Haemoptysis

1. Overview

Haemoptysis means coughing up blood originating from the lower respiratory tract. It must be distinguished from blood coming from the nose, mouth, throat or gastrointestinal tract. In an OSCE, the first priority is to assess severity and decide whether this is minor haemoptysis or potentially life-threatening haemoptysis.

Common causes include acute bronchitis, pneumonia, bronchiectasis, tuberculosis, lung cancer, pulmonary embolism and pulmonary oedema. Anticoagulant use can worsen bleeding and should always be asked about.

Key OSCE priorities

• Confirm that the patient is coughing up blood, not vomiting blood or bleeding from the nose or mouth.
• Quantify the amount of blood.
• Assess airway compromise and oxygenation.
• Ask about cough, fever, sputum, chest pain, breathlessness and weight loss.
• Screen for tuberculosis, lung cancer, pneumonia, bronchiectasis and pulmonary embolism.
• Ask about smoking, anticoagulants and immunosuppression.
• Check observations and oxygen saturation early.
• Perform respiratory and cardiovascular examination.
• Escalate urgently if haemoptysis is large-volume, recurrent, associated with hypoxia or haemodynamic instability.

Important causes

• Acute bronchitis.
• Pneumonia.
• Bronchiectasis.
• Tuberculosis.
• Lung cancer.
• Pulmonary embolism.
• Pulmonary oedema.
• COPD exacerbation.
• Lung abscess.
• Fungal infection.
• Vasculitis, such as granulomatosis with polyangiitis.
• Anticoagulation-related bleeding.
• Trauma or recent bronchoscopy.

Red flag features

• Large-volume haemoptysis.
• Ongoing active bleeding.
• Shortness of breath.
• Low oxygen saturation.
• Chest pain.
• Syncope or collapse.
• Haemodynamic instability.
• Weight loss or anorexia.
• Night sweats or TB exposure.
• Heavy smoking history.
• Known lung cancer or suspected malignancy.
• Anticoagulant use.
• Immunosuppression.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about the blood they coughed up.
• Gain consent.
• Check whether the patient is currently coughing blood.
• Check whether the patient has severe breathlessness, chest pain, dizziness or feels faint.
• If acutely unwell, state that you would assess using ABCDE and call for senior help.

Confirm the source of bleeding

• Ask whether the blood was coughed up.
• Ask whether the patient vomited blood.
• Ask whether there was nausea or retching before the bleeding.
• Ask whether there is nosebleed, bleeding gums or blood from the mouth.
• Ask whether blood was mixed with sputum.
• Ask whether blood was bright red, dark, clotted, frothy or coffee-ground.
• Ask whether there is melaena or abdominal pain suggesting gastrointestinal bleeding.

Quantify the haemoptysis

• Ask whether it was streaks of blood, teaspoons, tablespoons, cups or larger amounts.
• Ask how many episodes occurred.
• Ask when the bleeding started.
• Ask whether it is ongoing.
• Ask whether the amount is increasing.
• Ask whether there are clots.
• Ask whether the patient is choking on blood.
• Ask whether they feel light-headed or faint.

Associated respiratory symptoms

• Cough.
• Sputum production.
• Change in sputum colour or volume.
• Shortness of breath.
• Wheeze.
• Pleuritic chest pain.
• Chest tightness.
• Fever.
• Rigors.
• Night sweats.
• Weight loss.
• Hoarseness.

Infection and pneumonia screen

• Fever.
• Rigors.
• Productive cough.
• Purulent sputum.
• Pleuritic chest pain.
• Breathlessness.
• Recent viral illness.
• Recent hospital admission.
• Aspiration risk.
• Immunosuppression.
• Confusion or reduced oral intake in older patients.

Tuberculosis screen

• Persistent cough.
• Fever.
• Night sweats.
• Weight loss.
• Loss of appetite.
• Fatigue.
• Previous TB.
• Close contact with TB.
• Travel or residence in a high TB prevalence area.
• Homelessness, prison exposure or crowded living conditions.
• HIV risk or known immunosuppression.

Lung cancer screen

• Persistent cough.
• Change in chronic smoker's cough.
• Unexplained weight loss.
• Loss of appetite.
• Chest pain.
• Hoarseness.
• Recurrent chest infections.
• Finger clubbing.
• Smoking history.
• Occupational exposure such as asbestos.
• Previous cancer.

Bronchiectasis screen

• Chronic productive cough.
• Large-volume sputum.
• Recurrent chest infections.
• Foul-smelling sputum.
• Previous severe pneumonia.
• Previous TB.
• Known bronchiectasis.
• Frequent antibiotic courses.
• Symptoms worse in the morning or with posture.

Pulmonary embolism screen

• Sudden breathlessness.
• Pleuritic chest pain.
• Syncope or collapse.
• Unilateral leg swelling or calf pain.
• Recent surgery.
• Recent immobility or long-haul travel.
• Active cancer.
• Previous DVT or PE.
• Pregnancy or postpartum state.
• Combined oral contraceptive pill or oestrogen therapy.
• Known thrombophilia.

Pulmonary oedema and cardiac screen

• Pink frothy sputum.
• Severe breathlessness.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Ankle swelling.
• Chest pain.
• Palpitations.
• Known heart failure.
• Previous myocardial infarction.
• Hypertension or valvular disease.

Vasculitis and diffuse alveolar haemorrhage screen

• Haematuria.
• Frothy urine.
• Reduced urine output.
• Rash or purpura.
• Joint pains.
• Sinus symptoms.
• Nosebleeds.
• Mouth ulcers.
• Weight loss.
• Known autoimmune disease.

Past medical history

• Previous haemoptysis.
• Asthma.
• COPD.
• Bronchiectasis.
• Previous pneumonia.
• Tuberculosis.
• Lung cancer.
• Pulmonary embolism or DVT.
• Heart failure.
• Valvular heart disease.
• Bleeding disorder.
• Chronic kidney disease.
• Autoimmune disease or vasculitis.
• Recent bronchoscopy, biopsy or thoracic procedure.

Drug history and allergies

• Anticoagulants such as warfarin, apixaban, rivaroxaban, dabigatran or heparin.
• Antiplatelets such as aspirin or clopidogrel.
• NSAID use.
• Recent thrombolysis.
• Current inhalers.
• Recent antibiotics.
• Steroids or immunosuppressants.
• Chemotherapy.
• Drug adherence.
• Recent medication changes.
• Drug allergies and reaction.

Family history

• Lung cancer.
• Tuberculosis exposure in family.
• Bleeding disorders.
• VTE or thrombophilia.
• Autoimmune disease or vasculitis.
• Inherited lung disease if relevant.

Social history

• Smoking status and pack-year history.
• Vaping.
• Alcohol intake.
• Recreational drug use.
• Occupation and asbestos, silica, dust or chemical exposure.
• TB contacts.
• Recent travel.
• Living conditions.
• Pets, birds or mould exposure.
• Baseline exercise tolerance.
• Living situation and support.
• Impact on work, sleep and daily activities.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the bleeding.
• Ask what they are most worried about.
• Ask whether they are worried about cancer, TB, infection or blood clots.
• Ask what they were hoping would happen today.
• Acknowledge that coughing blood is frightening and explain that it will be assessed carefully.

Red flags

• Large-volume bleeding.
• Ongoing haemoptysis.
• Breathlessness or hypoxia.
• Chest pain.
• Collapse or syncope.
• Haemodynamic instability.
• Weight loss.
• Night sweats.
• Heavy smoker.
• Known malignancy.
• Anticoagulant use.
• Immunosuppression.
• Recurrent haemoptysis.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would check observations, oxygen saturation, examine the respiratory and cardiovascular systems, and arrange urgent investigations depending on severity.

3. Physical Examination

The examination should assess severity, respiratory compromise, source of bleeding, signs of infection, malignancy, bronchiectasis, pulmonary embolism, heart failure and systemic disease.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask whether the patient is currently coughing blood or feels short of breath.
• Position the patient upright if breathless.
• Expose the chest appropriately while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment

• Look from the end of the bed.
• Assess whether the patient is comfortable, breathless, cyanosed, pale, sweaty or distressed.
• Assess whether the patient can speak in full sentences.
• Look for active coughing of blood.
• Look for sputum pot, tissues, oxygen therapy, nebulisers, suction or monitoring.
• Look for signs of large-volume blood loss or airway compromise.
• If acutely unwell, perform ABCDE assessment and call for senior help.

ABCDE assessment if acutely unwell

• Airway: assess whether blood is obstructing the airway and call for urgent help if airway compromise is present.
• Breathing: assess respiratory rate, oxygen saturation, work of breathing and auscultate the chest.
• Circulation: assess pulse, blood pressure, capillary refill, skin temperature, ECG monitoring and obtain IV access.
• Disability: assess consciousness level and capillary blood glucose.
• Exposure: check temperature, inspect for rash, bruising, DVT signs and systemic disease while maintaining dignity.

Vital signs

• Respiratory rate.
• Oxygen saturation.
• Heart rate.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Volume and frequency of ongoing haemoptysis if active.

Hands

• Look for peripheral cyanosis.
• Check capillary refill time.
• Look for finger clubbing.
• Look for nicotine staining.
• Look for palmar pallor suggesting anaemia.
• Look for bruising suggesting bleeding tendency or anticoagulation effect.
• Look for splinter haemorrhages if endocarditis is considered.
• Look for tremor or asterixis if relevant.

Pulse and blood pressure

• Assess pulse rate.
• Assess pulse rhythm.
• Tachycardia may suggest hypoxia, infection, PE or blood loss.
• Irregularly irregular pulse suggests atrial fibrillation and possible anticoagulant use.
• Measure blood pressure.
• Hypotension is concerning for severe bleeding, sepsis or massive PE.

Face, mouth and neck

• Look for central cyanosis.
• Look for conjunctival pallor.
• Inspect the nose and mouth for alternative bleeding source if appropriate.
• Look for poor dentition or oral bleeding.
• Assess cervical and supraclavicular lymph nodes.
• Look for cachexia or weight loss.
• Check tracheal position.
• Assess jugular venous pressure.

Chest inspection

• Inspect chest shape.
• Look for respiratory distress.
• Look for asymmetrical chest movement.
• Look for scars from thoracic surgery or procedures.
• Look for chest wall deformity.
• Observe respiratory pattern.
• Look for signs of chronic lung disease.

Palpation

• Assess chest expansion.
• Compare expansion bilaterally.
• Assess tactile vocal fremitus if consolidation or effusion is suspected.
• Palpate for chest wall tenderness.
• Confirm tracheal position.

Percussion

• Percuss symmetrical areas of the chest.
• Dullness may suggest consolidation, collapse, tumour or pleural effusion.
• Hyperresonance may suggest pneumothorax.
• Compare side to side.

Auscultation

• Auscultate symmetrical areas of the chest.
• Assess air entry.
• Listen for crackles.
• Listen for bronchial breathing.
• Listen for wheeze.
• Listen for pleural rub.
• Assess vocal resonance if consolidation or effusion is suspected.

Expected respiratory findings

• Focal crackles and bronchial breathing may suggest pneumonia.
• Coarse crackles may suggest bronchiectasis.
• Wheeze may suggest asthma, COPD or airway obstruction.
• Reduced breath sounds with dullness may suggest tumour, collapse or pleural effusion.
• Pleural rub may occur with pulmonary embolism or pleurisy.
• Normal examination does not exclude PE, early cancer or mild haemoptysis.

Cardiovascular examination

• Assess JVP.
• Auscultate heart sounds.
• Listen for murmurs.
• Look for signs of heart failure.
• Check for peripheral oedema.
• Pulmonary oedema can cause pink frothy sputum.
• Mitral stenosis can rarely be associated with haemoptysis.

Peripheral and systemic examination

• Check calves for unilateral swelling or tenderness if PE is suspected.
• Look for petechiae, purpura or bruising.
• Look for rash suggesting vasculitis.
• Assess for signs of anaemia.
• Assess abdomen for hepatosplenomegaly if systemic disease is suspected.
• Check temperature and signs of sepsis.

Specific findings to mention in haemoptysis OSCE

• Clubbing may suggest lung cancer, bronchiectasis or chronic suppurative lung disease.
• Fever and focal chest signs suggest pneumonia.
• Weight loss and lymphadenopathy raise concern for malignancy or TB.
• Unilateral leg swelling with pleuritic chest pain suggests PE.
• Raised JVP, crackles and oedema suggest pulmonary oedema.
• Bruising or pallor may suggest bleeding tendency or significant blood loss.
• A normal examination does not exclude serious pathology.

To complete the examination

To complete my examination, I would review observations, check oxygen saturation, assess ongoing bleeding volume, request chest X-ray, blood tests including full blood count and coagulation profile, group and save if significant bleeding, and arrange CT chest or CT pulmonary angiography, sputum tests or bronchoscopy depending on severity and suspected cause.

4. Differential Diagnosis

Infective causes

• Acute bronchitis.
• Pneumonia.
• Tuberculosis.
• Bronchiectasis exacerbation.
• Lung abscess.
• Fungal lung infection.
• Necrotising pneumonia.

Malignant causes

• Primary lung cancer.
• Endobronchial tumour.
• Metastatic lung disease.
• Tumour erosion into airway or vessels.

Vascular causes

• Pulmonary embolism.
• Pulmonary arteriovenous malformation.
• Pulmonary hypertension.
• Mitral stenosis with pulmonary venous hypertension.

Cardiac causes

• Acute pulmonary oedema.
• Heart failure.
• Mitral stenosis.
• Severe pulmonary hypertension secondary to cardiac disease.

Inflammatory and systemic causes

• Granulomatosis with polyangiitis.
• Goodpasture syndrome.
• Systemic lupus erythematosus.
• Diffuse alveolar haemorrhage.
• Coagulopathy.
• Anticoagulant or antiplatelet-related bleeding.

Other causes and mimics

• Epistaxis with swallowed or coughed blood.
• Haematemesis from gastrointestinal bleeding.
• Oral or dental bleeding.
• Trauma.
• Recent bronchoscopy or lung biopsy.
• Foreign body aspiration.

5. Investigations

Bedside tests

• Full observations.
• Oxygen saturation.
• Assess volume and frequency of haemoptysis.
• Sputum pot to quantify and inspect blood.
• Capillary blood glucose if acutely unwell.
• Urine dip for blood and protein if vasculitis or pulmonary-renal syndrome is suspected.
• Pregnancy test in women of reproductive age when relevant.

Blood tests

• Full blood count.
• Urea and electrolytes.
• Creatinine and estimated GFR.
• CRP.
• Coagulation profile.
• Group and save or crossmatch if significant bleeding.
• Liver function tests if coagulopathy or systemic disease is suspected.
• Blood cultures if sepsis or severe pneumonia is suspected.
• D-dimer only if PE is possible and clinical probability supports testing.
• ANCA, anti-GBM and autoimmune tests if vasculitis or pulmonary-renal syndrome is suspected.

Microbiology

• Sputum culture if infection is suspected.
• Sputum acid-fast bacilli testing if TB is suspected.
• Viral testing depending on local epidemiology and policy.
• Blood cultures before antibiotics if severe infection or sepsis is suspected.

Imaging

• Chest X-ray as an initial investigation in most patients.
• CT chest if chest X-ray is abnormal or suspicion remains high.
• CT pulmonary angiography if pulmonary embolism is suspected.
• CT bronchial artery angiography may help identify bleeding source in significant haemoptysis.
• Repeat imaging or urgent referral may be needed if haemoptysis persists despite normal initial tests.

Bronchoscopy

• May identify the site of bleeding.
• May identify endobronchial tumour or foreign body.
• May allow sampling for infection or malignancy.
• May help control bleeding in selected cases.
• Urgent bronchoscopy may be needed in massive or ongoing haemoptysis depending on stability and local expertise.

Other investigations

• ECG if PE, ACS, arrhythmia or cardiac disease is suspected.
• BNP or NT-proBNP if heart failure is suspected.
• Echocardiography if valvular disease, pulmonary hypertension or heart failure is suspected.
• Lower limb ultrasound if DVT is suspected.
• Renal investigations if pulmonary-renal syndrome is suspected.

Important investigation points

• Investigations depend on severity and stability.
• Do not delay emergency airway management for imaging in unstable massive haemoptysis.
• Chest X-ray can be normal despite serious causes.
• CT is useful for identifying cause and bleeding source.
• Bronchoscopy and CT are complementary in selected patients.
• Coagulation profile is important if the patient is anticoagulated or has significant bleeding.

6. Management

Management depends on volume, ongoing bleeding, oxygenation, haemodynamic stability and likely cause. In an OSCE, always separate minor haemoptysis from life-threatening haemoptysis.

Immediate approach if severe or unstable

1. Assess using ABCDE.
2. Call for senior, respiratory, anaesthetic, ICU and interventional radiology or thoracic surgery help as appropriate.
3. Sit the patient upright if able.
4. Give oxygen if hypoxaemic according to local protocol.
5. Use suction if available and appropriate.
6. Obtain large-bore IV access.
7. Send urgent bloods including FBC, U&E, coagulation profile and group and save or crossmatch.
8. Stop anticoagulants and antiplatelets temporarily if clinically appropriate and seek senior advice.
9. Reverse anticoagulation if life-threatening bleeding according to local protocol.
10. Prepare for airway protection if bleeding is compromising ventilation.

Positioning in significant haemoptysis

• If the bleeding side is known, position the patient bleeding side down.
• This helps protect the non-bleeding lung from flooding with blood.
• Avoid lying the patient flat if this worsens airway contamination or breathlessness.
• Prioritise airway, oxygenation and senior help.

Definitive control of bleeding

• Bronchoscopy may localise and temporarily control bleeding.
• CT angiography can help identify bleeding source in stable patients.
• Bronchial artery embolisation is an important treatment for significant or recurrent haemoptysis.
• Surgery may be needed rarely when bleeding is uncontrolled or due to resectable pathology.
• Management requires a multidisciplinary approach in severe cases.

If infection or pneumonia is suspected

• Assess severity and sepsis features.
• Give oxygen if hypoxaemic.
• Send sputum and blood cultures if indicated.
• Start antibiotics according to local antimicrobial guideline.
• Arrange chest imaging.
• Consider admission if hypoxic, unstable, elderly, frail or high risk.

If tuberculosis is suspected

• Use infection-control precautions.
• Arrange chest X-ray and sputum testing for TB.
• Notify or refer according to local TB pathway.
• Assess HIV risk and offer testing where appropriate.
• Assess close contacts if TB is confirmed according to public health guidance.
• Avoid inappropriate antibiotics that may delay diagnosis if TB is strongly suspected.

If lung cancer is suspected

• Arrange urgent chest imaging.
• Refer through urgent suspected cancer or respiratory pathway according to local protocol.
• Assess smoking history and occupational exposure.
• Assess performance status and comorbidities.
• Provide clear explanation and safety-net advice.

If pulmonary embolism is suspected

• Assess haemodynamic stability.
• Check oxygen saturation and give oxygen if hypoxaemic.
• Assess PE probability using local protocol.
• Arrange D-dimer or CTPA according to probability and local pathway.
• Anticoagulation decisions require senior input because haemoptysis may increase bleeding risk.
• Escalate urgently if hypotension, syncope, severe hypoxia or shock is present.

If anticoagulant-related bleeding is suspected

• Check indication for anticoagulation.
• Check medication, dose and last dose.
• Check renal function and coagulation profile.
• Temporarily withhold anticoagulant if clinically appropriate.
• Seek senior or haematology advice for reversal in major bleeding.
• Balance bleeding risk against thrombosis risk.

Minor haemoptysis management

• Assess for red flags and risk factors.
• Check observations and oxygen saturation.
• Arrange chest X-ray if clinically indicated.
• Treat likely cause such as infection according to local guidance.
• Review medication and anticoagulant use.
• Arrange follow-up if symptoms persist or recur.
• Safety-net for increasing bleeding, breathlessness, chest pain, fever, weight loss or recurrence.

Safety-net advice

• Seek urgent help if coughing up more blood.
• Seek urgent help if bleeding does not stop.
• Seek urgent help for breathlessness, chest pain, dizziness, collapse or blue lips.
• Seek urgent review for fever, weight loss, night sweats or persistent cough.
• Return urgently if haemoptysis recurs.
• Do not ignore haemoptysis in smokers or high-risk patients.

7. Examiner Questions

1. What is haemoptysis?
2. How do you confirm the blood is from the respiratory tract?
3. What are the common causes of haemoptysis?
4. What causes massive haemoptysis?
5. What red flags would you ask about?
6. How do you quantify haemoptysis?
7. What features suggest tuberculosis?
8. What features suggest lung cancer?
9. What features suggest pulmonary embolism?
10. What medications are important to ask about?
11. What investigations would you request?
12. What is the role of CT chest?
13. What is the role of bronchoscopy?
14. How would you manage massive haemoptysis?
15. Why is bleeding-side-down positioning used?

Suggested short answers

8. OSCE Pearls

• First confirm it is haemoptysis, not haematemesis or epistaxis.
• Always quantify the amount of blood.
• Large-volume haemoptysis is an airway emergency.
• Ask about anticoagulants and antiplatelets.
• Ask about smoking and lung cancer red flags.
• Ask about TB symptoms: fever, night sweats, weight loss and contact history.
• Ask about PE symptoms: pleuritic chest pain, sudden breathlessness and unilateral leg swelling.
• Bronchiectasis often gives chronic productive cough and recurrent infections.
• Check oxygen saturation early.
• Chest X-ray can be normal even in serious disease.
• CT chest is important when cause is unclear or serious pathology is suspected.
• Bronchoscopy can help localise bleeding and identify endobronchial lesions.
• Bronchial artery embolisation is important for significant or recurrent haemoptysis.
• Bleeding side down helps protect the normal lung when the bleeding side is known.
• Always safety-net recurrent or worsening bleeding.

9. Example Presentation to Examiner

10. References

• NICE Clinical Knowledge Summary: Cough.
• British Thoracic Society resources on bronchoscopy and respiratory investigation.
• European Respiratory Society literature on moderate-to-severe haemoptysis.
• Standard acute medicine approach to haemoptysis and massive haemoptysis.
• Local respiratory, emergency medicine, TB, interventional radiology and anticoagulation reversal protocols.