Haemoptysis in adults

Probability diagnosis

Acute chest infection:

• URTI (24%)

• bronchitis

Chronic bronchitis

Trauma: chest contusion, prolonged coughing

Cause often unknown (22%)

Serious disorders not to be missed

Vascular:

• pulmonary infarction/embolus

• LHF / pulmonary oedema

• mitral stenosis

Infection:

• lobar pneumonia (rusty sputum)

• tuberculosis

• lung abscess

Cancer/tumour (4%):

• bronchogenic carcinoma

• tumour of the larynx or trachea

Other:

• blood disorders including anticoagulants

Pitfalls (often missed)

Foreign body

Bronchiectasis (13%)

Iatrogenic (e.g. endotracheal intubation)

Spurious haemoptysis (blood from nose or throat)

Rarities:

• idiopathic pulmonary haemosiderosis

• pulmonary AV malformation

• Goodpasture syndrome

• connective tissue disorder

Key history

Presenting symptom clarification—is it haemoptysis, haematemesis or bleeding from the nose or throat? General symptoms (e.g. weight loss, fever, pain, esp. pleuritic pain). Respiratory and cardiac history including past history and exposure to TB (e.g. refugees). Drug history especially smoking, alcohol, anticoagulation.

Key examination

• General appearance and vital signs

• Full respiratory and cardiovascular examination including upper airways and mouth

• Check legs for evidence of deep venous thrombosis

Key investigations

• Chest X-ray

• FBE

• ESR/CRP

• Sputum M&C

• Other tests (e.g. CT, bronchoscopy, ECG, echocardiogram, ventilation/perfusion scan) according to clinical findings

Diagnostic tips

• Blood originating from any area can be aspirated throughout lung.

• Bright red haemoptysis in a young person may be the initial symptom of pulmonary TB.

• Large haemoptyses are usually due to bronchiectasis or TB.

• The commonest causes of haemoptysis are URTI (24%), acute or chronic bronchitis (17%), bronchiectasis (13%), TB (10%). Unknown causes total about 22%.