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symptom.hemoptysis.v1PRODUCTION
symptom.hemoptysis.v1

Hemoptysis (massive / submassive / mild)

symptomacutesubacuteundifferentiatedadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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
3
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0
Advance rule
Set
Advance when

True hemoptysis confirmed + volume tier assigned

Patient inputs (31)

Age >40 + smoking → cancer prior shifts up (USPSTF 2021 PMID 33687470); pediatric think foreign body / CF (CHEST 2018)

TB is worldwide #1 cause of hemoptysis; endemic, immunocompromised, incarceration, prior TB (ATS/IDSA 2016 PMID 27516382)

Lung cancer (especially squamous) prior (USPSTF 2021 PMID 33687470)

Recurrent hemoptysis from chronic suppurative lung disease — bronchiectasis / CF (CHEST 2018)

PE can present with hemoptysis (pulmonary infarct, 5-10% of PE) — route to pulm.pe.core.v1 (CHEST 2018)

Pulmonary-renal syndrome (GPA, MPA, anti-GBM, SLE) — route to renal.rpgn.core.v1 (ACR 2021 PMID 34235894)

Anticoagulant-associated hemoptysis — amplifies but does not exclude underlying lesion (CHEST 2018)

Stratifies massive (>100-200 mL) vs submassive (30-100 mL) vs mild (<30 mL) (CHEST 2018 PMID 31374211; Larici 2014 PMID 24808437)

Acute single vs recurrent vs chronic (CHEST 2018)

Distinguish true hemoptysis from hematemesis (acidic, food, dark) and epistaxis / oropharyngeal source (CHEST 2018)

Anemia from blood loss; eosinophilia (vasculitis, parasitic, EGPA) (CHEST 2018)

Coagulopathy contribution; baseline for reversal (CHEST 2018)

Pulmonary-renal syndrome screen + IV contrast risk for CT (CHEST 2018)

Glomerular hematuria → vasculitis / anti-GBM — route to renal.rpgn.core.v1 (ACR 2021)

TB / atypical mycobacteria / fungal — AFB ×3, Xpert MTB/RIF (ATS/IDSA 2016 PMID 27516382)

Initial localization; cavitary / mass / consolidation / lobar collapse (CHEST 2018)

Multidetector CT with bronchial-arterial phase if massive — localize bleed source, identify mass/bronchiectasis/aspergilloma/AVM/dissection (Larici 2014 PMID 24808437)

Gas-exchange compromise drives massive functional definition (CHEST 2018 PMID 31374211)

Hemodynamic compromise drives massive functional definition (CHEST 2018)

Tachypnea + accessory muscle use → airway flooding (CHEST 2018)

Tachycardia from hypovolemia / hypoxia (CHEST 2018)

Massive hemoptysis — transfusion preparation (CHEST 2018)

Malignancy screen — low sensitivity but specific (USPSTF 2021)

Pulmonary-renal vasculitis — PR3-ANCA (GPA), MPO-ANCA (MPA, EGPA), anti-GBM (Goodpasture) (ACR 2021 PMID 34235894; RAVE PMID 20647199)

Rule out PE if Wells/PERC suggests pulmonary infarct (CHEST 2018)

Localize, sample, bronchial blocker, electrocautery, APC; rigid bronch for massive (CHEST 2018; Yu 2010 PMID 28703105)

Mitral stenosis, Eisenmenger physiology, pulmonary hypertension if cardiac source suspected (CHEST 2018)

HHT pulmonary AVM (Faughnan 2020 PMID 32894695) female ≥ male; menstrual catamenial hemoptysis rare (endometriosis)

Pink frothy sputum from pulmonary edema vs true hemoptysis; rheumatic mitral stenosis (CHEST 2018)

Hereditary hemorrhagic telangiectasia — pulmonary AVM risk (Faughnan 2020 PMID 32894695)

Iatrogenic / trauma — recent bronchoscopy, PA catheter, transthoracic lung biopsy (CHEST 2018)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateningmassive_life_threatening_hemoptysis
    Hemoptysis >100-200 mL within 24 h OR any volume causing gas-exchange / hemodynamic / airway compromise — functional definition (CHEST 2018 PMID 31374211; Larici 2014 PMID 24808437)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningvasculitis_pulmonary_renal
    Hemoptysis + glomerular hematuria + AKI ± constitutional symptoms (fever, arthralgia, weight loss) → pulmonary-renal vasculitis (GPA / MPA / EGPA / anti-GBM Goodpasture) (ACR 2021 PMID 34235894; RAVE PMID 20647199)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresubmassive_hemoptysis
    Hemoptysis 30-100 mL/24 h — admit for inpatient diagnostic workup + therapeutic bronchoscopy (CHEST 2018 PMID 31374211)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereinfectious_pneumonia_lung_abscess
    Hemoptysis with cavitary consolidation or air-fluid level on CT, fever, leukocytosis, sputum bacterial growth (CHEST 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretb_cavitary_with_isolation
    Cavitary lung lesion + AFB+ sputum or Xpert MTB/RIF+ → confirmed pulmonary TB requires airborne isolation + public health notification (ATS/IDSA 2016 PMID 27516382)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepe_with_hemoptysis_route
    Hemoptysis + pleuritic chest pain + dyspnea ± Wells ≥4 → pulmonary infarct (5-10% of PE present with hemoptysis) — CTPA confirms (CHEST 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremalignancy_lung_cancer_concern
    Hemoptysis + smoker >40 + lung mass on CT — primary lung cancer (squamous, SCLC) or endobronchial metastasis (USPSTF 2021 PMID 33687470)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereanticoagulant_associated_hemoptysis
    Hemoptysis with supratherapeutic INR, recent DOAC ingestion, or therapeutic anticoag in patient with underlying lesion (CHEST 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaspergilloma_with_hemoptysis
    Cavitary lesion with mycetoma (fungus ball on CT — air crescent sign) + hemoptysis (CHEST 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehht_pulmonary_avm_with_hemoptysis
    Hemoptysis with telangiectasia (oral, nasal, GI), epistaxis history, family history, pulmonary AVM on CT — hereditary hemorrhagic telangiectasia (Faughnan 2020 PMID 32894695)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereiatrogenic_or_trauma_hemoptysis
    Hemoptysis following recent bronchoscopy, PA catheter (pulmonary artery rupture — rare but catastrophic), transthoracic lung biopsy, or chest trauma (CHEST 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebronchiectasis_or_cf_exacerbation_with_hemoptysis
    Known bronchiectasis / CF with acute hemoptysis during exacerbation (CHEST 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildmild_streaking_hemoptysis
    Hemoptysis <30 mL/24 h — outpatient diagnostic workup acceptable if low-risk profile (CHEST 2018)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpseudohemoptysis
    Bloody sputum NOT from lower respiratory tract — GI source (hematemesis with acidic dark blood, food particles) vs upper airway (epistaxis with post-nasal drip, oropharyngeal lesion) vs Serratia red sputum (CHEST 2018 PMID 31374211)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

Supportive + adjuncts (TXA, reverse anticoag, antibiotic if pneumonic, antifungal if aspergilloma) (CHEST 2018 PMID 31374211 + Cochrane 2018 PMID 30321510)
axis: hemoptysis_supportive_and_adjuncts
Selected axis "Supportive + adjuncts (TXA, reverse anticoag, antibiotic if pneumonic, antifungal if aspergilloma) (CHEST 2018 PMID 31374211 + Cochrane 2018 PMID 30321510)" by default fallback (first axis)
  • tranexamic_acid
    add on
    antifibrinolytic
    500-1000 mg IV/PO TID OR 500 mg nebulised TID • IV/PO/inhaled • TID × 5-7 d
    triggers: non_massive_hemoptysis_persistent
    Cochrane 2018 PMID 30321510 — supportive in non-massive; small RCTs suggest reduced bleed duration; nebulised route gains traction
    rxcui 10691
  • vitamin K (phytonadione)
    rescue
    vitamin_K
    5-10 mg IV/PO • IV/PO • single dose
    triggers: warfarin_supratherapeutic_hemoptysis
    Reverse warfarin in life-threatening hemoptysis (CHEST 2018)
    rxcui 11258
  • prothrombin complex concentrate (PCC)
    rescue
    prothrombin_complex
    25-50 IU/kg • IV • single dose
    triggers: life_threatening_hemoptysis_on_warfarin_or_FXa
    Faster reversal than FFP; combine with vitamin K for warfarin (CHEST 2018)
    rxcui 1670383
  • ceftriaxone
    first line
    3rd_gen_cephalosporin
    1 g IV • IV • daily
    triggers: CAP_overlay
    IDSA CAP coverage — route to pulm.cap.core.v1
    rxcui 2193
  • voriconazole
    first line
    azole_antifungal
    6 mg/kg load × 2 then 4 mg/kg • IV • BID
    triggers: aspergilloma_with_hemoptysis
    IDSA aspergillosis 2016 — refractory mycetoma often needs surgery
    rxcui 121243

outpatient playbook — drug actions (5)

  1. 1. tranexamic acid
    500-1000 mg PO TID • PO • TID × 5-7 d PRN
    trigger: Mild persistent streaking + complete workup (Cochrane 2018 PMID 30321510)
    Outpatient bridge while etiology workup
  2. 2. targeted abx for bronchiectasis exacerbation
    amoxicillin-clavulanate 875/125 PO BID × 7-14 d or per culture • PO • BID
    trigger: Bronchiectasis flare with hemoptysis (CHEST 2018)
    Treat underlying suppurative process; route to pulm.copd.core.v1
  3. 3. inhaled corticosteroid / bronchodilator
    per package • inhaled • daily
    trigger: Bronchiectasis maintenance
    Standard chronic airway therapy
  4. 4. smoking cessation pharmacotherapy
    varenicline / NRT / bupropion • PO/patch • per regimen
    trigger: Active smoker (USPSTF 2021 PMID 33687470)
    Lung cancer risk reduction + bronchiectasis stabilization
  5. 5. maintenance immunosuppression
    rituximab maintenance / azathioprine / methotrexate per regimen • IV/PO • per regimen
    trigger: ANCA-vasculitis remission maintenance (ACR 2021 PMID 34235894)
    Route to renal.rpgn.core.v1 for chronic immunosuppression

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Coughing blood, blood-streaked sputum, or frank hemoptysis (CHEST 2018 PMID 31374211); Massive hemoptysis (>100-200 mL/24 h OR any volume causing gas exchange / hemodynamic / airway compromise) (CHEST 2018 PMID 31374211; Larici 2014 PMID 24808437); Submassive 30-100 mL/24 h — admit for workup (CHEST 2018).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Hemoptysis (massive / submassive / mild)** (symptom.hemoptysis.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Supportive + adjuncts (TXA, reverse anticoag, antibiotic if pneumonic, antifungal if aspergilloma) (CHEST 2018 PMID 31374211 + Cochrane 2018 PMID 30321510)**.
1. tranexamic_acid 500-1000 mg IV/PO TID OR 500 mg nebulised TID IV/PO/inhaled TID × 5-7 d (antifibrinolytic, add on) — Cochrane 2018 PMID 30321510 — supportive in non-massive; small RCTs suggest reduced bleed duration; nebulised route gains traction
2. vitamin K (phytonadione) 5-10 mg IV/PO IV/PO single dose (vitamin_K, rescue) — Reverse warfarin in life-threatening hemoptysis (CHEST 2018)
3. prothrombin complex concentrate (PCC) 25-50 IU/kg IV single dose (prothrombin_complex, rescue) — Faster reversal than FFP; combine with vitamin K for warfarin (CHEST 2018)
4. ceftriaxone 1 g IV IV daily (3rd_gen_cephalosporin, first line) — IDSA CAP coverage — route to pulm.cap.core.v1
5. voriconazole 6 mg/kg load × 2 then 4 mg/kg IV BID (azole_antifungal, first line) — IDSA aspergillosis 2016 — refractory mycetoma often needs surgery

Setting playbook (outpatient) — Mild streaking <30 mL/24 h low-risk workup OR chronic recurrent stable bronchiectasis / HHT / vasculitis maintenance — diagnostic CT + bronchoscopy + cytology + cessation counseling; risk stratification for occult malignancy (CHEST 2018; USPSTF 2021 PMID 33687470)
6. tranexamic acid 500-1000 mg PO TID PO TID × 5-7 d PRN — Mild persistent streaking + complete workup (Cochrane 2018 PMID 30321510) (Outpatient bridge while etiology workup)
7. targeted abx for bronchiectasis exacerbation amoxicillin-clavulanate 875/125 PO BID × 7-14 d or per culture PO BID — Bronchiectasis flare with hemoptysis (CHEST 2018) (Treat underlying suppurative process; route to pulm.copd.core.v1)
8. inhaled corticosteroid / bronchodilator per package inhaled daily — Bronchiectasis maintenance (Standard chronic airway therapy)
9. smoking cessation pharmacotherapy varenicline / NRT / bupropion PO/patch per regimen — Active smoker (USPSTF 2021 PMID 33687470) (Lung cancer risk reduction + bronchiectasis stabilization)
10. maintenance immunosuppression rituximab maintenance / azathioprine / methotrexate per regimen IV/PO per regimen — ANCA-vasculitis remission maintenance (ACR 2021 PMID 34235894) (Route to renal.rpgn.core.v1 for chronic immunosuppression)

Non-pharmacologic actions:
- Airway clearance for bronchiectasis (chest physiotherapy, oscillatory PEP, hypertonic saline neb)
- Pulmonary rehab if chronic
- Cancer screening LDCT per USPSTF 2021
- HHT screening — contrast echo for pulmonary AVM + brain MRI for cerebral AVM (Faughnan 2020 PMID 32894695)
- IR follow-up post-BAE q3-6 mo for rebleed surveillance (Yu 2010 PMID 28703105)
- Vaccinations — influenza annual, pneumococcal, COVID

AVOID / contraindication checks:
- TXA_caution_in_DIC_seizure_history (CHEST 2018)
- Reverse_anticoag_only_if_truly_life_threatening (CHEST 2018)
- Voriconazole_LFT_visual_monitoring

Monitoring

Regimen monitoring:
- Hgb q4 to 6 h in active bleed (CHEST 2018)
- INR after reversal
- rebleed 24 48 h post embolization (Yu 2010 PMID 28703105)

Setting (outpatient) monitoring:
- Hemoptysis diary
- Hgb q3-6 mo if chronic
- CT chest q6-12 mo if HHT, bronchiectasis, post-BAE
- Sputum cultures q3-6 mo if chronic infection
- ANCA titer q3 mo on maintenance immunosuppression
- Spirometry q6-12 mo

Follow-up plan: Pulmonology / IR / thoracic surgery / oncology / ID / rheumatology / genetics (HHT) per pathway (CHEST 2018; Faughnan 2020)
- Close-out criterion: Referrals scheduled

Monitoring phase: Serial Hgb, recurrence, post-embolization rebleed (10-30% at 1 yr — Yu 2010), treatment outcome, ANCA titer trend (ACR 2021)

Disposition

Current setting: outpatient — Mild streaking <30 mL/24 h low-risk workup OR chronic recurrent stable bronchiectasis / HHT / vasculitis maintenance — diagnostic CT + bronchoscopy + cytology + cessation counseling; risk stratification for occult malignancy (CHEST 2018; USPSTF 2021 PMID 33687470)

Disposition criteria:
- Continue outpatient if controlled + etiology established
- Refer pulm/IR/oncology/rheum/ID/genetics per etiology
- Cancer specialty referral if confirmed malignancy (USPSTF 2021)

Escalation triggers (move to higher acuity):
- Volume increase to ≥30 mL/24 h → ED admit
- NEW dyspnea / chest pain / fever / weight loss → urgent workup for PE / cancer / infection
- Rebleed post-BAE → IR + CT angio (Yu 2010)
- Progressive renal dysfunction on vasculitis Rx → rheum/neph route renal.rpgn.core.v1
- New focal neuro deficit (HHT paradoxical embolism via AVM) → ED + brain imaging (Faughnan 2020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Hemoptysis >100-200 mL within 24 h OR any volume causing gas-exchange / hemodynamic / airway compromise — functional definition (CHEST 2018 PMID 31374211; Larici 2014 PMID 24808437)
- [LIFE_THREATENING] Hemoptysis + glomerular hematuria + AKI ± constitutional symptoms (fever, arthralgia, weight loss) → pulmonary-renal vasculitis (GPA / MPA / EGPA / anti-GBM Goodpasture) (ACR 2021 PMID 34235894; RAVE PMID 20647199)
- [SEVERE] Hemoptysis 30-100 mL/24 h — admit for inpatient diagnostic workup + therapeutic bronchoscopy (CHEST 2018 PMID 31374211)

Citations

- CHEST 2018 hemoptysis algorithm (Ittrich/Bockhorn PMID 31374211) + Larici 2014 massive hemoptysis CT (PMID 24808437) + Yu 2010 BAE outcomes (PMID 28703105) + HHT Faughnan 2020 (PMID 32894695) + USPSTF 2021 lung cancer screening (PMID 33687470) + RAVE rituximab in ANCA-vasculitis (PMID 20647199) + Cochrane 2018 TXA (PMID 30321510) + ATS/IDSA TB 2016 (PMID 27516382) + ACR 2021 ANCA-vasculitis (PMID 34235894) + Savale 2007 cryptogenic hemoptysis (PMID 31164971) [PMID:31374211](https://pubmed.ncbi.nlm.nih.gov/31374211/)
- Cited evidence (PMID 24808437) [PMID:24808437](https://pubmed.ncbi.nlm.nih.gov/24808437/)
- Cited evidence (PMID 28703105) [PMID:28703105](https://pubmed.ncbi.nlm.nih.gov/28703105/)
- Cited evidence (PMID 32894695) [PMID:32894695](https://pubmed.ncbi.nlm.nih.gov/32894695/)
- Cited evidence (PMID 33687470) [PMID:33687470](https://pubmed.ncbi.nlm.nih.gov/33687470/)

Last reconciled with current guidelines: 2026-05-14.
References
  • CHEST 2018 hemoptysis algorithm (Ittrich/Bockhorn PMID 31374211) + Larici 2014 massive hemoptysis CT (PMID 24808437) + Yu 2010 BAE outcomes (PMID 28703105) + HHT Faughnan 2020 (PMID 32894695) + USPSTF 2021 lung cancer screening (PMID 33687470) + RAVE rituximab in ANCA-vasculitis (PMID 20647199) + Cochrane 2018 TXA (PMID 30321510) + ATS/IDSA TB 2016 (PMID 27516382) + ACR 2021 ANCA-vasculitis (PMID 34235894) + Savale 2007 cryptogenic hemoptysis (PMID 31164971) — PMID:31374211
  • Cited evidence (PMID 24808437) — PMID:24808437
  • Cited evidence (PMID 28703105) — PMID:28703105
  • Cited evidence (PMID 32894695) — PMID:32894695
  • Cited evidence (PMID 33687470) — PMID:33687470