Haemoptysis 🫁🩸
On-call guide to haemoptysis: confirm the source, grade severity, investigate, and escalate life-threatening bleeding. Irish Rapid Access Lung Clinic pathway for unexplained cases.
🧠 Definition
- Coughing blood from below the vocal cords. Volume estimates are unreliable: treat the patient, not the millilitres.
- Life-threatening means airway compromise, hypoxia, haemodynamic instability, or large-volume ongoing bleeding: that is an emergency, not a clinic referral. Unexplained haemoptysis still needs Rapid Access Lung Clinic work-up even if the CXR is normal (NCCP).
📞 What to Ask / Orders to Make
- Vitals, SpO₂, RR, and how unwell they look. Sit up, oxygen.
- Unstable: large-bore IV access, group and save (crossmatch if large bleed), portable CXR, nil by mouth, stay with the patient. Do not send them off the ward for imaging.
- Confirm with the nurse: anticoagulants or antiplatelets, known lung cancer, bronchiectasis, aspergilloma, or TB.
🚩 Red Flags / Escalate
- Airway threat, falling SpO₂, rising RR, shock, or large-volume ongoing bleeding: senior, ICU/anaesthetics, and respiratory immediately. Major haemorrhage protocol if indicated. IR for possible bronchial artery embolisation if bleeding continues.
- Known aspergilloma, cavitating disease, or lung cancer with a big bleed: high risk of rapid deterioration.
- Active haemoptysis plus possible PE: do not start anticoagulation until a senior has weighed bleed versus clot risk.
- Suspected TB: isolate and involve infection control before moving the patient.
🧾 History
- Confirm true haemoptysis (coughed blood) versus epistaxis or haematemesis (food, acidity, concurrent melaena).
- Volume and rate (streaks vs mL/h; fresh vs rust; ongoing?). Can they clear the airway? First episode or recurrent, including small “sentinel” bleeds (common in malignancy before a larger bleed).
- Associated: dyspnoea (more likely if large volume), fever (infection), weight loss (malignancy or chronic infection). Also chest pain, night sweats, hoarseness.
- Prior lung disease, TB exposure, immunosuppression, smoking pack-years, PE risk, recent lung procedure.
- Anticoagulants, antiplatelets, bleeding diathesis, and bleeding from other sites.
- Autoimmune clues: rash, haematuria or known renal disease, arthralgia.
🩺 Examination
- ABCs, work of breathing, vitals (RR, SpO₂, HR, BP, temperature, GCS). Nose and oropharynx: if that is the source, call ENT not respiratory.
- Chest: crackles, bronchial breathing, reduced air entry, wheeze. Clubbing, cervical nodes, Horner syndrome.
- Legs for DVT. Skin, joints, and urine dip if vasculitis or alveolar haemorrhage is possible.
- Bleeding side known: lie on that side (bleeding lung down). If unknown, sit up.
📋 Common Causes
Bronchitis / pneumonia
- Typical features
- Fever, coloured sputum; usually streaks
Bronchiectasis
- Typical features
- Recurrent infection, copious sputum; can be substantial
Pulmonary embolism
- Typical features
- Sudden dyspnoea or pleuritic pain; Wells PE criterion
Lung cancer
- Typical features
- Age, smoking, weight loss, persistent cough; often small and recurrent
Anticoagulation / coagulopathy
- Typical features
- Warfarin, DOACs, antiplatelets; check INR and platelets
TB
- Typical features
- Night sweats, weight loss, exposure; isolate if suspected
Aspergilloma / cavity
- Typical features
- Known cavity; can be life-threatening
Heart failure
- Typical features
- Pink frothy sputum more than frank blood; raised JVP, oedema
Vasculitis / alveolar haemorrhage
- Typical features
- Systemic features, falling Hb, diffuse infiltrates, hypoxia
Iatrogenic
- Typical features
- Recent lung biopsy or airway procedure
| Cause | Typical features |
|---|---|
| Bronchitis / pneumonia | Fever, coloured sputum; usually streaks |
| Bronchiectasis | Recurrent infection, copious sputum; can be substantial |
| Pulmonary embolism | Sudden dyspnoea or pleuritic pain; Wells PE criterion |
| Lung cancer | Age, smoking, weight loss, persistent cough; often small and recurrent |
| Anticoagulation / coagulopathy | Warfarin, DOACs, antiplatelets; check INR and platelets |
| TB | Night sweats, weight loss, exposure; isolate if suspected |
| Aspergilloma / cavity | Known cavity; can be life-threatening |
| Heart failure | Pink frothy sputum more than frank blood; raised JVP, oedema |
| Vasculitis / alveolar haemorrhage | Systemic features, falling Hb, diffuse infiltrates, hypoxia |
| Iatrogenic | Recent lung biopsy or airway procedure |
🔍 Investigations
- Bloods: FBC, U&E, coagulation, group and save. Crossmatch if large or ongoing. ABG if hypoxic or unwell. ECG. Sputum MCS; add AFB if TB is possible.
- CTPA if PE is the leading diagnosis. Contrast CT thorax (typically to the adrenals) if unexplained or suspected cancer. Discuss protocol with senior and radiology; do not delay once they can travel.
- D-dimer only if PE is unlikely and there is no active large bleed. Do not use it to defer imaging in a high-probability PE.
CXR
- Localises
- ~46%
- Finds cause
- ~35%
- On-call use
- First image if safe to travel; a normal film does not stop CT or cancer-pathway work-up
Contrast CT / CT angiography
- Localises
- 70–88%
- Finds cause
- ~86%
- On-call use
- Best for cause; do early (ongoing bleed can hide the source); maps vessels for embolisation. Better than bronchoscopy for aetiology (Chalumeau-Lemoine et al, 2013)
Bronchoscopy
- Localises
- ~70%
- Finds cause
- ~70%
- On-call use
- Airway clearance and bleeding control. Often not required if the airway is protected and CT shows the lesion
Catheter angiography
- Localises
- Maps the vessel
- Finds cause
- Treats the bleed
- On-call use
- Diagnostic and treatment: bronchial artery embolisation (BAE) via IR
| Test | Localises | Finds cause | On-call use |
|---|---|---|---|
| CXR | ~46% | ~35% | First image if safe to travel; a normal film does not stop CT or cancer-pathway work-up |
| Contrast CT / CT angiography | 70–88% | ~86% | Best for cause; do early (ongoing bleed can hide the source); maps vessels for embolisation. Better than bronchoscopy for aetiology (Chalumeau-Lemoine et al, 2013) |
| Bronchoscopy | ~70% | ~70% | Airway clearance and bleeding control. Often not required if the airway is protected and CT shows the lesion |
| Catheter angiography | Maps the vessel | Treats the bleed | Diagnostic and treatment: bronchial artery embolisation (BAE) via IR |
💊 Management
- Oxygen to target SpO₂ 94–98%, or 88–92% if a known CO₂ retainer, pending ABG.
- Non-massive: treat infection if pneumonia is likely; correct coagulopathy as advised. Unexplained cases need Rapid Access Lung Clinic / specialist review even if the CXR is normal. Respiratory also for recurrent bronchiectasis bleeds or bronchoscopy.
- Hold anticoagulants and antiplatelets only after a senior has weighed indication versus bleed. Reverse warfarin or DOACs if bleeding is significant, per local protocol.
- Life-threatening: two large-bore cannulae, fluids and blood products, nil by mouth, reverse anticoagulation, call ICU, respiratory, and IR. Bronchial artery embolisation, rigid bronchoscopy, or a bronchial blocker is a senior decision.
- Tranexamic acid (IV or nebulised): discuss dose and route with senior rather than starting from memory. Avoid chest physiotherapy while bleeding is active.
Related NICE guidance
NICENICE NG12 — Suspected cancer: recognition and referral
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Note Template
Ready-to-use clinical note structure
🕒 16 / 10 / 2026 — 16:16 ATRP re: haemoptysis Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [COPD / bronchiectasis / cancer / VTE / TB / none] Anticoagulation / antiplatelets: [none / warfarin INR __ / DOAC / antiplatelet] 🧾 Hx: • Source: [coughed vs vomited vs nosebleed]; concurrent melaena [N / Y] • Volume / rate: [streaks / mL/h]; can clear airway [Y/N]; sentinel bleeds [N / Y] • Associated: dyspnoea, fever, weight loss, chest pain, night sweats • Prior lung disease / TB exposure / immunosuppression / recent lung procedure: [ ] • Anticoagulants / antiplatelets / other bleeding: [ ] • Autoimmune clues: rash, haematuria / renal disease, arthralgia [N / Y] • Smoking pack-years: __ PE risk: [ ] 🩺 Exam: • RR: __ SpO₂: __% on __ HR: __ BP: __ Temp: __ GCS: __ • Work of breathing / laterality: [sit up / bleeding side down] • Nose / oropharynx source: [none / ] • Chest: [AE / crackles / wheeze / dull] • DVT signs / clubbing / nodes: [ ] 📋 Impression: Severity: [streaks / non-massive / life-threatening] Likely cause: [infection / PE / cancer / bronchiectasis / anticoagulation / other / unclear] 📌 Plan: • O₂ target [94–98% / 88–92% if CO₂ retainer]; NBM if large bleed • Bloods: FBC, coag, G&S [± crossmatch]; ABG if unwell • CXR; [CT thorax / CTA / CTPA] early if stable • Hold / reverse anticoagulation: [discussed with senior] • Treat infection if likely; isolate if TB possible • Follow-up: NCCP Rapid Access Lung Clinic if unexplained (even if CXR normal) • Escalate ICU / respiratory / IR if airway threat or ongoing large bleed 👤 [Your Name], [Role] IMC: _______
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