Hemoptysis
at the bedside
- airway, breathing, circulation; full vitals, cardiac monitor, IV access
- how much → look at the pot: streaks, cupfuls, ongoing
- is it from the lung → coughed, bright red, frothy; else GI bleed or epistaxis
- which side → known lesion, focal crackles, CXR
escalate now if
- more than 100 mL/h or 500 mL/24 h, or any amount with hypoxia, increased work of breathing or hypotension → life-threatening hemoptysis, ICU now
- on an anticoagulant or antiplatelet, or platelets low, and bleeding → correct the bleeding tendency
- with AKI, hematuria or rash → pulmonary-renal syndrome, nephrology and respiratory now
- pleuritic pain, leg swelling, tachycardia → pulmonary embolism → dyspnea
- weeks of cough, night sweats, weight loss, cavity → possible TB, isolate now
differentials
- airway → bronchiectasis, lung cancer, bronchitis
- infection → pneumonia, abscess, TB, aspergilloma
- vascular → PE, heart failure, mitral stenosis, AVM
- alveolar → vasculitis, anti-GBM, lupus: hypoxia, bilateral infiltrates, little blood coughed up
- bleeding tendency → anticoagulants, low platelets; usually unmask a lesion
- after a procedure → bronchoscopy, biopsy
focused check
- symptoms → fever, sputum, chest pain, weight loss, leg swelling, hematuria, rash
- drug chart → anticoagulant (last dose), antiplatelets, heparin prophylaxis
- history → bronchiectasis, cancer, TB contact, valve disease, smoking
- exam → work of breathing, focal chest signs, nose and mouth, murmur, DVT
send now
- CBC → hemoglobin and platelets; coagulation → coagulation profile
- group and save → beyond streaks; crossmatch if life-threatening
- RFT, urinalysis → pulmonary-renal syndrome
- sputum → culture; TB suspected: AFB and NAAT ×3
imaging
- CXR → now, portable if unwell
- CT angiogram of the chest → when stable; maps the source before embolization
- too unstable for CT → bronchoscopy (respiratory or ICU)
treat
life-threatening hemoptysis
- ICU and respiratory now; IR early
- bleeding side known → bleeding side down
- oxygen to target, suction ready → oxygen desaturation
- two large IV cannulas, crossmatch; stop and reverse antithrombotics → below
- airway failing → intubate (most experienced operator), tube ≥ 8.0 mm for bronchoscopy
- definitive control → CT angiogram, then bronchial artery embolization; surgery if it fails
- tranexamic acid → temporizing option with respiratory, 1 g IV over 10 min (not studied in life-threatening hemoptysis)
- shock → hypotension, massive hemorrhage
small volume, stable
- sputum pot, record volume each shift
- infection or bronchiectasis flare → empiric antibiotics
- nebulized tranexamic acid → option with respiratory, 500 mg in 5 mL TDS
- cause unclear → CT chest by the treating team
anticoagulant, antiplatelet or low platelets
- life-threatening → stop and reverse by drug → coagulation profile; platelets → platelet drop
- small volume → hold or continue with the prescribing team
- heparin prophylaxis → hold; mechanical instead
pulmonary-renal syndrome
- nephrology and respiratory now; ICU if hypoxic; do not wait for results
- ANCA, anti-GBM, ANA, complement, urine microscopy
possible TB
- airborne isolation, N95; infection control
- sputum AFB and NAAT ×3; ID before treatment
- hand over → volume trend, side, airway plan, anticoagulant, escalation trigger
evidence
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.
updated Oct 2026file complaint/hemoptysis