Download A4Medicine Mobile App

Empower Your RCGP AKT Journey: Master the MCQs with Us! πŸš€

A4Medicine

Haemoptysis in Primary Care: Differential Diagnosis and Management

Haemoptysisβ€”the coughing up of blood originating from the lower respiratory tractβ€”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 severityβ€”particularly identifying red flagsβ€”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 β‰₯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 managementβ€”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 Β± 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, Β± 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 β‰₯40, hemoptysis Β± 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 Β± 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.


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


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




References

Abdulmalak, C., Cottenet, J., Beltramo, G., Georges, M., Camus, P., Bonniaud, P., … Quantin, C. (2015). Haemoptysis in adults: A 5-year study using the French nationwide hospital administrative database. European Respiratory Journal, 46(2), 503–511. https://doi.org/10.1183/09031936.00218214

BMJ Best Practice. (2024). Haemoptysis. https://bestpractice.bmj.com

British Lung Foundation & NHS England. (n.d.). Primary care guide to managing chronic cough and haemoptysis.

British Thoracic Society. (2019). Guidelines on bronchiectasis in adults. https://www.brit-thoracic.org.uk

British Thoracic Society. (n.d.). Guidelines on the management of haemoptysis in adults. https://www.brit-thoracic.org.uk

British Thoracic Society. (2021). Guidance on Pulmonary Embolism – Risk assessment and primary care action. https://www.brit-thoracic.org.uk

Eltahir, M., Elshafei, M., & Elzouki, A. (2020). Inhaled tranexamic acid for non-massive haemoptysis in a rivaroxaban-receiving patient not responding to the oral form. European Journal of Case Reports in Internal Medicine. https://doi.org/10.12890/2020_001930

European Society for Medical Oncology (ESMO). (2023). Guidelines on the diagnosis and staging of lung cancer. https://www.esmo.org

Govindan, B. (2019). Aetiological profile of cases of haemoptysis attending a tertiary care centre in South India. Journal of Evidence Based Medicine and Healthcare, 6(8), 482–489. https://doi.org/10.18410/jebmh/2019/101

GOLD (Global Initiative for Chronic Obstructive Lung Disease). (2023). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. https://goldcopd.org

Hirshberg, B., Biran, I., Glazer, M., & Kramer, M. R. (1997). Hemoptysis: Etiology, evaluation, and outcome in a tertiary referral hospital. Chest, 112(2), 440–444.

Khalil, A., Parrot, A., Nedelcu, C., Fartoukh, M., Marsault, C., & Carette, M.-F. (2016). Pulmonary tuberculosis: Imaging findings and diagnostic strategy. Diagnostic and Interventional Imaging, 97(5), 435–444. https://doi.org/10.1016/j.diii.2015.06.011

Mondoni, M., Carlucci, P., Job, S., Parazzini, E., Cipolla, G., Pagani, M., … Sotgiu, G. (2018). Observational, multicentre study on the epidemiology of haemoptysis. European Respiratory Journal, 51(1), 1701813. https://doi.org/10.1183/13993003.01813-2017

National Institute for Health and Care Excellence (NICE). (2023). Suspected cancer: recognition and referral (NG12). https://www.nice.org.uk/guidance/ng12

National Institute for Health and Care Excellence (NICE). (n.d.). Clinical Knowledge Summary – Haemoptysis. https://cks.nice.org.uk/topics/haemoptysis

Prasad, R., Garg, R., Singhal, S., & Srivastava, P. (2009). Lessons from patients with hemoptysis attending a chest clinic in India. Annals of Thoracic Medicine, 4(1), 10–13. https://doi.org/10.4103/1817-1737.43062

RCGP GP Notebook. (n.d.). Haemoptysis – A reference guide for UK GPs. https://gpnotebook.com

Rodrigues, J., Brogueira, P., Rodrigues, S., Cardoso, M., & Pack, T. (2018). When the diagnosis is a victim of the circumstances. European Journal of Case Reports in Internal Medicine. https://doi.org/10.12890/2018_000862

Royal College of Radiologists. (n.d.). Guidelines for investigation of haemoptysis and timing of chest X-ray. https://www.rcr.ac.uk

Sakr, L., & Dutau, H. (2010). Massive haemoptysis: An update on the role of bronchoscopy in diagnosis and management. Respiratory Medicine, 104(5), 693–701.

Sakr, L., Dutau, H., & Thomas, P. (2007). Management of nonmassive haemoptysis in general practice. Postgraduate Medical Journal, 83(984), 446–450.

Scottish Intercollegiate Guidelines Network (SIGN). (2023). SIGN 157: Management of respiratory tract infections. https://www.sign.ac.uk

Shankar, M., Saha, K., Kumar, P., Tiwari, M., & Kumar, S. (2018). Haemoptysisβ€”Aetiopathological, radiological profile and its outcome: Our experience. Journal of Evolution of Medical and Dental Sciences, 7(17), 2078–2083. https://doi.org/10.14260/jemds/2018/466

UK Lung Cancer Coalition. (n.d.). Referral guidelines for suspected lung cancer. https://www.uklcc.org.uk

Uzun, Γ–., Atasoy, Y., Findik, S., Atici, A., & Erkan, L. (2010). A prospective evaluation of hemoptysis cases in a tertiary referral hospital. The Clinical Respiratory Journal, 4(3), 131–138. https://doi.org/10.1111/j.1752-699x.2009.00158.x