Red flag symptoms: Haemoptysis

Possible causes of haemoptysis, advice on examinations and investigations and when to refer.

Bronchiectasis is one of the main causes of haemoptysis (SPL)
Bronchiectasis is one of the main causes of haemoptysis (SPL)

Red flags

  • Shortness of breath
  • Reduced/absent breath sounds
  • Malaise
  • Weight loss
  • Fatigue
  • Back pain

Haemoptysis, a common symptom, may be caused by URTI. For example, most cases of haemoptysis in adults are caused by bronchitis, TB and bronchiectasis. In children, the most common causes are lower respiratory tract infection and foreign body aspiration.

Another important cause to consider is primary lung cancer in smokers over the age of 40 years.

Haemoptysis is thought to arise from the bronchial arteries, although it may arise from pulmonary arteries if there is trauma or erosion from granulomatous disease or malignancy. Infection may cause inflammation of mucosa with oedema, which in turn may result in rupture of superficial blood vessels. Malignancy, bronchiectasis and pneumonia may cause massive haemoptysis.

Possible causes
  • Chronic lung disease: COPD, TB, cystic fibrosis, bronchiectasis
  • Malignancy
  • Bleeding disorders
  • Pulmonary embolism
  • Heart failure
  • Pulmonary-renal syndromes (Goodpasture's syndrome, Wegener's granulomatosis)

Key questions

In the history, it is important to establish details of any current illness, as well as anticoagulant use. Assess the quantity of blood the patient is reporting, for example, is there streaking of blood in the sputum or a larger quantity?

Massive haemoptysis is a medical emergency, defined as >600mL in 24 hours or 150mL in one hour.

Frothy sputum with bright red blood may suggest haemoptysis. Postnasal drip or epistaxis may suggest pseudohaemoptysis, that is, blood arising from the nasopharynx rather than the respiratory tract. Coffee-ground vomitus is more suggestive of haematemesis. Blood arising from an extrapulmonary source tends to be darker than that arising from the respiratory tract.

Ask if there is a history of fever, sputum, night sweats, weight loss, chest pain, shortness of breath, leg swelling and bloody nasal discharge.

If there is a suspicion of TB, it is helpful to consider any risk factors, such as specific exposure, travel history and immunosuppression.

A history of recent surgery, immobilisation or pregnancy, or a family history of venous thromboembolism, may suggest pulmonary embolism as the underlying cause.

Examination and investigations

Observations may indicate fever, increased respiratory and heart rate, and low oxygen saturation. There may be evidence of cachexia or accessory muscle use.

Lung examination should include assessment of air entry, presence of crepitations, wheeze and stridor. Dullness to percussion may suggest lung consolidation. There may also be cervical or supraclavicular lymphadenopathy.

Examination of the cardiovascular system may reveal distended neck veins, peripheral oedema, or murmurs, which may indicate heart failure. Abdominal examination may reveal hepatomegaly or a mass.

There may be evidence of a bleeding disorder, for example, a history of recurrent epistaxis, and ecchymoses or petechiae may be seen.

Patients with a chronic disorder such as cystic fibrosis, bronchiectasis or COPD usually have a history of this, so haemoptysis is less likely to be an initial presentation of their underlying disease.

Malignancy or TB should be considered if there are symptoms or signs of chronic illness in the absence of chronic lung disease. Haemoptysis may be the presenting symptom of lung cancer.

Haemoptysis may be caused by pulmonary-renal syndromes, such as Goodpasture's syndrome or Wegener's granulomatosis. Recurrent cyclical haemoptysis may be caused by pulmonary endometriosis.

In approximately one-third of patients, the underlying cause of haemoptysis is not identified, in spite of assessment.

Blood tests, including FBC and coagulation screening, may be performed. Urinalysis may also be relevant, to look for haematuria and/or proteinuria if glomerulonephritis is suspected.

When to refer

Patients with minor haemoptysis may be managed in the outpatient setting, but those with massive haemoptysis require stabilisation in A&E before investigating.

Patients presenting with haemoptysis should be referred urgently for chest X-ray, with the report being available within five days, according to NICE guidelines. Smokers or ex-smokers aged 40 years and older presenting with persistent haemoptysis should be urgently referred on a suspected cancer pathway (for an appointment within two weeks).

Those with abnormal results may undergo CT scanning, as well as bronchoscopy. CT angiography may be indicated. Fibre-optic investigation, as well as upper GI endoscopy, may be performed to establish whether there is haematemesis.

  • Dr Kochhar is a GP in Bexhill, East Sussex

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