← Full haemoptysis algorithm
Reasoning GP · Algorithm · 1-page summary

Haemoptysis

For: adults coughing up blood in primary care. Not for: children (consider inhaled foreign body and paediatric advice); bleeding from the nose or vomited blood (epistaxis and haematemesis algorithms).
Reviewed October 2026 · next review April 2027
NICE NG12NICE NG158NICE NG250NICE NG33BTS
Core rule: unexplained haemoptysis at 40 and over is a suspected cancer referral whatever the smoking history — and a normal chest X-ray does not exclude lung cancer.

0Stop — call 999 now — judge breathing, SpO₂ and circulation, not volume alone

  • Massive or ongoing bleeding, or any amount with breathlessness, falling SpO₂, hypotension or tachycardia → 999; sit up or lie on the bleeding side, oxygen if hypoxic.
  • Suspected PE with hypotension or collapse, high-risk sepsis, or stridor with airway compromise → 999

1Triage — is it from the lungs?

FeaturePoints to
Coughed, bright red, frothyTrue haemoptysis → this pathway
Nosebleed, gums, throatPseudohaemoptysis → treat the source
Vomited, dark, with foodHaematemesis → upper GI pathway
Age 40 and overUnexplained → Suspected cancer referral

2Screen

  • Pleuritic pain, breathlessness, leg swelling, VTE risk → Same-day PE pathway (NG158)
  • Pneumonia: CRB-65 of 2 or more → consider hospital referral; 1 → decide individually (primary care, virtual ward, SDEC or hospital), with clinical judgement.
  • On an anticoagulant, more than streaks → Same-day hospital
  • Haematuria, AKI or vasculitic rash → Same-day admission
  • TB features + risk factors → Urgent TB service; notify UKHSA

3Assess

☐ RR, SpO₂, HR, BP, temperature, CRB-65  ☐ Nose and mouth  ☐ Chest, clubbing, nodes  ☐ Legs  ☐ Urine dipstick  ☐ CXR, FBC, U&E, CRP, INR if on warfarin  ☐ Sputum culture; three AFB samples if TB suspected  ☐ Smoking pack-years

Do not: delay referral for CT or bronchoscopy, or give empirical quinolones (mask TB).

4Classify

  • Acute infection — commonest; streaks with purulent sputum and fever → treat, but CXR if 40 and over or a smoker.
  • Lung cancer — smoker, weight loss, clubbing, recurrent streaks → suspected cancer referral.
  • PE — pleuritic pain, tachycardia → same-day.
  • TB — chronic cough, night sweats → TB service.
  • Bronchiectasis / COPD — daily sputum, exacerbation → sputum, antibiotic, respiratory clinic.
  • Uncertain — recurrent or persistent with a normal CXR → respiratory referral.

5Treat today — doses: NICE/SPC, BNF, local formulary

  • Low-severity pneumonia: amoxicillin 500 mg three times daily for 5 days; reassess at 48–72 hours.
  • Anticoagulated, streaks only: INR, FBC, renal function; do not stop without weighing thrombotic risk.
  • Suspected PE: same-day pathway; receiving team decides interim anticoagulation.
  • Everyone: stop-smoking support; paracetamol rather than NSAIDs.

6Refer routinely

  • Respiratory clinic: suspected bronchiectasis (CT); recurrent bleeding with a normal CXR and no NG12 criterion.
  • Primary care: under 40, single episode with clear infection, normal CXR and full resolution.

7Never reassure by

  • A normal chest X-ray in someone aged 40 and over.
  • "Never smoked" — NG12 does not require smoking.
  • An infection that "explains" recurrent bleeding.
  • Anticoagulation as the whole explanation.
  • An estimated small volume in a breathless or hypoxic patient.

8Safety-net — say it, then document it

999 “Call 999 if you cough up more than a few teaspoons of blood, it will not stop, you become very breathless, have chest pain or feel faint.” Same day “Contact us the same day with new breathlessness or chest pain, a swollen painful leg, blood in your urine, or any bleeding on a blood thinner that is more than streaks.”

Referred: diagnosis or cancer ruled out within 28 days. Any recurrence → act on NG12 or refer.

✓Safe to manage in primary care only if — all five, documented

True haemoptysis confirmed; no block 0–2 feature Under 40, or NG12 referral made Observations, chest and legs examined; CXR arranged Cause named; review booked Safety-net given; smoking addressed
Summary of the full Reasoning GP haemoptysis algorithm, which holds the detail and evidence. Sources: NICE NG12 (updated April 2026); NICE NG158; NICE NG250; NICE NG33; BTS bronchiectasis guideline. Clinical reference — follow local pathways and check doses in the current SPC/BNF.