Diagnostic Imaging Pathways - Haemoptysis

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© Government of Western Australia

Diagnostic Imaging Pathways - Haemoptysis

Population Covered By The Guidance

This pathway provides guidance on the imaging of adult patients with confirmed haemoptysis.

Date reviewed: January 2012

Date of next review: 2017/2018
Published: January 2012
Quick User Guide

Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient
points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL RRL EFFECTIVE DOSE RANGE

None 0

Minimal < 1 millisieverts

Low 1-5 mSv

Medium 5-10 mSv

High >10 mSv

Pathway Diagram

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Image Gallery
Note: These images open in a new page

1 Post-Primary Pulmonary Tuberculosis

Image 1 (Plain Radiograph): Pulmonary tuberculosis is an important cause

of haemoptysis. This chest radiograph demonstrates patchy bilateral
opacification of the upper lung lobes with cavitation most marked on the left
(arrow) consistent with post-primary tuberculosis.
2 Pulmonary Haemorrhage

Image 2 (Plain Radiograph): There is widespread airspace opacification of

both lungs with air brochograms. This patient had bilateral pulmonary
haemorrhage due to Goodpasture's (Anti-GBM) syndrome.

3a Pulmonary Haemorrhage

Image 3a (Plain Radiograph) and 3b (Bronchial Angiogram): Image 3a

demonstrates right apical consolidation with cavitation due to mycetoma
formation on a background of tuberculosis (arrow). The bronchial artery was
embolised with gel foam and coils due to recurrent haemoptysis (Image 3b).
3b

Teaching Points
A chest radiograph may reveal a cause of haemoptysis
If there is a clinical suspicion of an underlying abnormality, CT of the chest is indicated
Further investigations are dictated by CT findings. This may include a bronchoscopy if a neoplastic
lesion is seen or an angiogram if a vascular abnormality is suspected
Massive haemoptysis (>300mL in 24hrs) is a medical emergency. Depending on whether the
patient is haemodynamically stable, diagnostic tests (e.g. CT scan) may be undertaken. However,
if the patient is compromised bronchoscopy is preferred initially, as it affords therapeutic
intervention at the same time

Bronchial Angiography

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Indicated when bronchial embolisation is intended 9

Angiographic signs of pulmonary haemorrhage include extravasation of contrast media,
hypervascularisation, abnormal arborisation of bronchial arteries, systemic-pulmonary shunts and
bronchial artery aneurysms

Bronchoscopy / Biopsy
Allows biopsies to be taken for histology or brushings and washings for cytology and microbiology
1,2,3,4
Provides the option of therapeutic intervention
Limitations - failure to visualise peripheral lesions 3,5
Disadvantages - invasive procedure with a risk of complications

Flexible Or Rigid Bronchoscopy

Urgent bronchoscopy is indicated in unstable patients with massive haemoptysis
Rigid bronchoscopy offers greater suctioning ability and maintenance of airway patency but flexible
bronchoscopy may be more appropriate for peripheral lesions 9,10
Precedes bronchial angiography and embolisation to locate the bleeding site (sensitivity 67%) 1

Computed Tomography (CT)

Most sensitive diagnostic test with a positive yield of 67% 1,5,6
Primary investigation in patients with normal or non-localising chest radiographs 6,9
Initial Chest CT before bronchoscopy in patients in whom the chest radiograph is abnormal or
suggestive of malignancy is cost effective in improving diagnostic yield from invasive diagnostic
procedures and in some cases, eliminates the need for any further investigation 3,6,7
In patients with non-massive haemoptysis, intravenous contrast is given if there are abnormalities
seen on the chest radiography
Useful for
Diagnosing peripheral airway disease, in particular, bronchiectasis, as well as
radiographically occult parenchymal neoplasms 3,6
Staging of bronchogenic carcinoma 8
Guiding percutaneous needle biopsy
Providing roadmap for both bronchial and transbronchial biopsy
Bronchiectasis is the second most common cause of haemoptysis diagnosed on CT. Multidetector
CT with thin collimation or conventional High Resolution CT is required to identify and define the
type and extent of this disease 3
More information on high resolution computed tomography (HRCT)
Limitations of CT - insensitive to early mucosal abnormalities 3,5

Bronchial Artery Embolisation

Effective treatment adjunct to control bronchial bleeding and reduces the need for high-risk
emergency lung resections (immediate control of bleeding in 75-93% of cases) 10,11,12
Aims to reduce the systemic arterial perfusion pressures to the fragile vessels within inflammatory

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tissue and to try to prevent the development and enlargement of non-bronchial systemic arterial
collaterals 9
Reserved for patients with life threatening haemoptysis
Helps avoid surgery in patients who are not good surgical candidates 11
Limitations 11,12
20% recurrence rate
Potential complications include accidental embolisation of the spinal artery either by
contrast material or the embolising particles causing ischaemic injury to the spinal cord
0-20% technical failure rate due to inability to cannulate the vessel, instability of the
catheter tip, or visualisation of anterior spinal artery

High Resolution Computed Tomography (HRCT)

Investigation of choice for suspected bronchiectasis which is the second most common cause of
haemoptysis. 3
Thick slice helical CT is not effective as a screening modality for bronchiectasis.

Chest Radiograph (CXR)

May detect a cause of haemoptysis in 40-50% of cases 1,10
Patients with negative chest radiograph and two or more risk factors for malignancy (>50yrs old,
>40 pack year smoking history) need to be further investigated 2
Patients with fewer than two risk factors for malignancy can be followed by observation 2

References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine,
Levels of Evidence. Download the document

1. Hirshberg B, Biran I, Glazer M, et al. Hemoptysis: etiology, evaluation, and outcome in a

tertiary referral hospital. Chest. 1997;112:440-4. (Level II/III evidence)
2. Poe RH, Israel RH, Marin MG, et al. Utilization of fiberoptic bronchoscopy in patients with
hemoptysis and a nonlocalizing chest roentgenogram. Chest. 1988;93(1):70-5. (Level II/III
evidence)
3. McGuiness G, Beacher JR, Harkin TJ, et al. Hemoptysis: prospective high-resolution CT /
bronchoscopic correlation. Chest. 1994;105:1155-62. (Level II/III evidence)
4. Lederle FA, Nichol KL, Parenti CM. Bronchoscopy to evaluate hemoptysis in older men with
nonsuspicious chest roentgenograms. Chest. 1989;95:1043-7. (Level III evidence)
5. Set PAK, Flower CDR, Smith IE, et al. Hemoptysis: comparative study of the role of CT and
fiberoptic bronchoscopy. Radiology. 1993;189:677-80. (Level II/III evidence)
6. Millar AB, Boothroyd AE, Edwards D, et al. The role of computed tomography (CT) in the
investigation of unexplained hemoptysis. Respir Med. 1992;86(1):39-44. (Level II/III evidence)
7. Laroche C, Fairbairn I, Moss H, et al. Role of computed tomographic scanning of the thorax
prior to bronchoscopy in the investigation of suspected lung cancer. Thorax. 2000;55:359-63.
(Level II evidence). View the reference
8. Nadich DP, Funt S, Ettenger NA, et al. Hemoptysis: CT-bronchoscopic correlation in 58 cases.
Radiology. 1990;177(2):357-62. (Level II/III evidence)

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9. Marshall TJ, Flower CDR, Jackson JE. The role of radiology in the investigation and
management of patients with haemoptysis. Clin Radiol. 1996;51:391-400. (Review article)
10. Jean-Bapiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med.
2000;28:1642-7. (Review article)
11. Swanson KL, Johnson CM, Prakash UBS, et al. Bronchial artery embolization: experience with
54 patients. Chest. 2002;121:789-95. (Level III evidence)
12. Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery
embolisation for life threatening hemoptysis. Chest. 1999;115:996-1001. (Level III evidence)

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