Assessment of haemoptysis

Viral agents are the most common infectious causes of acute bronchitis.

In minor haemoptysis, bronchoscopy may not be needed if the CXR is normal, and a history of acute bronchitis can be elicited.

Diagnosis of bronchitis is clinical.

Seldom diagnostic, but useful in ruling out other pathologies

Evidence of unrecognised pulmonary TB or evidence of old healed TB (e.g., upper lobe fibrosis) may be present; such abnormalities should prompt sputum collection for smear, culture, and nucleic acid amplification testing.

Testing of 3 specimens (minimum 8 hours apart, including an early morning specimen) is recommended in many countries; consult local guidance.[68]Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan 15;64(2):e1-e33. https://www.doi.org/10.1093/cid/ciw694 http://www.ncbi.nlm.nih.gov/pubmed/27932390?tool=bestpractice.com

​Sputum specimen should be tested in patients with suspected extrapulmonary TB, as active pulmonary TB is seen in 15% to 20% of patients with extrapulmonary TB.[69]Geldmacher H, Taube C, Kroeger C, et al. Assessment of lymph node tuberculosis in northern Germany: a clinical review. Chest. 2002 Apr;121(4):1177-82. http://www.ncbi.nlm.nih.gov/pubmed/11948050?tool=bestpractice.com [70]Weir MR, Thornton GF. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature. Am J Med. 1985 Oct;79(4):467-78. http://www.ncbi.nlm.nih.gov/pubmed/4050833?tool=bestpractice.com [71]Baydur A. The spectrum of extrapulmonary tuberculosis. West J Med. 1977 Apr;126(4):253-62. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1237539/pdf/westjmed00272-0024.pdf http://www.ncbi.nlm.nih.gov/pubmed/855317?tool=bestpractice.com

Culture of Mycobacterium tuberculosis typically takes several weeks (up to 8), decisions on treatment are usually made before culture results are known.​​​

NAAT should be performed on at least one respiratory specimen when a diagnosis of pulmonary TB is being considered. NAAT may speed the diagnosis in smear-negative cases and may be helpful to differentiate non-tuberculous mycobacteria when sputum is AFB smear positive but NAAT negative.[72]Centers for Disease Control and Prevention. Updated guidelines for the use of nucleic acid amplification tests in the diagnosis of tuberculosis. Jan 2009 [internet publication]. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5801a3.htm ​ Genotyping might be considered useful in outbreaks of TB to identify transmission of TB, especially when contact had not been appreciated in the course of epidemiological investigations. 

Several rapid NAATs are available for the diagnosis of TB and some are also able to detect genes encoding resistance to TB drugs.[73]World Health Organization. WHO consolidated guidelines on tuberculosis: module 3: diagnosis: rapid diagnostics for tuberculosis detection. Mar 2024 ​[internet publication]. https://www.who.int/publications/i/item/9789240089488

Bronchoalveolar lavage may be indicated in patients in whom sputum induction is unsuccessful or in whom smear and NAAT are negative. Bronchoscopy is useful when other diagnoses are strongly considered or in patients in whom pulmonary TB is still suspected after other methods proved non-diagnostic.

Transbronchial lung biopsies are useful in the diagnosis of miliary disease as granulomas may be visible.

Bronchiectasis can be seen in chronic cases. Haemoptysis usually originates from bronchial arteries, but Rasmussen's aneurysms from a pulmonary artery adjacent to a cavity can be the source of bleeding.

Residual bronchiectasis from old TB can cause haemoptysis.

One Cochrane review found the lateral flow urine lipoarabinomannan (LF-LAM) assay to have a sensitivity of 42% in diagnosing TB in HIV-positive individuals with TB symptoms, and 35% in HIV-positive individuals not assessed for TB symptoms.[74]Bjerrum S, Schiller I, Dendukuri N, et al. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev. 2019 Oct 21;10(10):CD011420. https://www.doi.org/10.1002/14651858.CD011420.pub3 http://www.ncbi.nlm.nih.gov/pubmed/31633805?tool=bestpractice.com [ ] What is the accuracy of lateral flow urine lipoarabinomannan (LF‐LAM) for detecting tuberculosis (TB) in symptomatic HIV‐positive adults?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2824/fullShow me the answer [ ] What is the accuracy of lateral flow urine lipoarabinomannan (LF‐LAM) for detecting tuberculosis (TB) in unselected HIV‐positive adults (symptomatic or asymptomatic)?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2825/fullShow me the answer​​​​​ WHO recommends that LF-LAM can be used to assist in the diagnosis of active TB in HIV-positive adults, adolescents, and children with signs and symptoms of TB, or in those with advanced HIV or who are seriously ill.[73]World Health Organization. WHO consolidated guidelines on tuberculosis: module 3: diagnosis: rapid diagnostics for tuberculosis detection. Mar 2024 ​[internet publication]. https://www.who.int/publications/i/item/9789240089488

Culture would still be required for drug susceptibility testing (DST).

Useful for evaluating endobronchial obstruction as a cause of abscess.

Radiographic presentations of common aetiological agents are focal (pleural effusion, usually bacterial), cavity (bacterial abscess, fungal, acid-fast bacilli, Nocardia), rapid progression/multifocal (Legionella, pneumococcal, staphylococcal), and interstitial (viral, Pneumocystis, Mycoplasma, Chlamydia psittaci).

Tracheal tumours may be seen on standard radiographs in some cases, although sensitivity is low.[76]Bedayat A, Yang E, Ghandili S, et al. Tracheobronchial tumors: radiologic-pathologic correlation of tumors and mimics. Curr Probl Diagn Radiol. 2020 Jul-Aug;49(4):275-84. https://pmc.ncbi.nlm.nih.gov/articles/PMC7115773 http://www.ncbi.nlm.nih.gov/pubmed/31076268?tool=bestpractice.com ​ [Figure caption and citation for the preceding image starts]: Tracheal tumourFrom the personal collection of Dr Erik Folch [Citation ends].

Airway tumours tend to necrose when they outgrow their vascular supply. Deeper biopsies should be done in these cases.

Uptake of FDG indicates metabolically active disease. This can occur with malignancy or in the setting of active infection or inflammatory lung diseases.

False-positive tests may occur with infectious or inflammatory granulomas. False negatives may occur with sub-solid nodules and carcinoids.

A search for the primary site should be performed. It may include abdominal and pelvic CT scans accompanied by imaging of the brain with CT scanning or MRI. Extrapulmonary cancers that metastasise to the lung include melanoma, sarcomas, and adenocarcinoma of the colon, breast, kidney, or testicle.

In metastatic disease, a PET scan aids in the identification of the primary site, and allows for appropriate staging whenever malignancy is confirmed.

The accurate sampling of a nodule depends on the location and size of the nodule, presence of bronchus sign (e.g., a bronchus leading directly to a peripheral pulmonary lesion visible on CT), and local expertise and availability of fluoroscopy.

Endobronchial lesions may occur as metastases of a wide variety of cancers, including renal cell carcinoma, thyroid carcinoma, oesophageal cancer, ovarian cancer, melanoma, breast cancer, colorectal cancer, and sarcomas. Bronchoscopy has a very high yield for endobronchial lesions.[Figure caption and citation for the preceding image starts]: Right upper lobe metastatic renal cell carcinomaFrom the personal collection of Dr Erik Folch [Citation ends].[Figure caption and citation for the preceding image starts]: Endobronchial metastatic melanomaFrom the personal collection of Dr Erik Folch [Citation ends].

Yield is higher in large endobronchial lesions or large masses.

The metabolism of the specific drug will determine the appropriate test and its effect in the coagulation cascade.

The metabolism of the specific drug will determine the appropriate test and its effect in the coagulation cascade.

Endobronchial signs of coagulopathy. [Figure caption and citation for the preceding image starts]: Endobronchial signs of coagulopathy in a patient taking clopidogrel and aspirinFrom the personal collection of Dr Erik Folch [Citation ends].

Sloughing of mucosal surfaces, soot in airways.

High-resolution CT scan is the best diagnostic tool for bronchiectasis in adults. In children and adolescents, high-resolution multi-detector CT (MDCT) scans and a lower diagnostic threshold (broncho-arterial dilatation >0.8 vs. the adult cut-off of >1 to 1.5) are recommended due to the importance of early diagnosis on improving prognosis.[79]Chang AB, Fortescue R, Grimwood K, et al. European Respiratory Society guidelines for the management of children and adolescents with bronchiectasis. Eur Respir J. 2021 Aug 26;58(2):2002990. http://www.ncbi.nlm.nih.gov/pubmed/33542057?tool=bestpractice.com

Bronchoscopy is useful in identifying the site of bleeding, and micro-organisms infecting or colonising the airway.

Bronchoalveolar lavage or washings may isolate micro-organisms.

Use of intravenous contrast with a pulmonary embolism (PE) protocol is necessary to reliably identify PE.

Indirect findings include pulmonary infarct, large pulmonary artery, pleural effusion, atelectasis, and mosaic attenuation.

Use bedside echocardiography for haemodynamically unstable patients who cannot have CTPA.[80]Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019 Sep;54(3). https://www.doi.org/10.1183/13993003.01647-2019 http://www.ncbi.nlm.nih.gov/pubmed/31473594?tool=bestpractice.com

Echocardiography can also identify important alternative causes of shock, such as pericardial tamponade, acute valvular dysfunction, severe global or regional left ventricular dysfunction, aortic dissection, or hypovolaemia.

A negative test in a low-probability case has a very high negative predictive value.

A high pre-test probability or a positive result requires further work-up with imaging techniques.

Due to the non-specific nature of the assay, the D-dimer should be used only in low-probability settings, as many other conditions (e.g., surgery, malignancy, active infection, vascular disease, trauma) increase the D-dimer level.[81]Kearon C, de Wit K, Parpia S, et al. Diagnosis of pulmonary embolism with D-dimer adjusted to clinical probability. N Engl J Med. 2019 Nov 28;381(22):2125-34. https://www.nejm.org/doi/10.1056/NEJMoa1909159 http://www.ncbi.nlm.nih.gov/pubmed/31774957?tool=bestpractice.com

V/Q scan is a contrast medium-sparing procedure and may be appropriate for people with an allergy to contrast media, severe renal impairment (estimated creatinine clearance less than 30 ml/min) or a high risk from irradiation.[53]Duffett L, Castellucci LA, Forgie MA. Pulmonary embolism: update on management and controversies. BMJ. 2020 Aug 5;370:m2177. https://www.doi.org/10.1136/bmj.m2177 http://www.ncbi.nlm.nih.gov/pubmed/32759284?tool=bestpractice.com [82]National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Aug 2023 [internet publication]. https://www.nice.org.uk/guidance/ng158

Unlike CTPA, a V/Q scan can not provide an alternative diagnosis if PE is excluded.[80]Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). Eur Respir J. 2019 Sep;54(3). https://www.doi.org/10.1183/13993003.01647-2019 http://www.ncbi.nlm.nih.gov/pubmed/31473594?tool=bestpractice.com

Not diagnostic of PE but may be useful to support the diagnosis and is important to rule out other causes.[82]National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Aug 2023 [internet publication]. https://www.nice.org.uk/guidance/ng158

Decreased vascularity in one lung (Westermark's sign) causing unilateral lucency has been described.

Prominence of a central pulmonary artery or a wedge-shaped peripheral infiltrate (Hampton's hump) may be seen.

A large central pulmonary artery with abrupt tapering (Fleischner's sign) may also be observed.

Atelectasis and pleural effusions are common but non-specific.

Repeat platelet count in order to rule out pseudothrombocytopenia.

A CT scan provides a better yield than a CXR. [Figure caption and citation for the preceding image starts]: Aspergillus infectionFrom the personal collection of Dr Jeffrey Kanne, with permission [Citation ends].

Mucorales hyphae have a variable width of 6-24 micrometres), with a 90° branching angle.[75]Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis. 2019 Dec;19(12):e405-21. https://pmc.ncbi.nlm.nih.gov/articles/PMC8559573 http://www.ncbi.nlm.nih.gov/pubmed/31699664?tool=bestpractice.com ​ Fungi are best observed by using stains such as periodic acid Schiff or Gomori methenamine silver.

Mucorales hyphae have a variable width of 6-24 micrometres), with a 90° branching angle.[75]Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis. 2019 Dec;19(12):e405-21. https://pmc.ncbi.nlm.nih.gov/articles/PMC8559573 http://www.ncbi.nlm.nih.gov/pubmed/31699664?tool=bestpractice.com ​ Fungi are best observed by using stains such as periodic acid Schiff or Gomori methenamine silver. Used if a patient cannot have a CT guided biopsy.[75]Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the European Confederation of Medical Mycology in cooperation with the Mycoses Study Group Education and Research Consortium. Lancet Infect Dis. 2019 Dec;19(12):e405-21. https://pmc.ncbi.nlm.nih.gov/articles/PMC8559573 http://www.ncbi.nlm.nih.gov/pubmed/31699664?tool=bestpractice.com

May cause post-obstructive pneumonia. The majority of tumours are central.[77]Aydin E, Yazici U, Gulgosteren M, et al. Long-term outcomes and prognostic factors of patients with surgically treated pulmonary carcinoid: our institutional experience with 104 patients. Eur J Cardiothorac Surg. 2011 Apr;39(4):549-54. https://academic.oup.com/ejcts/article/39/4/549/524862 http://www.ncbi.nlm.nih.gov/pubmed/21282063?tool=bestpractice.com Usually rounded and highly vascularised.​[78]Chong S, Lee KS, Chung MJ, et al. Neuroendocrine tumors of the lung: clinical, pathologic, and imaging findings. Radiographics. 2006 Jan-Feb;26(1):41-57; discussion 57-8. http://www.ncbi.nlm.nih.gov/pubmed/16418242?tool=bestpractice.com

Endobronchial biopsy is usually required to differentiate from small-cell carcinoma.

Despite risk of bleeding, endobronchial biopsies are indicated.

Only a small percentage of foreign bodies are radiopaque.

Aspiration may have occurred many years previously. Comparison with old films is key. Suspect foreign body aspiration in cases of recurrent focal pneumonias. Occasionally expiratory films show air trapping that can be missed on inspiratory films.

Findings depend on the characteristics of the object and chronicity of the aspiration.

Flexible and rigid bronchoscopes are complementary tools. The choice depends on the operator's expertise, size of the object, age of the patient, and clinical presentation.[Figure caption and citation for the preceding image starts]: Loquat seed completely occluding the bronchus intermediusFrom the collection of Dr Septimiu Murgu and Dr Henri Colt; used with permission [Citation ends].

In cases where aspiration occurred months or years previously, bronchial stenosis, bronchiectasis, or an endobronchial mass or granulation tissue can be seen.

Chest CT scan delineates the location of the lobar and segmental opacities. In advanced cases, the findings may be indistinguishable from those of acute respiratory distress syndrome.

Necrosis, cavity formation, and empyema are potential complications of aspiration that are visualised better with CT than with plain CXR.

When broncholith erodes into the airway, it can be seen as an irregular hard white-grey stone, which may partially or totally obstruct the airway.

Thickened water-soluble contrast should be used.

This is a non-specific finding but suggests vascular injury, rib fractures, or patchy infiltrates.

Bronchoscopy serves as a diagnostic tool, but it may also help to secure the airway by guiding endotracheal intubation. The trans-oral route is preferred.

More common in lower lobes. Usually round or oval. Also known as an arteriovenous fistula.[83]Lee HN, Hyun D. Pulmonary arteriovenous malformation and its vascular mimickers. Korean J Radiol. 2022 Feb;23(2):202-17. https://pmc.ncbi.nlm.nih.gov/articles/PMC8814702 http://www.ncbi.nlm.nih.gov/pubmed/35029077?tool=bestpractice.com [84]Saboo SS, Chamarthy M, Bhalla S, et al. Pulmonary arteriovenous malformations: diagnosis. Cardiovasc Diagn Ther. 2018 Jun;8(3):325-37. https://pmc.ncbi.nlm.nih.gov/articles/PMC6039795 http://www.ncbi.nlm.nih.gov/pubmed/30057879?tool=bestpractice.com ​​

Patients with multiple arteriovenous malformations in the lung usually have arteriovenous communications in the skin, mucosa, and other organs.

Osler-Weber-Rendu syndrome (hereditary haemorrhagic telangiectasia) may be considered.

In patients with cirrhosis with hepatopulmonary syndrome, pulmonary artery enlargement in dependent lungs creates intrapulmonary shunt.

In cases of significant haemoptysis, a pulmonary angiogram is combined with bronchial artery embolisation.

The test involves intravenous injection of macroaggregated albumin labelled with technetium-99m. In the presence of right-to-left shunts, the radiolabelled particles traverse through the lungs and become trapped in the brain and kidneys. The shunt fraction is calculated by quantifying the renal uptake as a percentage of the total administered dose.

In cases of severe systemic arteriovenous malformation, chronic hypoxaemia may cause polycythaemia. However, more commonly, epistaxis may result in anaemia.

If present may indicate pulmonary-renal syndrome.

ANA: antinuclear antibodies.

C-ANCA: anti-neutrophil cytoplasmic antibodies.

Anti-GBM: anti-glomerular basement membrane antibodies.

Anti-DNA: antibodies to double-stranded DNA.

If positive may point to the underlying connective tissue disease.

Anti-neutrophil cytoplasmic antibody (ANCA) testing results depend on the extent and severity of the disease.

Generalised granulomatosis with polyangiitis is >90% cytoplasmic ANCA positive.

Limited granulomatosis with polyangiitis is 60% ANCA positive.

Granulomas on tissue obtained by bronchoscopy should also be stained and cultured for infectious agents.

A positive biopsy is strongly supportive of a diagnosis of vasculitis, and biopsies are recommended to assist in establishing a new diagnosis and for further evaluation of patients suspected of having relapsing vasculitis.[85]Yates M, Watts RA, Bajema IM, et al. EULAR/ERA-EDTA recommendations for the management of ANCA-associated vasculitis. Ann Rheum Dis. 2016 Jun 23;75(9):1583-94. https://ard.bmj.com/content/75/9/1583 http://www.ncbi.nlm.nih.gov/pubmed/27338776?tool=bestpractice.com

Granulomas on tissue obtained by CT-guided transthoracic needle aspiration should be identified by a pathologist and stained for infectious agents before a non-infectious cause is assumed.

Part of assessment for glomerulonephritis.

Part of assessment for glomerulonephritis.

Histological examination of biopsy material is useful in confirming a diagnosis in the context of clinical findings and laboratory data. A negative biopsy does not necessarily exclude disease, and a positive biopsy does not always indicate the presence of disease.[86]Miller A, Chan M, Wiik A, et al. An approach to the diagnosis and management of systemic vasculitis. Clin Exp Immunol. 2010 Jan 12;160(2):143-60. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2249.2009.04078.x http://www.ncbi.nlm.nih.gov/pubmed/20070316?tool=bestpractice.com

In congenital heart disease, haemoptysis can be caused by post-capillary pulmonary hypertension or mitral stenosis.

When infection occurs, an air-fluid level may be seen.

Slow growth can occur over a period of years.

If higher-than-water density is seen, this is related to proteinaceous material or calcium deposits.