ACR Appropriateness Criteria®
Clinical Condition: Hemoptysis
Variant 1: Two risk factors (>40 years old and >40 pack-year history).
| Radiologic Procedure |
Appropriateness Rating |
Comments |
| X-ray, chest |
9 |
Baseline. Repeat chest x-rays when clinically indicated. In certain clinical settings, may not need to proceed to CT imaging. |
| CT, chest, with or without contrast |
9 |
Without contrast may be performed to simply localize bleeding site prior to bronchoscopy. With contrast–may show source of bleeding and not need CTA. |
| CTA, chest |
5 |
To evaluate source of bleeding (i.e., systemic or pulmonary artery vascular supply). If contrast enhanced MDCT is performed, CTA may not be needed. |
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 2: Persistent/recurrent hemoptysis and two risk factors (>40 years old, >40 pack-year history).
| Radiologic Procedure |
Appropriateness Rating |
Comments |
| X-ray, chest |
9 |
Baseline. Repeat chest x-rays when clinically indicated, (e.g., during episodes of recurrent hemoptysis). In certain clinical settings, may not need to proceed to CT imaging (e.g., diagnosis of chronic bronchitis). |
| CT, chest, with or without contrast |
9 |
Without contrast - to localize bleeding site prior to bronchoscopy. With contrast - may show source of bleeding and not need CTA. |
| CTA, chest |
6 |
With contrast - to evaluate source of bleeding (i.e., systemic or pulmonary artery vascular supply). If contrast enhanced MDCT is performed, CTA may not be needed. |
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Variant 3: Massive hemoptysis without cardiopulmonary compromise.
| Radiologic Procedure |
Appropriateness Rating |
Comments |
| X-ray, chest |
9 |
Portable if patient unstable. |
| INV, lung, bronchial artery embolization |
8 |
If clinically feasible. |
| CT, chest, with or without contrast |
9 |
If clinically feasible. Contrast preferred if not contraindicated. With contrast – may show source of bleeding and not need CTA. |
| CTA, chest |
5 |
If clinically feasible, to evaluate source of bleeding (i.e., systemic or pulmonary artery vascular supply), especially before bronchial artery embolization. If contrast enhanced MDCT is performed, CTA may not be needed. |
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Note: Abbreviations used in the tables are listed at the end of the "Major Recommendations" field.
Summary of Literature Review
Hemoptysis is defined as the expectoration of blood that originates from the tracheobronchial tree or pulmonary parenchyma. Life-threatening hemoptysis is rare. Most cases are benign, self-limiting events. However, the presentation of hemoptysis may be a harbinger of significant underlying tracheopulmonary pathology. Common causes of hemoptysis include chronic bronchitis, bronchiectasis, pneumonia, fungal infections, tuberculosis, and malignancy.
The majority of patients will have an identifiable source and etiology for the bleeding at the time of initial diagnosis. Cryptogenic hemoptysis, for which no cause can be identified, is responsible for 3.0%–42.2% of episodes of hemoptysis, particularly in smokers. It is a diagnosis of exclusion and might be expected to decrease in prevalence with more systematic use of computed tomography (CT).
Bronchoscopy versus CT
There is controversy in the literature regarding the use of CT vs. bronchoscopy when further study is indicated. This controversy is further compounded by the lack of a consistent clinical approach for evaluating patients with hemoptysis. Bronchoscopy, performed with either a rigid or a flexible fiberoptic endoscope, is useful in identifying a specific site of bleeding, diagnosing active hemorrhage, and controlling the airway in patients with catastrophic hemorrhage. However, its capacity to help localize the site of bleeding is equivalent to that of radiography or CT, and it is less useful in detecting an underlying disease process. The airways are often filled with blood at the time of bronchoscopy, making evaluation of the distal airways difficult.
Several articles have cited cases of hemoptysis with negative chest radiograph and bronchoscopy in which CT subsequently showed malignancies. In addition, CT can establish the diagnosis of bronchiectasis. Refer to the original guideline document for a brief review of some of the pertinent studies along with their varying conclusions.
Guidelines
Several articles have addressed the need for further evaluation of patients with negative or nonlocalizing chest radiographs. The overall diagnostic yield in this category of patients is low. However, there is a well-recognized 3%–10% incidence of malignancy in this population. One study reported that almost one-quarter of patients presenting with acute hemoptysis secondary to malignancy had normal chest radiographic findings, yet, clear guidelines for the initial workup and follow-up in patients without a definitive diagnosis are missing.
A review study of 119 cases of hemoptysis with negative chest radiographs recommended that patients younger than 40 years old who had negative chest radiographs be managed with observation only.
Another study with 196 patients with negative chest radiographs and subsequent bronchoscopy found by univariate and discriminant analysis three predictors of malignancy. Risk factors were found to include: sex (male), age 50 years or older, and >40 pack year smoking history. If the criteria of two to three risk factors or bleeding, in excess of 30 mL over a period of 24 hours were met, 100% of the cancers would have been found with an overall diagnostic yield of 82%. The use of bronchoscopy would have been reduced by 28%.
In another study, 119 bronchoscopies performed in patients with hemoptysis and negative or nonlocalizing findings on chest radiographs were evaluated. There was no significant difference in the rate of cancers or diagnostic yield at bronchoscopy between patients with normal chest radiograph versus those with nonlocalizing findings. The authors recommended an initial approach of observation and reserving bronchoscopy for persistent hemoptysis, development of focal chest radiograph findings or those at risk for malignancy. They suggested using the risk factors mentioned above but with the lower age limit changed to 40 years.
Another group of researchers reported that for smokers with hemoptysis of unknown origin who are >40 years of age, approximately 6% of them will have a lung cancer that manifests within 3 years. The authors recommend additional follow-up testing in patients presenting with hemoptysis in which the underlying cause was not detected at initial radiography.
In certain cases, it may be useful or even necessary to perform follow-up CT several months after the episode of hemoptysis to study the evolution of underlying parenchymal lung abnormalities or to exclude the possibility that a small malignancy may have been missed at initial CT.
Because of increasing frequency of lung cancer in women (the chance that a man will develop lung cancer is 1 in 13 and for a woman, it is 1 in 17), male gender should not be considered one of the risk factors.
Imaging
The imaging modalities pertinent to the evaluation of hemoptysis include chest radiograph, CT, multidetector CT (MDCT), and thoracic aortography–bronchial artery embolization. There is uniform recognition of the efficacy of chest radiograph in the initial stages of evaluation. Radiography can help lateralize the bleeding with a high degree of certainty and can often help detect underlying parenchymal and pleural abnormalities.
Conditions such as bronchiectasis, lung malignancy, tuberculosis, and chronic fungal infection are some of the most common underlying causes of hemoptysis and are easily detected with CT.
MDCT angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of hemorrhage into the airways and helps guide subsequent management. Contrast-enhanced MDCT can demonstrate the site of bleeding as accurately as bronchoscopy and detect underlying disease with high sensitivity. MDCT provides for high-resolution angiographic studies of the thoracic and upper abdominal vasculature, which are useful prior to anticipated bronchial artery embolization or surgical intervention.
Bronchial Artery Embolization
Bronchial artery embolization has been shown to be an effective therapy in the control of massive hemoptysis. Nonsurgical interventions for hemoptysis may be used as an interim solution before surgery or may constitute definitive therapy in a patient who is a not a candidate for surgery. In over 90% of cases of hemoptysis requiring intervention with arterial embolization or surgery, the bronchial arteries are responsible for the bleeding. Failure to recognize the presence of a nonbronchial systemic arterial supply in patients with massive hemoptysis may result in recurrent bleeding after successful bronchial artery embolization.
Peripheral pulmonary artery pseudoaneurysms occur in up to 11% of patients undergoing bronchial angiography for hemoptysis. Occlusion of the pulmonary artery pseudoaneurysm may require embolization of bronchial or nonbronchial systemic arteries or pulmonary artery branches.
Bronchoscopy before bronchial artery embolization is unnecessary in patients with hemoptysis of known causation if the site of bleeding can be determined from radiographs or CT and no bronchoscopic airways management is needed.
The following guidelines are recommended:
- Initial evaluation of patients with hemoptysis should include a chest radiograph.
- Patients at high risk for malignancy (>40 years old, >40 pack-year smoking history) with negative chest radiograph, CT scan, and bronchoscopy can be followed with observation for the following 3 years. Radiography and CT are recommended imaging modalities for the follow-up. Bronchoscopy may complement imaging during the period of observation.
- In patients who are at high risk for malignancy and have suspicious chest radiograph findings, CT is suggested for initial evaluation.
- Massive hemoptysis can be effectively treated with either surgery or percutaneous embolization. Contrast enhanced MDCT prior to embolization or surgery will define the source of hemoptysis to be bronchial systemic, nonbronchial systemic and/or pulmonary arterial. Percutaneous embolization may be used initially to halt the hemorrhage prior to definitive surgery.
Abbreviations
- CT, computed tomography
- CTA, computed tomographic angiography
- INV, invasive
- MDCT, multidetector computed tomography
