Haemoptysis—the coughing up of blood originating from the lower respiratory tract—can range from mild and self-limiting to indicative of serious pathology. Clinically, it is vital to differentiate true haemoptysis from haematemesis (blood vomited from the gastrointestinal tract) or pseudohaemoptysis (blood coughed up from a nasopharyngeal or oral source).

In adult primary care, respiratory infections are responsible for the majority of haemoptysis cases (around 60%), though other important causes include chronic inflammatory airway disease, pulmonary vascular disorders, and malignancy. GPs play a key role in the initial assessment of severity—particularly identifying red flags—and in conducting appropriate investigations (e.g. chest radiography) to uncover underlying causes.

In this structured overview, we will explore the key differential diagnoses for haemoptysis in adults, highlighting distinguishing clinical features and recommending evidence-based primary care management strategies, including initial treatment approaches and referral guidance.

Red Flag Features (Urgent Referral Indicators)

Early identification of high-risk features is critical. Red flags in a patient with haemoptysis that warrant urgent referral or emergency management include

Massive Haemoptysis	Coughing large volumes of fresh blood (e.g. >100–200 mL in 24 hours) is an emergency with high mortality risk. Immediate hospital admission is required for airway protection and bleeding control.
Age ≥40 or Significant Smoking History	Any unexplained haemoptysis in patients over 40 years old or with a heavy smoking history requires urgent investigation for malignancy. In the UK, these patients should receive a two-week wait referral to a lung cancer clinic (regardless of chest X-ray findings).
Systemic Symptoms	Weight loss, anorexia, night sweats, or persistent fever alongside haemoptysis raise concern for serious infections (e.g. tuberculosis) or malignancy. Such symptoms should prompt a lower threshold for urgent referral and thorough work-up.
Cardiorespiratory Distress	Haemoptysis accompanied by severe dyspnoea, tachycardia, hypoxia, or haemodynamic instability may indicate a life-threatening pathology (e.g. massive pulmonary embolism). These patients need immediate, same-day emergency evaluation.
Suspicion of Pulmonary Embolism	Pleuritic chest pain, acute onset breathlessness, tachypnoea, tachycardia, and even small-volume haemoptysis are red flags for pulmonary embolism. Arrange immediate hospital referral for diagnostic imaging and management—do not manage in routine clinic settings.
Signs of Vasculitis or Renal Involvement	Haemoptysis with concurrent hematuria or a vasculitic rash suggests conditions such as Goodpasture’s syndrome or granulomatosis with polyangiitis. Urgent specialist referral is essential for these rare but serious autoimmune causes.
Recurrent or Persistent Haemoptysis	Any ongoing or frequent haemoptysis without a clear benign cause warrants urgent investigation. Even small but repeated episodes raise suspicion for malignancy or other serious underlying diseases.

Other considerations

Immunocompromise ↑↓	In patients with HIV, those on chemotherapy, or transplant recipients, opportunistic infections (e.g., TB, aspergillosis) and lymphoma should be carefully excluded.
Anticoagulant Use ↑↓	New haemoptysis in individuals on DOACs or warfarin requires evaluation for supratherapeutic INR, potential drug interactions, and underlying pathology (e.g., malignancy).
Known Lung Disease ↑↓	COPD, TB sequelae, or bronchiectasis with new or worsening haemoptysis should prompt exclusion of superimposed infection or malignancy.
Clubbing/Lymphadenopathy ↑↓	These findings suggest chronic pathology such as lung cancer or bronchiectasis. Examine for supraclavicular lymph nodes and consider CT chest for further evaluation.
Travel/TB Exposure ↑↓	A history of recent travel to TB-endemic regions or close contact with tuberculosis indicates sputum PCR/culture and imaging (CXR or CT) to rule out active TB infection.
Unilateral Wheeze/Stridor ↑↓	This presentation raises concern for central airway obstruction (e.g., tumor, foreign body). Urgent bronchoscopy is needed for both diagnostic and possible therapeutic intervention.

GPs should maintain a low threshold for requesting a chest X-ray as the initial investigation in patients presenting with haemoptysis. A normal chest X-ray does not exclude serious underlying pathology, including lung cancer.

Therefore, if red flags or clinical suspicion persist despite normal imaging, further urgent evaluation (such as a CT scan or specialist referral) is essential. For massive haemoptysis or severe cardiorespiratory distress, immediate resuscitation measures (ABC approach, oxygen administration, IV access) should be initiated in primary care while arranging emergency hospital transfer.

Infections are the most common cause of haemoptysis in general practice​.They cause inflammation and rupture of bronchial blood vessels, typically resulting in blood-streaked sputum. Key differentials include:

Category	Differential	Key Features	Primary Care Actions	Referral
Infectious Causes	Acute Bronchitis	Mild, viral; cough ± fever; blood-streaked sputum	Supportive care; antibiotics if bacterial or COPD	Follow-up; refer if persistent or risk factors present
	Pneumonia	Fever, cough, pleuritic pain, rust-colored sputum	Antibiotics; assess with CURB-65	Urgent if severe; routine if persistent/recurrent
	Tuberculosis (TB)	Subacute; night sweats, weight loss, chronic cough	CXR, sputum AFB; isolation	Urgent referral to TB service or respiratory
	Lung Abscess / Mycetoma	Foul sputum (abscess), recurrent hemoptysis (fungal in old cavities)	Consider in resistant/recurrent cases	Refer for imaging and specialist care
Chronic Respiratory	Chronic Bronchitis / COPD	Long smoking history, productive cough, exacerbation triggers bleeding	Treat as COPD exacerbation; always investigate hemoptysis	CXR; refer if unexplained, recurrent, or >40 with smoking history
	Bronchiectasis	Chronic sputum, recurrent infections, clubbing, ± major bleeds	Sputum culture, manage exacerbations, consider HRCT	Refer for diagnosis, ongoing care, airway clearance education
Cardiovascular Causes	Pulmonary Embolism (PE)	Sudden pleuritic pain, dyspnea, tachycardia, hemoptysis	Wells score, D-dimer, oxygen	Same-day ED referral
	Pulmonary Edema / LVF	Pink frothy sputum, orthopnea, crackles, cardiac history	Sit up, oxygen, nitrates/diuretics if available	Emergency admission
	Mitral Stenosis	Dyspnea over years, atrial fibrillation, diastolic murmur	Suspect with new murmur + hemoptysis	Refer for echo and cardiology
	Pulmonary Hypertension	Dyspnea, signs of right heart strain, small hemoptysis	Monitor known cases	Urgent specialist review if new or worsening symptoms
Malignancy	Lung Cancer	Age ≥40, hemoptysis ± weight loss, hoarseness, clubbing, smoking history	CXR; do not delay urgent 2WW referral	2-week wait referral, even if CXR is normal
	Metastases / Carcinoid	Hemoptysis with known cancer history or young nonsmoker with recurrent bleeds	Similar to lung cancer approach	Urgent respiratory referral

Other Causes

A variety of other conditions can cause hemoptysis. While each individual cause is relatively less common in general practice, collectively they form important differentials, especially when common causes have been ruled out. These include:

Category	Differential	Key Features	Primary Care Actions	Referral
Other Causes	Coagulopathies / Anticoagulants	Bleeding from minor airway irritation; bruising; high INR; concurrent bleeding	Review medications, check coagulation profile; correct INR or platelet count if needed	Hospital if severe; otherwise liaise with anticoagulation clinic
	Autoimmune Vasculitis	Hemoptysis with renal symptoms, rash, arthralgia, sinus or nasal symptoms	Urgent labs: renal function, urinalysis, ANCA; do not delay referral	Urgent to secondary care (rheumatology/pulmonology)
	Pulmonary Endometriosis	Recurrent hemoptysis synced with menstruation in women of reproductive age	Suspect if bleeding occurs only during menses	Non-urgent referral to gynecology or respiratory
	Airway Trauma / Foreign Body	History of trauma or recent procedure; foreign body aspiration with sudden symptoms	Urgent assessment if trauma or airway compromise; bronchoscopy for foreign body	Emergency if obstruction; otherwise respiratory referral
	Idiopathic (Cryptogenic)	No cause found despite evaluation; often self-limited	Ensure thorough work-up done (CXR ± CT/bronchoscopy); smoking cessation advice	Follow-up to monitor recurrence; re-investigate if bleeding returns

Summary:

In developed countries, the most frequent causes of haemoptysis are:

• Acute bronchitis – typically benign and self-limiting, associated with respiratory infections.

• Bronchiectasis – often due to chronic infections or inherited conditions, leading to recurrent episodes.

• Lung cancer – a significant and serious cause, frequently presenting in advanced stages.

Studies (e.g., Abdulmalak et al., Mondoni et al.) confirm that bronchiectasis and lung cancer are among the most commonly observed causes in clinical practice.

In contrast, in developing countries, haemoptysis is most commonly caused by:

• Pulmonary tuberculosis (TB) – accounts for 30–50% or more of haemoptysis cases in endemic regions.

• Parasitic infections, such as paragonimiasis, can also contribute significantly in specific areas.

Lung cancer, particularly bronchogenic carcinoma, remains a major cause of haemoptysis globally, necessitating careful evaluation for malignancy in all patients presenting with this symptom.

┌─────────────────────────────────────┐
│ Step 1: Initial Assessment │
│ - History: volume, duration, RFs │
│ - Exam: vitals, chest, systemic │
└─────────────────────────────────────┘
│
▼
┌─────────────────────────────────────┐
│ Step 2: Risk Stratification │
│ - Massive haemoptysis? │
│ - Red flags (age >40, smoker, etc.)│
│ - Stable vs. unstable │
└─────────────────────────────────────┘
│
▼
┌─────────────────────────────────────┐
│ Step 3: Initial Investigations │
│ - CXR, bloods (FBC, INR, U&Es, CRP) │
│ - D-dimer, AFB, ANCA if indicated │
└─────────────────────────────────────┘
│
▼
┌─────────────────────────────────────┐
│ Step 4: Categorise Likely Cause │
│ (See branching tree below) │
└─────────────────────────────────────┘
│
▼
┌─────────────────────────────────────┐
│ Step 5: Management & Referral │
│ - Treat reversible causes │
│ - Urgent/emergency referrals │
│ - Safety netting and follow-up │
└─────────────────────────────────────┘

Likely Causes Based on Hx, Exam, and Tests
├─ Infectious
│ ├─ Bronchitis → Supportive care
│ ├─ Pneumonia → Antibiotics ± admission
│ └─ TB → Urgent respiratory referral
│
├─ Chronic Lung Disease
│ ├─ COPD → Treat exacerbation, investigate if new
│ └─ Bronchiectasis → Sputum culture, CT, refer
│
├─ Cardiovascular
│ ├─ PE → Same-day hospital assessment
│ ├─ LVF/Pulmonary Edema → Emergency Rx
│ └─ Mitral stenosis → Echo, cardiology referral
│
├─ Neoplastic
│ └─ Suspected lung cancer → 2WW referral
│
├─ Other Causes
│ ├─ Coagulopathy → Adjust meds, manage INR
│ ├─ Autoimmune (GPA, Goodpasture’s) → ANCA, refer
│ ├─ Trauma/Foreign body → Consider bronchoscopy
│ ├─ Pulmonary endometriosis → Gynae/Resp referral
│ └─ Cryptogenic → Monitor & re-investigate if recurrent

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