Volume, duration, true cough vs vomiting vs epistaxis
Fever, weight loss, night sweats, TB exposure, smoking
VTE risks; cocaine/crack; anticoagulation
Known bronchiectasis, aspergilloma, cancer, rheumatic heart disease
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Your objective: explain the approach, recognize important warning signs, then test your recall.
Abbreviations explained
- ACS
- Acute coronary syndrome
- OMI
- Occlusion myocardial infarction
- ECG
- Electrocardiogram
- PE
- Pulmonary embolism
- POCUS
- Point-of-care ultrasound
- QTc
- QT interval corrected for heart rate
- LBBB
- Left bundle branch block
- RBBB
- Right bundle branch block
- hs-cTn
- High-sensitivity cardiac troponin
- CTA
- Computed tomography angiography
- ICU
- Intensive care unit
Filter
The jobProtect the good lung; find whether this is massive.
- Confirm true hemoptysis (not hematemesis or a nosebleed).
- Massive is about the airway and gas exchange, not a millilitre cutoff.
- Bleeding lung down; call bronchoscopy and IR.
- Stable small-volume still needs a cancer/TB/PE plan in the right host.
Hemoptysis is blood from below the glottis.
First separate true hemoptysis from hematemesis and nasopharyngeal bleeding. Massive hemoptysis is defined variably (often ≥100 mL/h or ≥300–500 mL/24 h, or any volume that threatens the airway) — the practical definition is airway compromise or abnormal gas exchange. Place the bleeding lung down, call IR and pulmonology, and resuscitate.
Massive / airway-threatening hemoptysis Critical
Key: Sit up, bleeding-side down, low-volume ventilation of the good lung; reverse coagulopathy; call bronchoscopy and bronchial-artery embolization.
Diffuse alveolar hemorrhage Critical
Key: Falling hemoglobin, dropping saturations, bilateral infiltrates — capillaritis, cocaine, anticoagulants; bronchoscopy, immunosuppression per cause.
Pulmonary embolism Critical
Key: Hemoptysis can be the presenting feature; do not assume “bronchitis” in a patient with VTE risks.
Lung cancer / aspergilloma / bronchiectasis Critical
Key: The most common sources of massive bleeding in adults — CT and IR, not a discharge inhaler.
TB / necrotizing pneumonia / lung abscess Critical
Key: Fever, night sweats, endemic or reactivation risk — isolation + imaging + micro.
Mitral stenosis / pulmonary venous hypertension Emergent
Key: The cardiac cause that is easy to forget — murmur, AF, echo.
Bronchitis / mild bronchiectasis flare Common
Key: Small-volume, clear CXR, stable — still need a plan to exclude cancer in smokers over 40.
Tick what your patient has — the banner updates as you go.
Airway and work of breathing; which side sounds worse
Hemodynamic stability; fever
Clubbing, cachexia, cervical nodes
Cardiac
rumbling diastolic murmur of MS, AF
Oropharynx and nose to exclude an upper source
Bedside
- Upright posture; bleeding lung dependent if the side is known
- SpO₂, CXR, POCUS lungs; type & crossmatch if more than streaks
Labs
- CBC (the hemoglobin lags), coagulation, type & screen
- Sputum AFB/GeneXpert when TB is possible; BNP if cardiac suspicion; D-dimer/PE pathway if indicated
Imaging / procedures
- CXR first; CT chest (CTPA if PE is on the list) is the localizing study in stable patients
- Bronchoscopy for ongoing airway bleeding; bronchial-artery embolization for massive bleeding
Medication safety reminder
Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.
Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.
Discharge
- Streaks in a well patient with a clear CXR, no cancer/TB/VTE red flags, and arranged follow-up (including outpatient CT in smokers ≥40 y with a first episode).
Admit
- Recurrent or moderate-volume bleeding, need for further imaging, infection on IV therapy, anticoagulation management.
ICU / IR / bronchoscopy
- Airway-threatening or massive hemoptysis, DAH, unstable PE, need for embolization or intubation.
Use objective reassessment and the local pathway.
Before the next decision · reassess and hand over
Use these learning prompts with the presentation’s pathway. They are not discharge criteria.
- Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
- Warning signs for Hemoptysis:
- Any volume with hypoxia, shock, or inability to protect the airway
- Rapidly falling hemoglobin or bilateral infiltrates (DAH)
- TB risks with hemoptysis
- Anticoagulation with more than streaks
- Known aspergilloma, cavity, or cancer
- Hemoptysis plus VTE risks
- Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
- Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
- Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Clinical Pearls
- Massive is about gas exchange and airway, not a millilitre cutoff.
- Bleeding lung down, good lung up.
- Bronchial-artery embolization is the intervention of choice for most massive non-traumatic hemoptysis.
- Always ask: is this actually hematemesis or a nosebleed?
Pitfalls
- Intubating and laying the bleeding lung up drowns the good lung — bleeding side down.
- A normal CXR does not exclude a significant source — CT is the localizer in the stable patient.
- Do not use nebulized TXA as the only plan for massive bleeding — it is an adjunct, not a substitute for IR/airway.
- Hematemesis and posterior epistaxis are repeatedly mislabelled as hemoptysis — look in the mouth and the nose.
- Cancer until proven otherwise in a smoker with new hemoptysis, even if the volume is small.
PRACTICE REFRESHER
Rapid recall
Test your first action and the dangerous diagnoses before revealing the answer.
01 · First move
Before you scroll, what needs to happen first?
Confirm true hemoptysis (not hematemesis or a nosebleed).
02 · Immediate threats
Name at least two diagnoses that cannot wait.
Massive / airway-threatening hemoptysis · Diffuse alveolar hemorrhage · Pulmonary embolism
PRIVATE TO THIS DEVICE
Your learning note
Capture a weak point, a teaching pearl, or a question to take to your next shift.
Review schedule starts when marked reviewed
Selected guidance · source check 2026-09-07. These 1 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.
- Rosen’s Emergency Medicine, 10th ed. (2023) — hemoptysis
- BTS / ACCP hemoptysis statements; bronchial artery embolization series
- Tintinalli’s 9th ed. — pulmonary hemorrhage