🩺 Haemoptysis

Haemoptysis is the expectoration of blood from the lower respiratory tract. It is a frightening symptom for patients and often indicates serious underlying pathology, most notably malignancy, infection, or vascular events. In the UK, any unexplained haemoptysis in a patient over 40 requires urgent investigation for lung cancer. Management ranges from reassurance in minor viral bronchitis to emergency bronchial artery embolisation or surgery in cases of massive, life-threatening haemorrhage.

Determine the volume and frequency of blood expectorated (streaks vs clots vs frank blood). Ask about constitutional symptoms such as weight loss and night sweats (malignancy/TB). Clarify the presence of pleuritic chest pain (PE/pneumonia) or a history of chronic cough and purulent sputum (bronchiectasis). Social history must cover smoking, travel to TB-endemic areas, and occupational exposure to carcinogens. Anticoagulant use and previous history of DVT or pulmonary disease are critical facts to establish.

Focus on haemodynamic stability (heart rate, blood pressure, saturations) and signs of significant blood loss. The respiratory exam should look for signs of focal pathology (dullness, bronchial breathing) and chronic disease (clubbing in bronchiectasis or cancer). Inspection of the nasal cavity and oropharynx is necessary to exclude 'pseudo-haemoptysis' from the upper GI tract or nasopharynx. Signs of deep vein thrombosis (unilateral leg swelling) should be sought if pulmonary embolism is a priority differential.

Lung Cancer, Bronchiectasis, Bronchitis (acute), Pneumonia, Pulmonary Embolism, Tuberculosis, Pulmonary Oedema (pink frothy sputum), Goodpasture’s Syndrome/Vasculitis.

Massive volume (>200ml), smoking history, weight loss, night sweats, persistent hoarseness, age >40, or history of recent travel/TB contact.

Urgent Chest X-ray is the first-line investigation for all stable patients. If the CXR is abnormal or the patient is at high risk of malignancy (age >40 + smoking), a CT Chest with contrast (or CT Thorax/Abdomen/Pelvis if staging cancer) is required. Bloods should include FBC (anaemia/infection), U&Es, CRP, and Coagulation profile (especially if on warfarin). Sputum MC&S and AFB (acid-fast bacilli) cultures are essential if TB or infection is suspected. Bronchoscopy may be needed for direct visualisation and biopsy or to localise the site of bleeding.

Massive haemoptysis is a medical emergency usually defined by volume (>200-600ml in 24 hours) or the degree of airway compromise. In the UK, bronchiectasis and lung cancer are the leading causes of significant haemoptysis, whereas globally, TB remains the primary cause. Always differentiate haemoptysis from haematemesis (darker, acidic, mixed with food) or epistaxis (visible nasal bleeding dripping down the throat). Clinicians must have a high index of suspicion for PE in patients presenting with haemoptysis and pleuritic chest pain, even if they are otherwise well.

Aligned with the MLA content map 'Haemoptysis'. Students must prioritise the '2-week wait' (2WW) referral criteria for suspected lung cancer. Understanding the anatomical source (bronchial vs pulmonary arteries) helps in understanding why bleeding can be high-pressure and life-threatening. Emergency management (A to E) and positioning the patient 'bleeding side down' are key clinical points.