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Haemoptysisβthe coughing up of blood originating from the lower respiratory tractβcan 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 severityβparticularly identifying red flagsβand 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.
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. >100β200 mL in 24 hours) is an emergency with high mortality risk. Immediate hospital admission is required for airway protection and bleeding control. |
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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 managementβdo not manage in routine clinic settings. |
Signs of Vasculitis or Renal Involvement | Haemoptysis with concurrent hematuria or a vasculitic rash suggests conditions such as Goodpastureβs 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 ββ | In patients with HIV, those on chemotherapy, or transplant recipients, opportunistic infections (e.g., TB, aspergillosis) and lymphoma should be carefully excluded. |
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Anticoagulant Use ββ | 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 ββ | COPD, TB sequelae, or bronchiectasis with new or worsening haemoptysis should prompt exclusion of superimposed infection or malignancy. |
Clubbing/Lymphadenopathy ββ | 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 ββ | 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 ββ | 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 practiceβ.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 |
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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 |
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 |
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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 β typically benign and self-limiting, associated with respiratory infections.
Bronchiectasis β often due to chronic infections or inherited conditions, leading to recurrent episodes.
Lung cancer β 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) β accounts for 30β50% 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.
βββββββββββββββββββββββββββββββββββββββ
β Step 1: Initial Assessment β
β - History: volume, duration, RFs β
β - Exam: vitals, chest, systemic β
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β
βΌ
βββββββββββββββββββββββββββββββββββββββ
β Step 2: Risk Stratification β
β - Massive haemoptysis? β
β - Red flags (age >40, smoker, etc.)β
β - Stable vs. unstable β
βββββββββββββββββββββββββββββββββββββββ
β
βΌ
βββββββββββββββββββββββββββββββββββββββ
β Step 3: Initial Investigations β
β - CXR, bloods (FBC, INR, U&Es, CRP) β
β - D-dimer, AFB, ANCA if indicated β
βββββββββββββββββββββββββββββββββββββββ
β
βΌ
βββββββββββββββββββββββββββββββββββββββ
β Step 4: Categorise Likely Cause β
β (See branching tree below) β
βββββββββββββββββββββββββββββββββββββββ
β
βΌ
βββββββββββββββββββββββββββββββββββββββ
β Step 5: Management & Referral β
β - Treat reversible causes β
β - Urgent/emergency referrals β
β - Safety netting and follow-up β
βββββββββββββββββββββββββββββββββββββββ
Likely Causes Based on Hx, Exam, and Tests
ββ Infectious
β ββ Bronchitis β Supportive care
β ββ Pneumonia β Antibiotics Β± admission
β ββ TB β Urgent respiratory referral
β
ββ Chronic Lung Disease
β ββ COPD β Treat exacerbation, investigate if new
β ββ Bronchiectasis β Sputum culture, CT, refer
β
ββ Cardiovascular
β ββ PE β Same-day hospital assessment
β ββ LVF/Pulmonary Edema β Emergency Rx
β ββ Mitral stenosis β Echo, cardiology referral
β
ββ Neoplastic
β ββ Suspected lung cancer β 2WW referral
β
ββ Other Causes
β ββ Coagulopathy β Adjust meds, manage INR
β ββ Autoimmune (GPA, Goodpastureβs) β ANCA, refer
β ββ Trauma/Foreign body β Consider bronchoscopy
β ββ Pulmonary endometriosis β Gynae/Resp referral
β ββ Cryptogenic β Monitor & re-investigate if recurrent
References
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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 β 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), 482β489. 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), 440β444.
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), 435β444. https://doi.org/10.1016/j.diii.2015.06.011
Mondoni, M., Carlucci, P., Job, S., Parazzini, E., Cipolla, G., Pagani, M., β¦ 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
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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), 10β13. https://doi.org/10.4103/1817-1737.43062
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