JIACM 2002; 3(1): 14-22
CLINICAL MEDICINE
Approach to a Patient with Haemoptysis and
Normal Chest X-Ray
Rita Sood*, Sima Mukhopadhyaya**
Haemoptysis is a common clinical problem
reported to be the cause of attendance in 7-15%
of patients coming to chest clinics1. However, it is
a non-specific symptom and can occur in about
100 different clinical conditions2. Expectoration of
even relatively small amount of blood is an
alarming symptom and can be a marker for
potentially dangerous disease like bronchogenic
carcinoma. On the other hand, massive
haemoptysis can represent an acutely life-
threatening problem. Therefore, haemoptysis of
any degree needs thorough evaluation. The aim
of evaluation is to find treatable cause and at
times, to reassure the patient. Although in some
cases the aetiology may be readily apparent, in
others it may present a difficult diagnostic problem.
Despite thorough evaluation, upto 30% of patients
show no identifiable aetiology for their
haemoptysis3. These patients are classified as
having idiopathic or ‘cryptogenic’ haemoptysis.
The severity of haemoptysis has been arbitrarily
divided into mild, moderate, or severe depending
upon the amount of bleeding4. It is called mild if
less than 30 ml of blood is expectorated per day
or there is only streaking or flecks of blood in the
sputum. Haemoptysis is moderate if bleeding is
between 30 to 200 ml/day and severe if bleeding
occurs in excess of 200 ml/day. Massive
haemoptysis has been variably defined as blood
loss of 200-600 ml or more within 48 hours or as
much as to cause haemodynamic disturbance1,5.
Haemoptysis has been classified as single if there
is one episode of bleeding lasting upto 7 days,
but usually 1-2 days. It is called recurrent when
* Additional Professor
Department of Medicine
** Professor and Head
Department of Radiodiagnosis,
All India Institute of Medical Sciences,
New Delhi-110 029.
the bleeding continues for longer than 7 days or
there is a break in the continuity of at least 2-3
days 6. When pure blood without sputum is
expectorated, it is called frank haemoptysis.
Aetiopathogenesis
Lungs have dual blood supply, the low-pressure
pulmonary artery and high-pressure bronchial
artery supply. Bleeding of bronchial artery origin
is therefore more massive, consists usually of
fresh blood and may or may not be mixed with
sputum.
The mechanisms of bleeding from the
tracheobronchial tree include :

Inflammation of bronchial mucosa which
becomes vascular and friable and therefore
more amenable to erosion and bleeding,
e.g., chronic bronchitis;

Necrosis and infarction of pulmonary
parenchyma as occurs in pulmonary embolism
and infarction and necrotising pneumoniae;

Invasion of blood vessels by tumour resulting
in bronchial haemorrhage;

Rupture of distended pulmonary capillaries
or veins due to increased pulmonary
pressures as occurs in pulmonary oedema
due to mitral stenosis or left ventricular
failure;

Intracavitary anastomoses between bronchial
and pulmonary circulation as occurs in
bronchiectasis, lung abscess, pulmonary
tuberculosis, etc;

Erosion of bronchial wall and vessels by
calcified tuberculous lymph nodes or
broncholithiasis; and

Vasculitis of pulmonary vessels as may occur
in Wegener ’s granulomatosis or lupus
pneumonitis.
As blood originating from nasopharynx or Diagnostic approach to a patient with
gastrointestinal tract can mimic blood coming haemoptysis
from lower respiratory tract, it is important to rule
out bleeding from these alternative sites. An History is valuable in suggesting causes like
aetiologic classification of haemoptysis based bronchitis, bronchiectasis, lung abscess,
on the site of origin within the lungs is shown in pulmonary embolism, and infarction. A history
Table 17. of risk factors for bronchogenic carcinoma,
previous or co-existing disorders like renal,
Table I : Causes of haemoptysis. cardiac, collagen vascular diseases, etc. may
give clues to the cause of haemoptysis. A
Tracheobronchial source
thorough physical examination may provide

Neoplasm (bronchogenic carcinoma,
helpful clues to diagnosis. A chest radiograph
endo-bronchial metastatic tumour Kaposi’s
(CXR) is essential for the diagnostic evaluation
sarcoma, bronchial carcinoid)
of haemoptysis. It may provide evidence of mass

Bronchiectasis lesion, bronchiectasis, and focal or diffuse

Broncholithiasis parenchymal diseases. Depending upon the

Airway trauma clinical evaluation, the other diagnostic tests

Foreign body include a sputum examination for infective
causes particularly tuberculosis and sputum
Pulmonary parenchymal source
cytology for malignant cells. Bronchoscopy and

Lung abscess
computed tomography of the chest are the other

Pneumonia
very useful investigations. Bronchography was an

Tuberculosis important modality in earlier years for the

Mycetoma (‘fungus ball’) diagnosis of bronchiectasis but is obsolete now.

Goodpasture’s syndrome
A chest X-ray generally provides direction for

Idiopathic pulmonary haemosiderosis further work-up of the patients, as to the need for

Wegener’s granulomatosis other diagnostic tests. However, about 20-30%

Lupus pneumonitis of patients with haemoptysis may show CXR

Lung contusion which is normal or non-localising8. Chest X-ray
is considered non-localising if it shows non-
Primary vascular source
specific findings like increased bronchovascular

Arterio-venous malformation
markings, peri-bronchial thickening, pleural

Pulmonary embolism thickening, hyperinflation, minimal apical

Elevated pulmonary venous pressure capping, scattered hilar calcification, etc9. Some
(mitral stenosis) of the lung parenchyma is obscured by ribs,

Pulmonary artery rupture secondary to diaphragm, mediastinal structures, and clavicle,
balloon-tip pulmonary artery catheter and therefore abnormalities localised behind
manipulation these structures may not show-up on plain chest
Miscellaneous/rare causes radiographs.

Pulmonary endometriosis
Evaluation of a patient with

Systemic coagulopathy or use of
anticoagulants or thrombolytic agents
haemoptysis and normal CXR
Haemoptysis should be differentiated from bleeding from In a patient who has haemoptysis and normal
sources other than lower respiratory tract, i.e., upper airways or non-localising chest X-ray, an important aim
and gastrointestinal tract.
of investigation is to identify the few patients with

Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 1
January-March 2002 15

lung cancer, while subjecting many patients
without lung cancer to the smallest number of
tests needed to diagnose (NTND). A detailed
history must be elicited to distinguish spitting and
coughing of blood from sources other than lower
respiratory tract. Bleeding diathesis and cardiac
causes of haemoptysis can be excluded by
careful history and examination. Physical
examination must include thorough evaluation
of the nasopharynx and larynx. Sputum
examination, particularly for acid fast bacilli
(AFB) and malignant cells in patients at high risk
for bronchogenic malignancy must form a part
of work-up. Bronchoscopy and computed
tomography (CT) of chest play an important role
in patients with haemoptysis and normal CXR.
Role of FOB
Fibreoptic bronchoscopy (FOB) is an
investigation of proven efficacy in evaluating
patients with central endobronchial disease. In
addition, FOB is also useful in locating the source
of bleeding, removal of blood clots which may
produce obstruction and embolisation of vessels
to control bleeding. The other potential
therapeutic uses are local application of
fibrinogen-thrombin for treatment of massive
haemoptysis, endobronchial brachytherapy for
treatment of primary and recurrent
bronchogenic carcinoma.
The role of fibreoptic bronchoscopy in the
evaluation of haemoptysis and a mass lesion on
X-ray is undisputed 8. However, there is less
agreement about the need of the procedure in
patients with normal chest X-ray. Even though the
procedure is relatively benign, the small
complication rate and patient discomfort warrant
balancing of risk against benefit before
undertaking FOB10. Most experts feel that the
major function of FOB in the evaluation of
haemoptysis is to exclude bronchogenic
carcinoma, since early surgical treatment is the
only effective treatment. Patients usually have a
benign cause and good prognosis after a negative
FOB even if haemoptysis recurs11. Whether FOB is
16 Journal, Indian Academy of Clinical Medicine
always indicated in this group of patients has been
the subject of debate over the last few years.
Several studies have evaluated the incidence of
carcinoma in patients with haemoptysis and a
normal chest X-ray. In most series of such
patients who underwent bronchoscopy, the
incidence of bronchogenic carcinoma has
ranged from 0-16% with an average of 5.2%.
(Table II) Zavala et al found a significant
incidence of tumours in patients with
haemoptysis and non-localising chest
radiographs12 . Other authors, however, have
failed to confirm this4,13-19. Given this low yield,
it is useful to know the subgroup at risk, to
improve the cost-effectiveness of FOB and
eliminate the unnecessary risk. The low
probability of finding carcinoma in a patient
with haemoptysis and a normal CXR reflects the
fact that haemoptysis is usually a late symptom
of lung cancer by which time most of the patients
would show abnormal chest X-ray findings.
Heimer et al reviewed retrospectively the clinical
characteristics and diagnostic yield of FOB in
45 patients with normal or non-localising chest
X-ray 4. A follow-up was available for upto 3
years. In none of their patients any evidence of
malignancy was found either at the time of initial
evaluation or at the time of follow-up. This was
true for all age groups and for smokers as well
as non-smokers. The authors concluded that
routine FOB is not indicated in patients with
haemoptysis who have normal CXR as risk of
malignancy in this group is very small. They felt
that the presence of occasional recurrence of
haemoptysis does not appear to add to risk of
malignancies and does not per se constitute an
indication for FOB. A careful follow-up was
however, recommended.
However, Heaton, in a review of bronchoscopic
records of 41 patients who had presented with
haemoptysis and a normal CXR found a diagnosis
of bronchogenic carcinoma in 4 patients (9.7%)
and concluded that the yield was sufficiently high
to justify the use of FOB in such patients15.

Vol. 3, No. 1
January-March 2002
In another retrospective review of 48 patients most likely to be diagnostic9. They identified 196
who underwent FOB for evaluation of patients with haemoptysis and a normal or non-
haemoptysis with normal CXR, specific diagnosis localising CXR who underwent FOB. They examined
other than endobronchial inflammation was the relationship of advancing age, sex, smoking,
obtained only in four patients. One patient had non-specific CXR findings and the amount,
benign polyp, one showed Mycobacterium duration, and previous bouts of haemoptysis to
tuberculosis in bronchial washings, and two had the incidence of diagnostic FOB. Twelve patients
bronchogenic carcinoma. All the four patients (6%) had bronchogenic carcinoma and in 33 (17%)
were men older than 40 years with a smoking another specific cause was identified by FOB. Both
history of 40 pack years or more. Three out of univariate and multivariate analysis identified
four had recurrent haemoptysis 14. In another three clinical findings associated with a diagnosis
bronchoscopic evaluation of 106 men more than of bronchogenic carcinoma. (Table III) An age of
40 years old who had presented with 50 years or more, male sex, and smoking of 40
haemoptysis and a non-suspicious CXR, Lederly pack-years or more best predicted a diagnosis of
et al discovered six of them to have bronchogenic malignancy. Bronchogenic carcinoma was not
malignancy (5.7%). All the patients with cancer discovered in any of the 51 patients who never
were smokers and tended to have greater smoked. Bleeding in excess of 30 ml daily was
duration of haemoptysis. The majority of cancers associated with an increase in overall diagnostic
detected in this study were resectable16. yield.
Table II : Incidence of malignancy in patients with haemoptysis and normal CXR
Study Ref. Year No. of pts. with No. of pts. with
normal CXR malignancy (%)
Zavala et al 12 1975 55 9 (16.3)
Heimer et al 04 1985 45 0 (0.0)
Adelman et al 13 1985 67 1 (1.4)
Jackson et al 14 1985 48 2 (4.1)
Heaton 15 1987 41 4 (9.7)
Lederle et al 16 1989 106 6 (5.6)
Suri et al 17 1990 60 4 (6.6)
Jindal et al 18 1990 155 7 (4.5)
Sharma et al 19 1991 53 0 (0.0)
Total pts. 630 33 (5.23)

In the Indian studies, the diagnostic yield of FOB
in patients with haemoptysis and normal CXR
has varied from 0% to 6.6% as far as malignancy
is concerned17-19. Mycobacterium tuberculosis
was recovered from bronchial secretions in a
small number of patients.
In view of the low diagnostic yield of FOB for
malignancy in such patients, Poe et al developed
predictors that identify the patient in whom FOB is
Using these three predictors of malignancy,
authors further analysed the use of bronchoscopy
in this population. It was noted that limiting
bronchoscopies to patients with two or more risk
factors would have identified 100% of
carcinomas (Table IV) and would have reduced
the number of procedures overall by 28%.
While Poe and co-authors identified no cases of
bronchogenic carcinoma in patients younger

Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 1
January-March 2002 17

than 50 years, it is known to occur. About 5% of
955 patients with bronchogenic carcinoma seen
at Boston Veterans Affairs Medical Center were
less than 45 years of age10. Similar data have
been reported by Cortese et al who found that
5.5% of their patients with roentgenographically
occult lung cancer were younger than 50 years20.
bronchogenic carcinoma 21 .
Role of computed tomography
Computed tomography (CT) has come to play
a very important role in patients with chest
diseases. Many times, this procedure has
detected otherwise unappreciated, but treatable

Table III : Clinical features associated with FOB diagnosis of bronchogenic carcinoma
Features No. of pts. No. with carcinoma P value
n-196 (%) n-12 (%)
Age > 50 yrs 142 (72) 12 (100) <0.01
Male sex 114 (58) 11 (92) <0.02
Active smoking 90 (46) 6 (50) NS
Smoking > 40 pack yrs 87 (44) 11 (92) <0.01
Quantity of bleeding
<30 ml 128 (65) 8 (67) NS
>30-200 ml 49 (25) 2 (17)
>200 ml 19 (10) 2 (17)
Duration > 1 week 115 (59) 6 (50) NS
Previous episode 22 (11) 0 (00) NS
Non-specific CXR 78 (40) 5 (42) NS
Poe et al.Chest 1998;92:70-5

Table IV : Clinical features vs bronchoscopic conditions22. Conventional CT with 8/8 mm cuts

diagnosis of malignancy in 196 patients. can detect abnormalities in the larger airways.
Data No. of Clinical However, for peripheral airways particularly sub-
features* segmental bronchi, high resolution CT with 1/
10 mm cuts can be very informative. CT has
3 2 1 0
been shown to be accurate in the diagnosis of a
Bronchoscopic diagnosis wide range of abnormalities including both
of malignancy central tumours as well as peripheral
Yes 10 02 00 00 abnormalities particularly bronchiectasis. CT
No 47 51 65 21 findings in bronchiectasis were described in
Total 57 53 65 21 198223. As each bronchus is accompanied by a
* Three clinical features are (1) age > 50 yrs, (2) > 40 pack pulmonary artery, bronchiectasis frequently
years of smoking, and (3) male sex. produces a ‘signet ring’ sign. Thin section CT or
In view of these data, and observations by high resolution CT (HRCT) has been found to
Lederly and co-authors, it has been suggested have a sensitivity of 98% and specificity of 99%
that substituting age 40 years old instead of for the diagnosis of bronchiectasis, when
50, in the criteria proposed by Poe et al would compared to bronchography 24 . There was
be justified and should increase the sensitivity agreement between the two modalities in
of FOB in identifying patients with identifying different types of bronchiectasis. Since

18 Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 1
January-March 2002

then, HRCT has almost replaced bronchography
for the diagnosis and localisation of
brochiectasis.
In a series of 102 patients, CT was compared to
FOB to study its role in detection of bronchial
disease. CT was positive in 59 of the 64 cases in
which lesions were detected endoscopically
giving a sensitivity of about 92%25. Only in 5
patients of 64, did CT show normal airways in
the presence of focal bronchial disease detected
by FOB. In no case was the diagnosis of
malignancy missed by CT. While very accurate
in detecting focal lesions, CT was inaccurate in
predicting whether a given abnormality was
endobronchial, sub-mucosal, or peri-bronchial.
Also, a negative CT scan cannot be assumed
definitive in patients for whom there is a strong
clinical suspicion of endobronchial disease. The
results of this study support the use of CT in
screening patients for whom there is a low clinical
suspicion of endobronchial disease, especially
in young patients with haemoptysis and normal
CXR.
Similar observations were reported by Set et al,
in a prospective comparative study of FOB and
HRCT in patients with haemoptysis, with normal
or abnormal CXR26. Authors noted that CT scans
demonstrated all 27 tumours found at
bronchscopy and an additional seven, five of
which were beyond bronchoscopic range.
However, CT was insensitive in detecting early
bronchial abnormalities, bronchitis, and
squamous metaplasia, all detected at
bronchoscopy.
A prospective study on the role of CT in
evaluation of unexplained haemoptysis in 40
patients showed abnormalities in 50% of
patients. These abnormalities were tuberculosis,
malignancy and vascular abnormalities 27 .
Another study reported a diagnostic yield of 53%
in patients with haemoptysis and normal CXR28.
The various aetiologies were bronchiectasis
(20%), tuberculosis, pneumonia, bronchial
carcinoid, and allergic bronchopulmonary
Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 1
aspergillosis. No malignancy was detected and
none of the patients with normal CT had
recurrence of haemoptysis on follow-up.
Although chest X-rays are useful in the diagnosis
of pulmonary tuberculosis, minimal exudative
tuberculosis can be missed on a plain chest
radiograph. CT often detects occult parenchymal
disease or adenopathy when CXR is normal.
Hatipoglu et al have reported that centrilobular
densities in and around small airways and ‘tree
in bud’ appearance were the most characteristic
CT features of tuberculous disease activity29. CT
clearly differentiated old fibrotic lesions from
new active lesions and demonstrated early
bronchogenic spread.
CT Vs FOB
Comparative studies have been conducted on
the role of CT and FOB in the evaluation of
patients with haemoptysis and normal CXR. In a
prospective study performed by Patricia et al on
91 patients with haemoptysis, CT of the chest
and FOB were performed in all the patients
within 2 weeks of each other30. Forty-two patients
had normal CXR. A diagnosis was made on the
basis of bronchoscopic findings in 8 and on CT
findings in 7. Two carcinomas were detected by
both the means. Bronchiectasis localised to a
single lobe and distal airways was evident in 5
patients on CT where bronchoscopy was normal.
In 49 patients who had abnormal X-rays, a
diagnosis was made more often at CT than at
bronchoscopy, i.e., 48 vs 31. CT scans
demonstrated all 25 carcinomas diagnosed at
bronchoscopy. In addition, CT demonstrated 8
tumours, 5 of which were in the lung periphery
and confirmed pathologically by percutaneous
needle biopsy. In 9 patients, CT showed
evidence of unsuspected bronchiectasis where
bronchoscopy was non-informative.
Another study evaluated 50 patients with
haemoptysis and normal or non-localising CXR
using FOB and HRCT 31. A definitive diagnosis
was established in 17 patients (34%). The

January-March 2002 19
diagnosis was made by HRCT in 15
patients whereas FOB was
diagnostic in 5. No patient showed
evidence of malignancy. Three
showed endobronchial tumours, all
of whom were detected on CT
(Fig.1). However, histological
diagnosis was achieved only on
bronchoscopic biopsy. Twelve
patients showed bronchiectasis on
HRCT, all these patients had normal
or non-diagnostic bronchoscopies
(Fig.2). In one patient, who showed
non-specific abnormality on CT,
bronchial washings were positive for
Mycobacterium tuberculosis. Fig. 1 : Carcinoid left main bronchus, CT scan showing small mass inside left main
bronchus without causing obstruction.
A prospective study with blinded
interpreters using HRCT and FOB
designed to evaluate 57 patients
with haemoptysis and normal CXR
was conducted with assumption that
both procedures would likely
provide unique and complementary
information32. Aetiologies identified
included bronchiectasis (25%),
tuberculosis (16%), lung cancer
(12%), aspergilloma (12%), and
bronchitis (5%). All patients with lung
cancer were diagnosed both by
HRCT and FOB. HRCT was of
particular value in diagnosing
bronchiectasis and aspergillomas
while FOB was helpful in diagnosing Fig. 2 : Left lower lobe bronchiectasis, CT scan showing collapse of left lower lobe with
bronchitis and mucosal lesions. The cystic bronchiectasis, not seen in PA view of chest due to retrocardiac location.
high sensitivity of CT in identifying
both the intraluminal and extraluminal extent of both central and peripheral airways, and should
central lung cancers in conjunction with its value be useful in patients with haemoptysis and
in diagnosing bronchiectasis suggest that CT normal CXR. It allows the identification of
should be obtained prior to bronchoscopy in otherwise unsuspected abnormalities particularly
patients with haemoptysis. bronchiectasis and peripheral lung tumours.
Also, by precisely defining the extraluminal extent
Naidich et al in a CT-bronchoscopic correlation
of lesions in relation to bronchi and mediastinal
in 58 cases concluded that HRCT plays an
structures, it allows optimisation of
important role in screening patients presenting
bronchoscopic techniques.
with haempotysis33. These studies suggest that
HRCT effectively delineates abnormalities of When both CT and FOB fail to detect any

20 Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 1
January-March 2002

abnormality or lung cancer in presence of high
risk factors, patients should be subjected to serial
follow-up chest x rays when cancer not detected
initially would become apparent.
CT first or FOB first
As is evident from the literature, most cancers
found in patients with haemoptysis and a normal
CXR are in the central airways9,12. FOB allows
direct visual examination and collection of
histologic samples from the proximal
endobronchial tree. However, FOB is not useful
in detecting small tumours within the lung
parenchyma 22 . CT may detect both
endobronchial and parenchymal abnormalities,
but does not allow histologic confirmation of
abnormal findings as lung cancer. It might be a
useful non-invasive screen for choosing invasive
diagnostic tests. Proximal endobronchial
abnormalities detected by CT would need further
assessment by FOB and those in the periphery
and lung parenchyma by transthoracic needle
aspiration. Patients without abnormalities on CT
would be spared invasive diagnostic procedures.
Whether the clinician should choose CT or FOB
as the first diagnostic option in evaluating
patients of haemoptysis with normal CXR is still
debatable. Objective methods for developing
patient care algorithms such as mathematical
modelling and cost effectiveness are popular.
However, physicians are not always comfortable
with expressing outcomes in strictly economic
terms. An alternative approach providing
objective guidelines to the clinician choosing
between diagnostic strategies, the concept of the
number of tests needed to diagnose (NTND) has
been introduced34. With the NTND method, the
different diagnostic approaches to the clinical
problem are outlined and the number of
diagnostic tests needed to identify all the cases
(in this clinical scenario, all the patients with
haemoptysis and a normal CXR who have lung
cancer) is calculated for each approach.
On the basis of the existing literature, in an
Journal, Indian Academy of Clinical Medicine
Vol. 3, No. 1
analysis of the NTND in a hypothetical cohort
of patients presenting with haemoptysis and
normal CXR, Colice has found that number of
tests needed to diagnose (NTND) malignancy
will be much more if CT was performed first than
if FOB was performed first in this group of
patients.
Assumption based on existing literature on the
occurrence of malignancy in patients with
haemoptysis and normal CXR and utility of CT
and FOB in diagnosing these cases, has been
used to calculate the NTND these cancers in such
patients. Analysis shows that the NTND would
be 101, if FOB is performed first and 134 if CT
is performed first.
However, this analysis does not consider the
possibility that CT would provide diagnostic
explanations for haemoptysis due to causes
other than lung cancer. As has been discussed,
CT is especially useful for detecting
bronchiectasis and some cases of early
pulmonary tuberculosis. As the incidence of
malignancy in patients with haemoptysis and
normal CXR is low and bronchiectasis and
tuberculosis are important causes of
haemoptysis in India, it is suggested that a CT
scan should precede bronchoscopy in patients
with haemoptysis and normal CXR.
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Prime - Reviewers of JIACM
(1st January to 31st December, 2001)
JR Sankaran (Chennai)
Nitya Nand (Rohtak)
OP Kalra (Delhi)
Rita Sood (New Delhi)
Pratap Sanchetee (Jodhpur)
Rohini Handa (New Delhi)
22 Journal, Indian Academy of Clinical Medicine
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RSK Sinha (New Delhi)
Ravindra Kumar Garg (Lucknow)
Naveen Garg (Lucknow)
Praveen Aggarwal (New Delhi)
Naresh Gupta (New Delhi)
BO Tayade (Aurangabad/Nagpur)

Vol. 3, No. 1
January-March 2002