Haemoptysis

Population Covered By The Guidance

This pathway provides a diagnostic imaging algorithm for adult patients with confirmed haemoptysis.

Lead Researcher: Sian Chin

Experts & Contributors: Ravinder Dhillon, Mark Teh, Yuranga Weerakkody

Editorial Panel: Core Membership

Date reviewed: September 2018

Date Published: March 2019

Image 1 (Plain Radiograph): Pulmonary tuberculosis is an important cause of haemoptysis. This chest radiograph demonstrates patchy bilateral opacification of the upper lung lobes with cavitation most marked on the left (arrow) consistent with post-primary tuberculosis.

Post-Primary Pulmonary Tuberculosis

Image 2 (Plain Radiograph): There is widespread airspace opacification of both lungs with air brochograms. This patient had bilateral pulmonary haemorrhage due to Goodpasture's (Anti-GBM) syndrome.

Pulmonary Haemorrhage

Image 3a (Plain Radiograph) and 3b (Bronchial Angiogram): Image 3a demonstrates right apical consolidation with cavitation due to mycetoma formation on a background of tuberculosis (arrow). The bronchial artery was embolised with gel foam and coils due to recurrent haemoptysis (Image 3b).

Pulmonary Haemorrhage

Image 3a (Plain Radiograph) and 3b (Bronchial Angiogram): Image 3a demonstrates right apical consolidation with cavitation due to mycetoma formation on a background of tuberculosis (arrow). The bronchial artery was embolised with gel foam and coils due to recurrent haemoptysis (Image 3b).

Pulmonary Haemorrhage

  • A chest radiograph (CXR) may reveal a cause of haemoptysis. Abnormalities may require further evaluation on CT
    • If CXR and/or clinical picture are consistent with infection, consider treating for infection first and then pursuing further imaging if haemoptysis is persistent
  • CT of the chest is indicated in patients with persistent/recurrent haemoptysis, moderate volume haemoptysis more than 30mL or in patients with risk factors for lung malignancy such as more than 30 pack-year smoking history or age over 40
  • Further investigations are dictated by CT findings. This may include a bronchoscopy if a neoplastic lesion is seen
  • If no cause is identified after bronchoscopy and CT, the risk of malignancy is low. There are no recommendations for what imaging or bronchoscopy surveillance should be undertaken in this time, if at all
  • Massive haemoptysis refers to when the volume of blood is life threatening by virtue of airway obstruction, hypotension or blood loss and is a medical emergency. There is no universally accepted definition and volume thresholds range from 100mL to more than 1000mL of haemoptysis in 24h
    • Depending on whether the patient is haemodynamically stable, diagnostic tests (e.g. CT scan) may be undertaken
    • If the airway is not secure, bronchoscopy is preferred initially, as it affords therapeutic intervention at the same time and can allow the airway to be secured. When the patient is sufficiently stable, CTA can be undertaken to plan for embolisation or to localise the source if not already identified

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

  1. Ketai LH, Mohammed TL, Kirsch J, Kanne JP, Chung JH, Donnelly EF, et al. ACR appropriateness criteria(R) hemoptysis. J Thorac Imaging. 2014;29(3):W19-22. (Guidelines). View the reference
  2. Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest. 1997;112(2):440-4. (Level II-III evidence). View the reference
  3. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000;28(5):1642-7. (Review article). View the reference
  4. Earwood JS, Thompson TD. Hemoptysis: evaluation and management. Am Fam Physician. 2015;91(4):243-9. (Review article). View the reference
  5. Haro M, Jimenez J, Tornero A, Vizcaya M, Tirado R, Cros T. Usefulness of computerized tomography and bronchoscopy in patients with hemoptysis. Analysis of 482 cases. An Med Interna. 2002;19(2):59-65. (Level II evidence). View the reference
  6. Tsoumakidou M, Chrysofakis G, Tsiligianni I, Maltezakis G, Siafakas NM, Tzanakis N. A prospective analysis of 184 hemoptysis cases: diagnostic impact of chest X-ray, computed tomography, bronchoscopy. Respiration. 2006;73(6):808-14. (Level III evidence). View the reference
  7. Davoodi M, Kordi M, Gharibvand MM, Shoushtari MH, Borsi H, Bahadoram M. Hemoptysis: comparison of diagnostic accuracy of multi detector CT scan and bronchoscopy. Global Journal of Health Science. 2015;7(3):373-7. (Level II-III evidence). View the reference
  8. Bonlokke S, Guldbrandt LM, Rasmussen TR. Bronchoscopy in patients with haemoptysis and normal computed tomography of the chest is unlikely to result in significant findings. Danish medical journal. 2015;62(8):A5123. (Level II-III evidence). View the reference
  9. Nielsen K, Gottlieb M, Colella S, Saghir Z, Larsen KR, Clementsen PF. Bronchoscopy as a supplement to computed tomography in patients with haemoptysis may be unnecessary. European Clinical Respiratory Journal. 2016;3:10.3402/ecrj.v3.31802. (Level II evidence). View the reference
  10. Menchini L, Remy-Jardin M, Faivre JB, Copin MC, Ramon P, Matran R, et al. Cryptogenic haemoptysis in smokers: angiography and results of embolisation in 35 patients. Eur Respir J. 2009;34(5):1031-9. (Level II-III evidence). View the reference
  11. Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin. Chest. 2001;120(5):1592-4. (Level II evidence). View the reference
  12. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. Journal of Thoracic Disease. 2017;9(Suppl 10):S1069-S86. (Review article). View the reference
  13. Yendamuri S. Massive airway hemorrhage. Thorac Surg Clin. 2015;25(3):255-60. (Review article). View the reference
  14. Revel MP, Fournier LS, Hennebicque AS, Cuenod CA, Meyer G, Reynaud P, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol. 2002;179(5):1217-24. (Level II evidence). View the reference
  15. Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB. Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. AJR Am J Roentgenol. 2001;177(4):861-7. (Level III evidence). View the reference
  16. Torbiarczyk JM, Sobczak PA, Torbiarczyk KK, Milkowska-Dymanowska J, Antczak A, Gorski P, et al. Torbiarczyk JM, Sobczak PA, Torbiarczyk KK, Milkowska-Dymanowska J, Antczak A, Gorski P, et al. Advances in respiratory medicine. 2018;86(1):13-6. (Level III evidence). View the reference
  17. McGuinness G, Beacher JR, Harkin TJ, Garay SM, Rom WN, Naidich DP. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest. 1994;105(4):1155-62. (Level II-III evidence). View the reference
  18. Khalil A, Fartoukh M, Parrot A, Bazelly B, Marsault C, Carette MF. Impact of MDCT angiography on the management of patients with hemoptysis. AJR Am J Roentgenol. 2010;195(3):772-8. (Level II-III evidence). View the reference
  19. Zhao T, Wang S, Zheng L, Jia Z, Yang Y, Wang W, et al. The value of 320-row multidetector CT bronchial arteriography in recurrent hemoptysis after failed transcatheter arterial embolization. J Vasc Interv Radiol. 2017;28(4):533-41.e1. (Level III evidence). View the reference
  20. Yoon YC, Lee KS, Jeong YJ, Shin SW, Chung MJ, Kwon OJ. Hemoptysis: bronchial and nonbronchial systemic arteries at 16-detector row CT. Radiology. 2005;234(1):292-8. (Level III evidence). View the reference
  21. Remy-Jardin M, Bouaziz N, Dumont P, Brillet PY, Bruzzi J, Remy J. Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography. Radiology. 2004;233(3):741-9. (Level II-III evidence). View the reference

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