Clinical Commander

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symptom.hemoptysis.v1

Hemoptysis (massive / submassive / mild)

symptomacutesubacuteundifferentiatedadultacuteinpatientoutpatient
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Phase C shard-3-neuro-sym deepening pass (2026-05-14) — full §5.5 contract depth. Pattern peer: symptom.vertigo.v1 (2026-05-14) + symptom.chest_pain.ed_undifferentiated.v1 (be7b7d2f). Engine scope: triage + risk-stratification + airway/bleed control + etiology workup for the coughing-blood patient (ED + ICU + inpatient + outpatient). Downstream confirmed diagnoses route to pulm.pe.core.v1 (PE with hemoptysis), pulm.tuberculosis.v1 (active TB), pulm.cap.core.v1 (CAP / lung abscess), pulm.copd.core.v1 (bronchiectasis exacerbation — closest extant engine), renal.rpgn.core.v1 (pulmonary-renal vasculitis / DAH). Bayesian linkage (LR+, LR−, T_treat, T_test, conditional dependencies, pre-test priors by setting) lives in companion depth bundle _briefs/symptom.hemoptysis.v1.depth.md — schema has no first-class likelihood-ratio field. 5 setting playbooks (home — rare, only for low-volume episodic with completed workup; ed — airway-first bleeding-side-DOWN + IR mobilization; icu — massive with mechanical vent + BAE + MTP; inpatient — submassive workup + therapeutic bronch; outpatient — mild streaking + cancer screen + bronchiectasis maintenance). 14 severity triggers (≥6 per spec): massive_life_threatening_hemoptysis + submassive_hemoptysis + mild_streaking_hemoptysis + pseudohemoptysis + infectious_pneumonia_lung_abscess + tb_cavitary_with_isolation + pe_with_hemoptysis_route + vasculitis_pulmonary_renal + malignancy_lung_cancer_concern + anticoagulant_associated_hemoptysis + aspergilloma_with_hemoptysis + bronchiectasis_or_cf_exacerbation_with_hemoptysis + hht_pulmonary_avm_with_hemoptysis + iatrogenic_or_trauma_hemoptysis. 3 sibling differentiation rows (pulm.pe.core.v1 + pulm.tuberculosis.v1 + renal.rpgn.core.v1) — all verified to exist in ALL_DOSSIERS registry. Additional look-alikes (CAP, bronchiectasis, lung cancer, HHT, mitral stenosis, Eisenmenger, mycetoma, iatrogenic) captured as severity triggers + pivots in depth bundle. Schema-blocked items surfaced: hemoptysis volume codifier, Fartoukh massive hemoptysis severity score, BAE outcome tracker, ANCA-pattern codifier (cross-engine), TB isolation codifier — none in clinical-tools-registry.ts; cross-shard tickets emitted to shard-0 (registry maintainer). Modern view captured: BAE is first-line definitive treatment for massive hemoptysis (Yu 2010 PMID 28703105 — primary success 85-95%; rebleed 10-30% at 1 yr; mortality drops from ~50-80% untreated to ~10-25% with BAE). Position bleeding side DOWN protects non-bleeding lung. Selective single-lumen large-bore intubation of NON-bleeding mainstem rescues airway flooding. Rituximab non-inferior to cyclophosphamide for ANCA-vasculitis induction (RAVE PMID 20647199). Anticoag reversal ONLY when massive — underlying lesion still requires workup. PMIDs (10): CHEST 2018 (31374211), Larici 2014 (24808437), Yu 2010 (28703105), HHT Faughnan 2020 (32894695), USPSTF 2021 (33687470), RAVE (20647199), Cochrane TXA 2018 (30321510), ATS/IDSA TB 2016 (27516382), ACR 2021 ANCA (34235894), Savale 2007 (31164971). All marked NEEDS_SOURCE_REVIEW per shard convention.

Entry points (6)

  • symptom
    Coughing blood, blood-streaked sputum, or frank hemoptysis (CHEST 2018 PMID 31374211)
    cough_with_blood
  • symptom
    Massive hemoptysis (>100-200 mL/24 h OR any volume causing gas exchange / hemodynamic / airway compromise) (CHEST 2018 PMID 31374211; Larici 2014 PMID 24808437)
    massive_hemoptysis
  • symptom
    Submassive 30-100 mL/24 h — admit for workup (CHEST 2018)
    submassive_hemoptysis
  • symptom
    Mild streaking <30 mL/24 h — outpatient workup if low-risk (CHEST 2018)
    mild_streaking_hemoptysis
  • symptom
    Recurrent hemoptysis with prior workup pending (CHEST 2018)
    recurrent_hemoptysis
  • symptom
    Bloody sputum mimicking hemoptysis — GI source / epistaxis / oropharynx (CHEST 2018)
    pseudohemoptysis

Required inputs (31)

  • agerequired
    demographic • used at CONTEXT
    Age >40 + smoking → cancer prior shifts up (USPSTF 2021 PMID 33687470); pediatric think foreign body / CF (CHEST 2018)
  • sex
    demographic • used at CONTEXT
    HHT pulmonary AVM (Faughnan 2020 PMID 32894695) female ≥ male; menstrual catamenial hemoptysis rare (endometriosis)
  • spo2required
    vital • used at RED_FLAGS
    Gas-exchange compromise drives massive functional definition (CHEST 2018 PMID 31374211)
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic compromise drives massive functional definition (CHEST 2018)
  • rrrequired
    vital • used at RED_FLAGS
    Tachypnea + accessory muscle use → airway flooding (CHEST 2018)
  • hrrequired
    vital • used at RED_FLAGS
    Tachycardia from hypovolemia / hypoxia (CHEST 2018)
  • estimated_volume_24hrequired
    symptom • used at FRAME
    Stratifies massive (>100-200 mL) vs submassive (30-100 mL) vs mild (<30 mL) (CHEST 2018 PMID 31374211; Larici 2014 PMID 24808437)
  • duration_recurrencerequired
    symptom • used at FRAME
    Acute single vs recurrent vs chronic (CHEST 2018)
  • true_vs_pseudorequired
    symptom • used at FRAME
    Distinguish true hemoptysis from hematemesis (acidic, food, dark) and epistaxis / oropharyngeal source (CHEST 2018)
  • tb_riskrequired
    history • used at CONTEXT
    TB is worldwide #1 cause of hemoptysis; endemic, immunocompromised, incarceration, prior TB (ATS/IDSA 2016 PMID 27516382)
  • smoking_historyrequired
    history • used at CONTEXT
    Lung cancer (especially squamous) prior (USPSTF 2021 PMID 33687470)
  • bronchiectasis_or_CFrequired
    history • used at CONTEXT
    Recurrent hemoptysis from chronic suppurative lung disease — bronchiectasis / CF (CHEST 2018)
  • recent_pe_dvt_riskrequired
    history • used at CONTEXT
    PE can present with hemoptysis (pulmonary infarct, 5-10% of PE) — route to pulm.pe.core.v1 (CHEST 2018)
  • mitral_stenosis_or_HF
    history • used at CONTEXT
    Pink frothy sputum from pulmonary edema vs true hemoptysis; rheumatic mitral stenosis (CHEST 2018)
  • hht_or_avm_history
    history • used at CONTEXT
    Hereditary hemorrhagic telangiectasia — pulmonary AVM risk (Faughnan 2020 PMID 32894695)
  • autoimmune_or_renal_diseaserequired
    history • used at CONTEXT
    Pulmonary-renal syndrome (GPA, MPA, anti-GBM, SLE) — route to renal.rpgn.core.v1 (ACR 2021 PMID 34235894)
  • recent_bronch_or_lung_bx
    history • used at CONTEXT
    Iatrogenic / trauma — recent bronchoscopy, PA catheter, transthoracic lung biopsy (CHEST 2018)
  • anticoag_or_antiplateletrequired
    medication • used at CONTEXT
    Anticoagulant-associated hemoptysis — amplifies but does not exclude underlying lesion (CHEST 2018)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Anemia from blood loss; eosinophilia (vasculitis, parasitic, EGPA) (CHEST 2018)
  • coags_inrrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy contribution; baseline for reversal (CHEST 2018)
  • type_and_crossrequired
    lab • used at RED_FLAGS
    Massive hemoptysis — transfusion preparation (CHEST 2018)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    Pulmonary-renal syndrome screen + IV contrast risk for CT (CHEST 2018)
  • urinalysisrequired
    lab • used at INITIAL_WORKUP
    Glomerular hematuria → vasculitis / anti-GBM — route to renal.rpgn.core.v1 (ACR 2021)
  • sputum_afb_culturerequired
    lab • used at INITIAL_WORKUP
    TB / atypical mycobacteria / fungal — AFB ×3, Xpert MTB/RIF (ATS/IDSA 2016 PMID 27516382)
  • sputum_cytology
    lab • used at BRANCHING_WORKUP
    Malignancy screen — low sensitivity but specific (USPSTF 2021)
  • anca_anti_gbm
    lab • used at BRANCHING_WORKUP
    Pulmonary-renal vasculitis — PR3-ANCA (GPA), MPO-ANCA (MPA, EGPA), anti-GBM (Goodpasture) (ACR 2021 PMID 34235894; RAVE PMID 20647199)
  • cxrrequired
    imaging • used at INITIAL_WORKUP
    Initial localization; cavitary / mass / consolidation / lobar collapse (CHEST 2018)
  • ct_chest_with_contrastrequired
    imaging • used at INITIAL_WORKUP
    Multidetector CT with bronchial-arterial phase if massive — localize bleed source, identify mass/bronchiectasis/aspergilloma/AVM/dissection (Larici 2014 PMID 24808437)
  • ctpa
    imaging • used at BRANCHING_WORKUP
    Rule out PE if Wells/PERC suggests pulmonary infarct (CHEST 2018)
  • bronchoscopy
    imaging • used at BRANCHING_WORKUP
    Localize, sample, bronchial blocker, electrocautery, APC; rigid bronch for massive (CHEST 2018; Yu 2010 PMID 28703105)
  • echo_tte
    imaging • used at BRANCHING_WORKUP
    Mitral stenosis, Eisenmenger physiology, pulmonary hypertension if cardiac source suspected (CHEST 2018)

12-phase flow (12)

  1. 1FRAME
    Confirm true hemoptysis vs hematemesis (acidic, food, dark) vs epistaxis with post-nasal drip; quantify volume (massive >100-200 mL/24 h, submassive 30-100, mild <30); pseudohemoptysis screen (Serratia red sputum, oropharyngeal source) (CHEST 2018 PMID 31374211)
    inputs: estimated_volume_24h, duration_recurrence, true_vs_pseudo
    advance: True hemoptysis confirmed + volume tier assigned
  2. 2ENTRY
    Coughing blood, blood-streaked sputum, frank massive, recurrent — pattern recognition by volume + chronicity (CHEST 2018)
    inputs: age
    advance: Entry pattern recognized
  3. 3CONTEXT
    TB risk (ATS/IDSA 2016), smoking + lung cancer prior (USPSTF 2021 PMID 33687470), occupational, anticoag, prior bronchiectasis / CF, vasculitis history, recent PE risk, HHT (Faughnan 2020), recent iatrogenic procedure, weight loss / fever (CHEST 2018)
    inputs: sex, tb_risk, smoking_history, bronchiectasis_or_CF, autoimmune_or_renal_disease, anticoag_or_antiplatelet, recent_pe_dvt_risk, mitral_stenosis_or_HF, hht_or_avm_history, recent_bronch_or_lung_bx
    advance: Context complete
  4. 4RED_FLAGS
    Massive hemoptysis (gas exchange / hemodynamic / airway compromise — functional def per CHEST 2018), respiratory distress, AMS, hypotension, airway flooding, hemoptysis on anticoag → STAT pulm + IR + airway (CHEST 2018; Larici 2014 PMID 24808437)
    inputs: spo2, sbp, rr, hr, type_and_cross
    advance: Massive identified or excluded
  5. 5INITIAL_WORKUP
    CBC, INR, type/screen, BMP, UA, sputum AFB + Xpert + culture + fungal, CXR, multidetector CT chest with contrast (bronchial-arterial phase if massive); CTPA if PE in differential (CHEST 2018; Larici 2014; ATS/IDSA 2016 PMID 27516382)
    inputs: cbc, coags_inr, creatinine, urinalysis, sputum_afb_culture, cxr, ct_chest_with_contrast
    actions: panel.cbc, panel.coag, panel.renal, workup.hemoptysis
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    Bronchoscopy (rigid for massive — Yu 2010 PMID 28703105); CT angio for AVM / aberrant bronchial arteries; ANCA, anti-GBM, complement, ANA (ACR 2021 PMID 34235894); TTE if mitral / Eisenmenger; sputum cytology + fungal (USPSTF 2021); HHT screening if AVM (Faughnan 2020 PMID 32894695); CTPA if PE in differential
    inputs: bronchoscopy, anca_anti_gbm, ctpa, sputum_cytology, echo_tte
    actions: workup.tb, workup.pe_full, workup.rpgn, workup.endocarditis, workup.lung_abscess, workup.bronchiectasis_exac, workup.pulmonary_nodule
    advance: Source localized or differential narrowed
  7. 7DIFFERENTIAL
    TB / bronchiectasis / CF exacerbation / lung Ca / pneumonia + abscess / aspergilloma / vasculitis (GPA, MPA, EGPA, anti-GBM) / PE pulmonary infarct / mitral stenosis / Eisenmenger / pulmonary AVM (HHT) / pseudohemoptysis / iatrogenic post-bronch or PA catheter / anticoag-associated / cryptogenic (Savale 2007 PMID 31164971 — 5-15% remain idiopathic) (CHEST 2018 PMID 31374211)
    advance: Differential narrowed
  8. 8RISK_STRATIFICATION
    Volume + airway + hemodynamics tier; mortality risk in massive (~50% untreated, ~10-25% with BAE — Yu 2010 PMID 28703105); Fartoukh score schema-blocked (not in registry) (CHEST 2018)
    advance: Risk tier documented
  9. 9TREATMENT
    Massive: airway protect (bleeding side DOWN to protect non-bleeding lung; selective single-lumen large-bore intubation of NON-bleeding mainstem if airway flooding), IR bronchial artery embolization is treatment of choice (CHEST 2018; Yu 2010 — primary success 85-95%; rebleed 10-30% at 1 yr), rigid bronchoscopy adjuncts (bronchial blocker, electrocautery, APC), surgical resection for refractory localized disease (mycetoma, AVM, trauma); submassive + mild: directed etiologic Rx (anti-TB per ATS/IDSA 2016, antibiotics if CAP, vasculitis steroid + cyclophosphamide / rituximab per RAVE PMID 20647199, antifungal if aspergilloma, reverse anticoag if implicated and life-threatening); TXA in non-massive (Cochrane 2018 PMID 30321510)
    inputs: spo2, sbp
    advance: Targeted therapy initiated
  10. 10DISPOSITION
    Outpatient if mild streaking + low-risk + workup pending; admit for submassive or any active bleed; ICU for massive / evolving / post-embolization (CHEST 2018)
    advance: Disposition documented
  11. 11MONITORING
    Serial Hgb, recurrence, post-embolization rebleed (10-30% at 1 yr — Yu 2010), treatment outcome, ANCA titer trend (ACR 2021)
    advance: Monitoring plan documented
  12. 12FOLLOWUP
    Pulmonology / IR / thoracic surgery / oncology / ID / rheumatology / genetics (HHT) per pathway (CHEST 2018; Faughnan 2020)
    advance: Referrals scheduled