Key learning points

  • Haemoptysis refers to the expectoration of blood from a source below the glottis and may have a wide variety of causes 
  • It is important to rule out causes, for example, primary lung cancer and pulmonary embolus
  • The quantity of blood the patient is reporting must be established
  • Patients presenting with haemoptysis should be referred urgently for chest X-ray

Introduction

Haemoptysis refers to the expectoration of blood from a source below the glottis. This may range from blood-streaking of sputum to the presence of blood with or without the presence of sputum.1 Most cases of haemoptysis in adults are caused by bronchitis, tuberculosis (TB) and bronchiectasis. Patients with a chronic disorder such as cystic fibrosis, bronchiectasis or chronic obstructive pulmonary disease (COPD) usually have a history of haemoptysis, so this is less likely to be an initial presentation of their underlying disease.1 Malignancy or TB should be considered if there are symptoms or signs of chronic illness in the absence of chronic lung disease. In children, the most common causes are lower respiratory tract infection and foreign body aspiration.1

Haemoptysis may be the presenting symptom of lung cancer and one important cause to rule out is primary lung cancer in smokers over the age of 40 years. Another important cause to consider is pulmonary embolus.2 Haemoptysis may also 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 up to 40% of patients, the cause of haemoptysis is unknown (cryptogenic haemoptysis).2 In these cases, haemoptysis is usually self-limiting within six months.

Nearly all cardiac output traverses low-pressure pulmonary arteries to be oxygenated in the pulmonary capillary bed. The bronchial arteries are under much higher systemic pressure but carry only a small portion of the cardiac output.1 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. 

Clinical assessment

In the clinical history, it is important to establish the quantity of blood the patient is reporting, for example, is there streaking in the sputum or frank blood? Massive haemoptysis is a medical emergency and is defined as >600mL in 24 hours or 150mL in one hour. This may cause airway compromise and haemodynamic instability.2

Other symptoms such as chest pain, shortness of breath, malaise, fever, sputum, night sweats, nasal discharge, weight loss and back pain may be relevant.1 It is useful to establish whether there is a history of anticoagulant use or a bleeding disorder. 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 may be risk factors to suggest pulmonary embolism as the underlying cause.

Postnasal drip or epistaxis may suggest pseudohaemoptysis, that is, blood arising from the nasopharynx rather than the respiratory tract.1 Coffee-ground vomitus is more suggestive of haematemesis. 

Clinical evaluation includes baseline observations which may detect fever, tachypnoea, tachycardia or low oxygen saturation. Clinical examination may reveal cachexia or accessory muscle use. Examination of the chest 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. There may be signs of heart failure on examination of the cardiovascular system. Abdominal examination may reveal hepatomegaly or a mass.

Initial investigations

Blood tests, including full blood count (FBC) and coagulation screening may be performed. Urinalysis may also be relevant to look for haematuria and/or proteinuria if glomerulonephritis is suspected.
Patients presenting with haemoptysis should be referred urgently for chest X-ray, with the report being available within five days, according to NICE guidelines.3,4 Smokers or ex-smokers aged 40 years and older presenting with persistent haemoptysis should be urgently referred on a suspected cancer pathway.4

Dr Suneeta Kochhar is a GP principal in Bexhill, East Sussex

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