Presentations
Approach to hemoptysis
The same eight steps, every presentation: threats first, then the history and exam that discriminate, one honest sentence, a mechanism-grouped differential, and the tests read in order.
Immediate threats
- Massive hemoptysis (over ~100 mL or any airway compromise): the threat is asphyxiation, not exsanguination
- Bleeding side down if known, airway team early, large-bore access
- Anticoagulation to reverse; platelets and coagulation to correct
- PE causes hemoptysis: do not let the blood distract from the clot behind it
History that discriminates
- Truly coughed up, vomited (hematemesis), or from the nose? The gateway question
- Volume and tempo honestly quantified: streaks in sputum versus cupfuls
- Smoking history and age (malignancy weight); fever and purulence (infection); weight loss and night sweats (TB, cancer)
- VTE risks, anticoagulants, prior lung disease (bronchiectasis bleeds), travel and TB exposure
Examination
- Work of breathing and saturation first
- Focal crackles or bronchial breathing localize; clubbing raises chronic suppuration or malignancy
- Legs for DVT; skin and joints for the vasculitis that bleeds into lungs and kidneys together
Problem representation
Recurrent blood-streaked purulent sputum in a lifelong smoker with weight loss and new clubbing (points at malignancy over bronchiectasis) versus sudden hemoptysis with pleuritic pain and tachycardia ten days after a hip replacement (points at PE).
Differential, by mechanism
Airway / parenchymal
- Bronchitis
- Bronchiectasis
- Pneumonia and abscess
- TB
- Malignancy
Vascular
- PE with infarction
- Elevated pulmonary venous pressure (mitral stenosis, failure)
Systemic
- Vasculitis with pulmonary-renal syndrome
- Coagulopathy and anticoagulants
Not the lung
- Upper airway and nasal bleeding
- Hematemesis mislabeled
Investigations
- CXR first; CT chest (angiogram protocol where PE or briskness is in play) as the map
- CBC, coagulation, group and save when volume is real
- Urinalysis for blood and protein: the renal half of a pulmonary-renal syndrome hides here
- Sputum for culture and AFB; bronchoscopy localizes when imaging does not
Interpretation
- A normal CXR does not close malignancy in a smoker over 40: the CT and the follow-up do
- Hemoptysis plus an active urine sediment is vasculitis until proven otherwise: that pairing changes the speed of everything
- Streak hemoptysis with a clean workup still earns an interval chest review, not a shrug
Next steps
- Massive bleeding: airway control, bleeding side down, urgent CT and interventional radiology for embolization
- Treat the found cause: antibiotics, anticoagulation for PE (yes, even with hemoptysis from infarction, weighed case by case)
- Document the safety-net: volumes that must trigger return, and the review that closes the loop
Connected
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