even with normal chest radiograph when there is suspicion of airway malignancy 1, 2
• For clinically stable patients, bronchoscopy provides 70-80% diagnostic yield for identifying the bleeding source 2
• For unstable patients with massive hemoptysis, proceed directly to bronchial artery embolization without bronchoscopy 2

Risk Stratification for Lung Cancer

High-Risk Features Requiring Urgent Evaluation

• Heavy cigarette smoking (>50 pack-years) with new hemoptysis 2, 5
• Age >60 years with any smoking history and hemoptysis 2
• COPD, which independently increases lung cancer risk 1, 2
• Dyspnea accompanying cough, particularly suggesting intraluminal tumor in trachea or mainstem bronchi 1, 2

Common Pitfalls to Avoid

• Do not assume respiratory infection explains hemoptysis in a smoker—lung cancer must be excluded first 1, 2
• Do not delay imaging because physical examination is normal—a 60-year-old smoker with hemoptysis requires immediate chest imaging regardless 2
• Centrally located tumors (squamous cell, small cell) are more likely to cause hemoptysis and may not appear on chest X-ray 2

Immediate Management Steps

Supportive Care

• Stop NSAIDs immediately as they impair platelet function and worsen bleeding 2
• Ensure adequate oxygenation and hemodynamic support 3
• Position patient with bleeding side down if laterality is known 3

Treatment Based on Severity

• Mild hemoptysis (>90% of cases) has good prognosis but requires diagnostic workup to identify underlying cause 3
• Massive hemoptysis requires bronchial arterial embolization, particularly when involved artery is identified on CT angiography 2, 3
• Surgery is reserved for patients whose medical treatment and embolization fail 3

Additional Diagnostic Considerations

Alternative Causes in Non-Smokers

• Acute respiratory infections, bronchiectasis, and tuberculosis (if endemic area) are common causes 3
• No cause is identified in 20-50% of cases, but cancer must still be excluded 3
• Confirm true hemoptysis versus pseudohemoptysis from nasopharyngeal or gastrointestinal sources 3

Follow-Up

• Treatment of underlying etiology is essential because recurrence often occurs without addressing the identified cause 3
• Even if initial workup is negative, continued surveillance is warranted in high-risk patients 1