Haemoptysis Algorithm

Safety

Red Flags — Is This an Emergency?

Done

Judge the emergency on the patient — breathing, oxygen saturation, circulation and whether bleeding is ongoing — not on an estimated volume alone. Death in massive haemoptysis is usually from asphyxiation, not blood loss.

Massive or ongoing haemoptysis Large volumes (cupfuls), continuous bleeding, or any amount with breathlessness, falling SpO₂, hypotension or tachycardia → 999 Sit up or lie on the bleeding side if known; oxygen if hypoxic; nil by mouth

Suspected pulmonary embolism Pleuritic pain, breathlessness, tachycardia, hypoxia, unilateral leg swelling, recent surgery or immobility → Same-day PE pathway (NICE NG158); 999 if hypotensive or collapsed

Pneumonia with sepsis or high CRB-65 RR ≥30, new confusion, low BP, SpO₂ below target → 999 if high-risk sepsis; CRB-65 of 2 or more → consider hospital referral, combined with clinical judgement (NICE NG250 1.2.3)

Bleeding on an anticoagulant Warfarin, a DOAC or heparin with more than streaks, or other bleeding sites → Same-day hospital assessment (major bleed → 999). Do not assume the anticoagulant is the whole explanation

Haemoptysis with haematuria, AKI or a vasculitic rash Possible pulmonary–renal syndrome (ANCA vasculitis, anti-GBM disease) → Same-day medical admission

Stridor or suspected inhaled foreign body → 999 if airway compromise; otherwise Same-day ENT / respiratory assessment

Unexplained haemoptysis aged 40 and over Smoking not required → Suspected cancer pathway lung referral (NICE NG12)

Suspected active TB Weeks of cough, fever, night sweats, weight loss, TB risk factors → Urgent TB service referral and notify UKHSA on suspicion (NICE NG33); Same-day if systemically compromised

Massive haemoptysis is often defined in the literature by volumes of 100–600 mL in 24 hours, but patients and clinicians estimate volume poorly; what matters is airway compromise, gas exchange and haemodynamic stability. Lying on the bleeding side protects the unaffected lung.

NICE NG12 (updated April 2026) recommends a suspected cancer pathway referral for anyone aged 40 and over with unexplained haemoptysis — smoking history is not required. PE commonly causes small-volume haemoptysis with pleuritic pain; the Wells score guides the NG158 pathway.

Diagnose

Is It Really From the Lungs? — History

Done

True or pseudohaemoptysis

Lungs: coughed up, bright red or frothy, mixed with sputum, alkaline. Nose or mouth: nosebleed, blood trickling down the back of the throat, bleeding gums. Gut (haematemesis): vomited, dark or coffee-ground, mixed with food, nausea, dyspepsia, melaena → see the Epistaxis or Haematemesis algorithms

Amount and pattern

Streaks or frank blood, single episode or recurrent, duration, getting worse

Infection

Acute cough, fever, purulent sputum, pleuritic pain — the commonest cause

Cancer

Age 40 and over, smoking (pack-years), asbestos or other occupational exposure, weight loss, appetite loss, persistent cough, chest pain, hoarseness, bone pain, fatigue

Sudden breathlessness, pleuritic pain, leg swelling, recent surgery, immobility, long travel, cancer, pregnancy or postpartum, oestrogen, previous VTE

Cough over 3 weeks, fever, night sweats, weight loss; born in or lived in a high-incidence country, contact with TB, homelessness, prison, drug or alcohol misuse, HIV or other immunosuppression (including biologics)

Bronchiectasis and COPD

Daily productive cough, recurrent chest infections, previous severe pneumonia or whooping cough; known COPD with an exacerbation

Drugs

Anticoagulants, antiplatelets, NSAIDs; cocaine smoking or inhalation; vaping

Systemic and cardiac

Haematuria, rash, joint pain, nasal crusting or sinus symptoms (vasculitis); orthopnoea and pink frothy sputum (pulmonary oedema); known mitral stenosis

Bleeding disorder

Easy bruising, other bleeding, liver disease, family history

Separating true haemoptysis from bleeding in the nose, mouth or upper gut changes the whole pathway. In adults, acute infection is the commonest cause; lung cancer, bronchiectasis, PE and TB are the must-not-miss diagnoses. Haemoptysis is one of the symptoms with the highest positive predictive value for lung cancer in primary care, especially in smokers over 40.

Diagnose

Targeted Examination

Done

Observations

RR, SpO₂ on air (against the patient's target), HR, BP, temperature, conscious level — calculate CRB-65 if pneumonia is likely; use a structured sepsis assessment (NICE NG253)

Nose and mouth

Anterior nasal bleeding point, posterior pharynx, gums and dentition (pseudohaemoptysis)

Chest

Focal crackles or bronchial breathing (pneumonia), coarse crackles (bronchiectasis), wheeze, effusion (dullness), stridor, pleural rub

Hands and nodes

Clubbing (lung cancer, bronchiectasis), tar staining, supraclavicular and cervical nodes

Legs

Unilateral swelling or tenderness (DVT)

Heart and other

Murmurs (mitral stenosis), raised JVP, oedema; skin rash, purpura or bruising; weight against previous records

Urine dipstick

Blood and protein — pointer to vasculitis

A normal chest examination does not exclude cancer, PE or TB. Clubbing with haemoptysis points strongly to lung cancer or bronchiectasis. A urine dipstick takes seconds and can be the only early clue to a pulmonary–renal syndrome.

Diagnose

Investigations

Done

Chest X-ray

CXR for every adult with true haemoptysis unless they are going straight to hospital. Aged 40 and over: the suspected cancer referral is made on the haemoptysis — many local pathways use a straight-to-test CXR or CT, but a normal CXR does not exclude lung cancer and must not stop the referral

Bloods

FBC (anaemia, platelets, infection), U&Es (renal involvement), CRP, clotting / INR if on warfarin or a bleeding disorder is suspected, LFTs; calcium if cancer is suspected

Sputum

Culture if infection or bronchiectasis; three sputum samples for AFB (microscopy, culture, rapid molecular testing) if TB is suspected — ideally one early-morning sample (NICE NG33)

Suspected PE

Two-level PE Wells score (NICE NG158): PE likely → same-day CTPA pathway; PE unlikely → D-dimer, positive → CTPA. PERC can be used when the pre-test probability is low

Urine

Dipstick; if blood or protein, urine ACR and urgent discussion (vasculitis)

Not in primary care

CT chest and bronchoscopy are arranged by the respiratory or lung cancer team; do not delay referral to arrange them

A CXR misses a meaningful proportion of lung cancers (central tumours, small lesions, those hidden behind the heart), which is why NG12 makes haemoptysis at 40 and over a direct referral criterion. TB is notifiable on clinical suspicion; do not wait for culture before notifying.

Diagnose

Differential Diagnosis

Done

Acute respiratory infection

Bronchitis or pneumonia: streaks with purulent sputum and fever. Commonest cause — but in smokers aged 40 and over it is a diagnosis made after a CXR, not instead of one

Lung cancer

Recurrent or persistent streaking, smoker, weight loss, clubbing, hoarseness, supraclavicular nodes

Pulmonary embolism

Small-volume haemoptysis with pleuritic pain, breathlessness, tachycardia and risk factors

Tuberculosis

Chronic cough, night sweats, weight loss, upper-zone shadowing or cavity on CXR, risk factors

Bronchiectasis

Daily purulent sputum, recurrent infections; haemoptysis often with exacerbations — confirmed on CT

COPD exacerbation

Known COPD with increased sputum; still consider cancer, as risk factors overlap

Anticoagulant or bleeding disorder

Bleeding on warfarin or a DOAC often unmasks an underlying lesion — investigate as for anyone else

Cardiac

Pulmonary oedema (pink frothy sputum), mitral stenosis

Vasculitis

Granulomatosis with polyangiitis, anti-GBM disease: sinus or nasal symptoms, haematuria, AKI

Pseudohaemoptysis

Epistaxis, gum bleeding, haematemesis, oropharyngeal or laryngeal lesions

Other

Inhaled foreign body (especially children), trauma, cocaine, arteriovenous malformation, aspergilloma; idiopathic only after specialist investigation

Several causes often coexist: a smoker with COPD and a chest infection may also have a cancer. Use the "unexplained" test of NG12 honestly — haemoptysis is explained only when a cause is confirmed and the symptom resolves with its treatment.

Refer

Referral — Route and Urgency

Done

999

Massive or ongoing bleeding, airway compromise, hypoxia below target, haemodynamic instability, suspected high-risk PE, high-risk sepsis

Same-day

Suspected PE (NG158 pathway); pneumonia with CRB-65 of 2 or more (consider hospital referral), or 1 where clinical judgement favours hospital assessment; bleeding on an anticoagulant beyond streaks; suspected pulmonary–renal syndrome; suspected TB with systemic compromise; inhaled foreign body

Suspected cancer pathway · NICE NG12

Aged 40 and over with unexplained haemoptysis; any age with a CXR suggesting lung cancer. Consider for persistent or recurrent haemoptysis under 40 with risk factors (clinical judgement, local pathway)

Urgent TB service

Suspected active TB (NICE NG33); notify UKHSA on clinical suspicion; do not start TB treatment in primary care

Respiratory clinic

Suspected bronchiectasis (needs CT); persistent or recurrent haemoptysis with a normal CXR and no cancer criterion met; known bronchiectasis or COPD with recurrent bleeding

Primary care manage

Under 40, a single episode of streaking with a clear infection, normal CXR and full resolution — with a clear plan to reassess if it recurs

CRB-65 (NICE NG250 1.2.3), always combined with clinical judgement: 0 = low severity, usually primary-care-led care with safety-netting advice; 1 = decide individually between primary-care-led care, a virtual ward, same-day emergency care, hospital at home or hospital; 2 or more = consider hospital referral (3–4 = high severity). Refer anyone with sepsis or cardiorespiratory failure whatever the score. Active pulmonary TB needs specialist multidrug treatment, contact tracing and public health input.

Treat

Management at This Consultation

Done

Low-severity pneumonia (CRB-65 0)

Amoxicillin First-line

Usual adult dose: amoxicillin 500 mg three times daily for 5 days (NICE NG250). Penicillin allergy: doxycycline 200 mg on day 1 then 100 mg once daily (5 days in total), or clarithromycin 500 mg twice daily for 5 days (erythromycin in pregnancy), per NG250 and the local formulary. Arrange a CXR if not already done; reassess at 48–72 hours

Acute bronchitis with streaks

No routine antibiotic

Self-care, paracetamol; antibiotics only if pneumonia or higher risk. Aged 40 and over the haemoptysis still meets NG12 unless a cause is confirmed and the bleeding resolves — do not wait for an infection to settle before acting on persistent or recurrent bleeding

On an anticoagulant

Assess the bleed, check INR

Streaks only and stable: check INR (warfarin), FBC and renal function, review the indication, dose and interacting drugs; do not stop anticoagulation without weighing the thrombotic risk (discuss with the prescriber). More than streaks → same-day hospital. Investigate the cause regardless

Suspected PE

Same-day PE pathway

Refer for same-day assessment and imaging. Interim anticoagulation is usually given while awaiting CTPA (NICE NG158), but with active haemoptysis the decision is made by the receiving team — discuss rather than start a DOAC in the surgery

Suspected TB

Notify, sputum, refer

Notify UKHSA, send three sputum samples, CXR, refer to the TB service. Avoid waiting-room exposure (mask, separate room). Do not prescribe empirical quinolones — they can mask TB

Bronchiectasis / COPD exacerbation

Sputum culture then antibiotic

Send sputum before antibiotics; choose by previous culture results and the local formulary. Bronchiectasis exacerbations are usually treated for 7–14 days (NICE NG117). COPD: per the COPD protocol

EveryoneSmoking — very brief advice and referral to stop-smoking services; record pack-years

PseudohaemoptysisTreat the source — nosebleed or upper GI bleeding pathway; ENT examination if a throat or laryngeal source is suspected (persistent hoarseness at 45 and over → suspected cancer pathway, head and neck)

Next steps: see Pulmonary embolism · Chest infections · COPD · Bronchiectasis · Antiplatelets and anticoagulants

Fluoroquinolones have activity against Mycobacterium tuberculosis and can delay the diagnosis of TB. Small-volume haemoptysis is common in PE and is not by itself an absolute contraindication to anticoagulation, but the balance needs to be judged by the team doing the imaging.

Lifestyle

Self-Care & Prevention

Done

Stop smoking The single biggest modifiable risk for lung cancer, COPD and recurrent infection; combine medication with behavioural support.

Avoid NSAIDs Use paracetamol for pain or fever while bleeding is being investigated, particularly if on an anticoagulant.

Keep a record Note each episode, amount and colour, and bring a sample or photograph if it recurs.

Airway clearance In bronchiectasis, daily physiotherapy techniques reduce exacerbations — refer to respiratory physiotherapy.

Vaccination Annual flu and pneumococcal vaccines for those eligible (COPD, bronchiectasis, older age).

Lung health checks Eligible ever-smokers aged 55 to 74 are invited for targeted lung cancer screening (NHS England) — screening does not replace referral for symptoms.

Even after a cancer referral, stopping smoking improves outcomes of treatment and reduces post-operative complications. Patient records of the bleeding help the specialist judge severity.

Safety

Follow-Up & Safety-Netting

Done

48–72 hours

Reassess infection treated at home: fever, breathlessness, sputum and bleeding should be improving

Suspected cancer referral

Check the appointment is booked and attended; diagnosis or cancer ruled out within 28 days (Faster Diagnosis Standard). If tests are normal but symptoms persist, re-refer or seek respiratory advice

About 6 weeks

Repeat CXR after pneumonia if symptoms or signs persist, or in people at higher risk of cancer such as smokers aged over 50 (BTS); NICE NG250 does not advise a routine follow-up CXR when symptoms have resolved

Any recurrence

Recurrent bleeding is no longer "explained" by a past infection — act on the NG12 criteria or refer to respiratory

Safety-net 999

Coughing up more than a few teaspoons of blood, bleeding that will not stop, severe breathlessness, chest pain, blue lips, collapse or feeling faint

Safety-net same-day

New breathlessness or pleuritic chest pain, a swollen painful leg, blood in the urine, high fever or confusion, any bleeding while on a blood thinner that is more than streaks

Repeat imaging after pneumonia identifies underlying cancer in a small but important proportion of higher-risk adults. Documenting the safety-net, including what counts as a large bleed, protects the patient and the clinician.

💉 Haemoptysis

Red Flags — Is This an Emergency?

Is It Really From the Lungs? — History

Targeted Examination

Investigations

Differential Diagnosis

Referral — Route and Urgency

Management at This Consultation

Self-Care & Prevention

Follow-Up & Safety-Netting