Haemoptysis 🫁🩸

• 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).

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

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