What is the workup for hemoptysis?

Workup for Hemoptysis

Immediate Severity Assessment and Stabilization

The initial workup for hemoptysis must begin with rapid severity classification and simultaneous hemodynamic stabilization, as the rate of bleeding—not total volume—determines mortality risk. 1

Severity Classification

Classify hemoptysis by volume to guide subsequent management: 1, 2

• Scant: <5 mL/24 hours
• Mild-to-moderate: 5-240 mL/24 hours
• Massive: >240 mL/24 hours OR any amount causing respiratory compromise or risk of asphyxiation/exsanguination

Critical point: The rate of bleeding correlates more closely with morbidity and mortality than absolute volume. 1 Massive hemoptysis carries 59-100% mortality if untreated. 1

Initial Stabilization (All Patients with ≥5 mL)

For any hemoptysis ≥5 mL, immediately: 1, 2

• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation 1
• Obtain baseline labs: complete blood count, PT/aPTT, Clauss fibrinogen (not derived), type and cross-match 1
• Actively warm patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1
• Stop all NSAIDs immediately (impair platelet function) 1, 2
• Hold anticoagulants during active bleeding 2
• Initiate empiric antibiotics (bleeding often represents pulmonary infection or exacerbation) 1, 2

Airway Management for Massive Hemoptysis

For massive hemoptysis with respiratory compromise, intubate immediately with a single-lumen cuffed endotracheal tube—never use double-lumen tubes or BiPAP. 1, 2

• Single-lumen tubes allow bronchoscopic suctioning and rapid clot removal (blood clot obstruction is the most common cause of respiratory insufficiency) 3, 1
• Consider selective right or left mainstem intubation to protect the non-bleeding lung if the bleeding side is identified 1, 2
• Avoid BiPAP entirely—positive pressure worsens bleeding 1, 2
• Stop all airway clearance therapies immediately to allow clot formation 1

Chest Radiograph

Obtain a chest radiograph to: 1

• Assess number of opacified lung quadrants (≥2 quadrants indicates increased mortality risk)
• Verify endotracheal tube placement

Diagnostic Pathway Based on Clinical Stability

For Clinically UNSTABLE Patients with Massive Hemoptysis

Proceed directly to bronchial artery embolization (BAE) without bronchoscopy or CT imaging—delays significantly increase mortality. 1, 2

• BAE achieves immediate hemostasis in 73-99% of cases 1, 2
• Over 90% of massive hemoptysis originates from bronchial arteries 1, 2
• Bronchoscopy in unstable patients is performed only for airway clearance and tamponade, not diagnosis 1
• Do NOT delay BAE for diagnostic procedures when the patient is hemodynamically unstable 1

For Clinically STABLE Patients

CT chest with IV contrast (or CTA) is the preferred initial diagnostic test, superior to bronchoscopy for identifying cause and location. 1, 2

CT Imaging Advantages: 1, 2

• 77% diagnostic accuracy for determining etiology
• CTA provides superior vessel opacification
• Detects aberrant bronchial arteries in 36% of cases
• Identifies pulmonary artery pseudoaneurysms missed on conventional arteriography
• Essential for arterial mapping before BAE

Bronchoscopy in Stable Patients: 1, 2

Perform bronchoscopy after CT imaging to: 1, 2

• Identify anatomic site and side of bleeding (70-80% diagnostic yield)
• Assess nature of bleeding source, severity, and therapeutic feasibility
• Provide therapeutic interventions for visible central airway lesions

Bronchoscopic therapeutic options include: 1, 2

• Tamponade by wedging bronchoscope tip into bleeding bronchus
• Iced saline instillation to constrict blood vessels
• Bronchial blockade balloons (may need to remain 24-48 hours)
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate) 3, 1
• Thermal ablation: argon plasma coagulation, Nd:YAG laser, or electrocautery for visible lesions 3, 1

Management Algorithm by Severity

Scant Hemoptysis (<5 mL/24h)

• Outpatient management acceptable if not first episode and not persistent 1
• Stop NSAIDs 1
• Contact healthcare provider if first episode or persistent 1
• Antibiotics NOT routinely indicated unless clinical features suggest infection 1

Mild-to-Moderate Hemoptysis (5-240 mL/24h)

All patients require hospital admission for monitoring and treatment. 1, 2

• Initiate empiric antibiotics immediately 1, 2
• Stop NSAIDs and hold anticoagulants 1, 2
• Perform bronchoscopy to identify bleeding source 2
• CT chest with IV contrast for etiology determination 2
• Consider tranexamic acid as adjunct 2

Massive Hemoptysis (>240 mL/24h or Respiratory Compromise)

Immediate ICU admission with direct progression to BAE for unstable patients. 1, 2

1. Airway protection: Single-lumen intubation 1, 2
2. Resuscitation: Large-bore IV access, volume replacement, correct coagulopathy 1
3. Definitive therapy: BAE without delay (73-99% immediate success) 1, 2
4. ICU monitoring: Coagulation parameters, hemoglobin, blood gases, ongoing bleeding 2
5. Venous thromboprophylaxis: Start as soon as bleeding controlled 1

Management of Recurrent Hemoptysis

Repeat BAE is the primary therapeutic option for recurrent bleeding, with no increased morbidity or mortality risk. 1, 2

• Recurrence occurs in 10-55% of cases after initial BAE 1
• Higher recurrence rates with: chronic pulmonary aspergillomas (55%), malignancy, sarcoidosis 1
• Recurrence within 3 months: usually incomplete/missed embolization 1
• Recurrence after 3 months: vascular collateralization or recanalization 1
• Perform CT angiography before repeat BAE for arterial mapping 1

Surgical Considerations

Surgery is reserved as a final therapeutic option when BAE fails or for surgically resectable tumors in stable patients. 2

Surgical indications: 2

• BAE unsuccessful in controlling bleeding
• Surgically resectable tumors in stable patients (50-70% survival rates) 1
• Aspergillomas causing recurrent hemoptysis after initial BAE 1

Caution: Surgery for massive hemoptysis carries 16% mortality, associated with blood aspiration into contralateral lung and pneumonectomy. 1

Radiation Therapy for Malignancy

For unresectable lung cancer with hemoptysis: 3, 2

• External beam radiation therapy (EBRT) provides palliation in ~60% of patients
• Hemoptysis is the best-palliated symptom (81-86% relief rates)
• Combined high-dose rate brachytherapy with EBRT provides superior symptom relief versus EBRT alone
• BAE for malignancy is typically palliative or temporizing before definitive surgery 1

Common Etiologies to Consider

The most common causes vary by setting: 1

• Outpatient/primary care: Acute respiratory tract infections, COPD, malignancy, bronchiectasis
• Tertiary centers (North America/Europe): Bronchiectasis (most common), respiratory infections, lung carcinomas
• Developing countries: Tuberculosis and its sequelae
• Other notable causes: Sarcoidosis, autoimmune capillaritis, coagulopathies, pulmonary arteriovenous malformations, pulmonary pseudoaneurysms
• Cryptogenic: ~20% of cases despite extensive workup

Critical Pitfalls to Avoid

• Never delay airway protection for diagnostic procedures in patients with respiratory distress 1
• Never use BiPAP in massive hemoptysis—positive pressure worsens bleeding 1, 2
• Never delay BAE for CT or bronchoscopy in unstable patients—significantly increases mortality 1
• Do not rely on single hematocrit measurements as isolated marker for bleeding severity 1
• Do not use derived fibrinogen levels—they are misleading; use Clauss fibrinogen 1
• Never continue NSAIDs or anticoagulants during active hemoptysis 1, 2