Diagnostic Imaging Pathways - Haemoptysis
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This pathway provides a diagnostic imaging algorithm for adult patients with confirmed haemoptysis.
Date reviewed: September 2018
Date of next review: September 2021
Published: March 2019
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Post-Primary Pulmonary Tuberculosis Image 1 (Plain Radiograph): Pulmonary tuberculosis is an important cause of haemoptysis. This chest radiograph demonstrates patchy bilateral opacification of the upper lung lobes with cavitation most marked on the left (arrow) consistent with post-primary tuberculosis. |
| 2 |  |
Pulmonary Haemorrhage Image 2 (Plain Radiograph): There is widespread airspace opacification of both lungs with air brochograms. This patient had bilateral pulmonary haemorrhage due to Goodpasture's (Anti-GBM) syndrome. |
| 3a |  |
Pulmonary Haemorrhage Image 3a (Plain Radiograph) and 3b (Bronchial Angiogram): Image 3a demonstrates right apical consolidation with cavitation due to mycetoma formation on a background of tuberculosis (arrow). The bronchial artery was embolised with gel foam and coils due to recurrent haemoptysis (Image 3b). |
| 3b |  |
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Teaching Points
Teaching Points
- A chest radiograph (CXR) may reveal a cause of haemoptysis. Abnormalities may require further evaluation on CT
- If CXR and/or clinical picture are consistent with infection, consider treating for infection first and then pursuing further imaging if haemoptysis is persistent
- CT of the chest is indicated in patients with persistent/recurrent haemoptysis, moderate volume haemoptysis more than 30mL or in patients with risk factors for lung malignancy such as more than 30 pack-year smoking history or age over 40
- Further investigations are dictated by CT findings. This may include a bronchoscopy if a neoplastic lesion is seen
- If no cause is identified after bronchoscopy and CT, the risk of malignancy is low. There are no recommendations for what imaging or bronchoscopy surveillance should be undertaken in this time, if at all
- Massive haemoptysis refers to when the volume of blood is life threatening by virtue of airway obstruction, hypotension or blood loss and is a medical emergency. There is no universally accepted definition and volume thresholds range from 100mL to more than 1000mL of haemoptysis in 24h
- Depending on whether the patient is haemodynamically stable, diagnostic tests (e.g. CT scan) may be undertaken
- If the airway is not secure, bronchoscopy is preferred initially, as it affords therapeutic intervention at the same time and can allow the airway to be secured. When the patient is sufficiently stable, CTA can be undertaken to plan for embolisation or to localise the source if not already identified
cxr
Chest Radiography (CXR)
- Frequently recommended as the initial imaging modality to investigate haemoptysis 1
- May detect a cause of haemoptysis in 40-50% of cases 2,3
- If CXR and/or clinical picture are consistent with infection, consider treating for infection first and then pursuing further imaging if haemoptysis is persistent 4
- In patients with a normal CXR, the incidence of malignancy is 3-10% 1
- Patients with negative CXR and two or more risk factors for malignancy (>40 years old, >30 pack year smoking history) should proceed to CT 1
- Moderate volume haemoptysis >30mL or persistent or recurrent haemoptysis also warrants further imaging 1
- CT is also indicated to further evaluate abnormalities detected on CXR such as a mass or parenchymal disease 4
cta
CT Angiography (CTA)
- Contrast enhanced CT with opacification of the pulmonary and systemic vessels is recommended to evaluate for the source of haemorrhage and can also be used for work up for intervention, such as embolisation. CTPA shows only opacification of the pulmonary vessels and may miss haemoptysis caused by systemic vessels
- CTA of the chest is indicated in patients with: 1
- Persistent/recurrent haemoptysis
- Moderate volume haemoptysis more than 30mL
- Risk factors for lung malignancy such as more than 30 pack-year smoking history or age over 40
- Localises the site of bleeding in 77-92.5% of cases of non-massive haemoptysis 5-7
- Intravenous contrast helps to characterise masses and vascular lesions; bronchiectasis and parenchymal disease can be evaluated with non-contrast images
- Patients with a normal CT are unlikely to have abnormal findings on bronchoscopy, 8,9 suggesting that CT may be sufficient
- No cause is identified after bronchoscopy and CT in 10-20% of cases. 10,11 These patients have a low risk of malignancy and may be followed up for 3 years, although there are no recommendations for what imaging or bronchoscopy surveillance should be undertaken in this time, if at all 1
bronch
Bronchoscopy
- Non-Massive Haemoptysis
- In non-massive haemoptysis, typically reserved for patients with recurrent bronchiectasis, or to further investigate abnormalities on CT 1,4,8
- With improvements in CT, bronchoscopy rarely reveals aetiologies not already diagnosed by CT, including malignancy 8,9
- No cause is identified after bronchoscopy and CT in 10-20% of cases. 10,11 These patients have a low risk of malignancy and may be followed up for 3 years, although there are no recommendations for what imaging or bronchoscopy surveillance should be undertaken in this time, if at all 1
- Bronchoscopy allows biopsies to be taken for histology or brushings and washings for cytology and microbiology 2
- Massive Haemoptysis
- Massive haemoptysis refers to when the volume of blood is life threatening by virtue of airway obstruction, hypotension or blood loss and is a medical emergency. 12 There is no universally accepted definition and volume thresholds range from 100mL to more than 1000mL of haemoptysis in 24h 12
- In unstable patients with massive haemoptysis, flexible bronchoscopy may be the first-line diagnostic test 12
- Identifies the site of bleeding in of massive haemoptysis in 73-93%, similar to CTA (70-88.5%) 14,15
- CTA is more useful than bronchoscopy for identifying the underlying cause. CTA reveals the underlying cause in 60-77% compared to 2.5-8% with bronchoscopy 14
- In non-massive haemoptysis, bronchoscopy has a much lower yield, especially in younger patients 9,16
- Disadvantages:
- Invasive procedure with a risk of complications
- Failure to visualise peripheral lesions 14,17
cta2
CT Angiography (CTA))
- Rapid, non-invasive investigation that can localise the site and cause of haemoptysis
- Contrast enhanced CT with opacification of the pulmonary and systemic vessels is recommended to evaluate for the source of haemorrhage. CTPA shows only opacification of the pulmonary vessels and may miss haemoptysis caused by systemic vessels
- Provides useful information to improve the success of bronchial artery embolisation 18,19
- Identifies the site of bleeding in 70-88.5% of massive haemoptysis, similar to bronchoscopy (73-93%) 14,15
- More useful than bronchoscopy for identifying the underlying cause. CTA reveals the underlying cause in 60-77% compared to 2.5-8% with bronchoscopy 14
- In the setting of true massive and life-threatening haemoptysis, flexible bronchoscopy is the first-line management so that the airway can be secured, as well as providing useful information about the site of bleeding
- Once airway stabilisation and site localisation is accomplished, CTA can add additional information, particularly about the underlying aetiology and vascular anatomy 20,21 if there is a view to embolisation
bronchang
Bronchial Angiography
- Invasive diagnostic test that is indicated when bronchial artery embolisation is intended 1
- Angiographic signs of pulmonary haemorrhage include extravasation of contrast media, hypervascularisation, abnormal arborisation of bronchial arteries, systemic-pulmonary shunts and bronchial artery aneurysms
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Ketai LH, Mohammed TL, Kirsch J, Kanne JP, Chung JH, Donnelly EF, et al. ACR appropriateness criteria(R) hemoptysis. J Thorac Imaging. 2014;29(3):W19-22. (Guidelines). View the reference
- Hirshberg B, Biran I, Glazer M, Kramer MR. Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest. 1997;112(2):440-4. (Level II-III evidence). View the reference
- Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000;28(5):1642-7. (Review article). View the reference
- Earwood JS, Thompson TD. Hemoptysis: evaluation and management. Am Fam Physician. 2015;91(4):243-9. (Review article). View the reference
- Haro M, Jimenez J, Tornero A, Vizcaya M, Tirado R, Cros T. Usefulness of computerized tomography and bronchoscopy in patients with hemoptysis. Analysis of 482 cases. An Med Interna. 2002;19(2):59-65. (Level II evidence). View the reference
- Tsoumakidou M, Chrysofakis G, Tsiligianni I, Maltezakis G, Siafakas NM, Tzanakis N. A prospective analysis of 184 hemoptysis cases: diagnostic impact of chest X-ray, computed tomography, bronchoscopy. Respiration. 2006;73(6):808-14. (Level III evidence). View the reference
- Davoodi M, Kordi M, Gharibvand MM, Shoushtari MH, Borsi H, Bahadoram M. Hemoptysis: comparison of diagnostic accuracy of multi detector CT scan and bronchoscopy. Global Journal of Health Science. 2015;7(3):373-7. (Level II-III evidence). View the reference
- Bonlokke S, Guldbrandt LM, Rasmussen TR. Bronchoscopy in patients with haemoptysis and normal computed tomography of the chest is unlikely to result in significant findings. Danish medical journal. 2015;62(8):A5123. (Level II-III evidence). View the reference
- Nielsen K, Gottlieb M, Colella S, Saghir Z, Larsen KR, Clementsen PF. Bronchoscopy as a supplement to computed tomography in patients with haemoptysis may be unnecessary. European Clinical Respiratory Journal. 2016;3:10.3402/ecrj.v3.31802. (Level II evidence). View the reference
- Menchini L, Remy-Jardin M, Faivre JB, Copin MC, Ramon P, Matran R, et al. Cryptogenic haemoptysis in smokers: angiography and results of embolisation in 35 patients. Eur Respir J. 2009;34(5):1031-9. (Level II-III evidence). View the reference
- Herth F, Ernst A, Becker HD. Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin. Chest. 2001;120(5):1592-4. (Level II evidence). View the reference
- Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. Journal of Thoracic Disease. 2017;9(Suppl 10):S1069-S86. (Review article). View the reference
- Yendamuri S. Massive airway hemorrhage. Thorac Surg Clin. 2015;25(3):255-60. (Review article). View the reference
- Revel MP, Fournier LS, Hennebicque AS, Cuenod CA, Meyer G, Reynaud P, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol. 2002;179(5):1217-24. (Level II evidence). View the reference
- Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB. Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. AJR Am J Roentgenol. 2001;177(4):861-7. (Level III evidence). View the reference
- Torbiarczyk JM, Sobczak PA, Torbiarczyk KK, Milkowska-Dymanowska J, Antczak A, Gorski P, et al. Torbiarczyk JM, Sobczak PA, Torbiarczyk KK, Milkowska-Dymanowska J, Antczak A, Gorski P, et al. Advances in respiratory medicine. 2018;86(1):13-6. (Level III evidence). View the reference
- McGuinness G, Beacher JR, Harkin TJ, Garay SM, Rom WN, Naidich DP. Hemoptysis: prospective high-resolution CT/bronchoscopic correlation. Chest. 1994;105(4):1155-62. (Level II-III evidence). View the reference
- Khalil A, Fartoukh M, Parrot A, Bazelly B, Marsault C, Carette MF. Impact of MDCT angiography on the management of patients with hemoptysis. AJR Am J Roentgenol. 2010;195(3):772-8. (Level II-III evidence). View the reference
- Zhao T, Wang S, Zheng L, Jia Z, Yang Y, Wang W, et al. The value of 320-row multidetector CT bronchial arteriography in recurrent hemoptysis after failed transcatheter arterial embolization. J Vasc Interv Radiol. 2017;28(4):533-41.e1. (Level III evidence). View the reference
- Yoon YC, Lee KS, Jeong YJ, Shin SW, Chung MJ, Kwon OJ. Hemoptysis: bronchial and nonbronchial systemic arteries at 16-detector row CT. Radiology. 2005;234(1):292-8. (Level III evidence). View the reference
- Remy-Jardin M, Bouaziz N, Dumont P, Brillet PY, Bruzzi J, Remy J. Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography. Radiology. 2004;233(3):741-9. (Level II-III evidence). View the reference
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