Coughing up Blood
Patients invariably view this relatively uncommon symptom as representing something serious – this is rarely the case in primary care. In practice, the origin of the blood may not be immediately obvious: Quite often, blood from the nose or throat may be coughed out with saliva (spurious haemoptysis) and described as ‘coughing up blood’.
- Chest Infection
- Pulmonary Embolism (PE)
- Bronchogenic Carcinoma
- Pulmonary Oedema
- Prolonged Coughing
- Mitral Stenosis
- Polyarteritis Nodosa
- Tumour of Larynx or Trachea
- Associated with SLE
- Goodpasture’s Syndrome
- Contusion Due to Trauma
- Pulmonary Arteriovenous Malformations (50% Associated with Hereditary Haemorrhagic Telangiectasia)
Key distinguishing features of the most common diagnoses
|Chest Infection||PE||Bronchogenic Carcinoma||Pulmonary Oedema||Prolonged Coughing|
|Pink Frothy Sputum||No||No||No||Yes||No|
Possible: FBC, ESR/CRP, autoantibody screen, sputum, pulse oximetry.
Small Print: Bronchoscopy, secondary care investigations for pulmonary embolism, echocardiogram, other chest imaging (e.g. CT scan).
- CXR: This is the single most valuable investigation for detecting many of the causes listed.
- Sputum microbiology: May be needed to look for acid-fast bacilli of TB.
- FBC and ESR/CRP: For anaemia (LVF and malignant disease); WCC raised in infection, ESR/CRP raised in malignancy, infection and inflammatory conditions.
- Autoantibody screen: For assessing possible connective tissue disease.
- Pulse oximetry: Hypoxia points to significant acute lung pathology.
- Hospital-based tests: Various other investigations may be considered according to the likely aetiology and would usually be arranged by the hospital specialist after referral, e.g. bronchoscopy, investigations for pulmonary embolism, CT scan and echocardiography.
- In younger patients, the symptom is most commonly caused by vigorous coughing. If this is clearly the case, and the haemoptysis was minor, do not engender unnecessary anxiety by arranging a CXR.
- Take a careful history. The terminology used by some patients can confuse the doctor as to whether blood was coughed or vomited up.
- Don’t forget that most patients – and smokers in particular – will be worried that the symptom represents cancer. Reassure firmly when appropriate, but investigate early those cases that concern you, providing an adequate explanation as to why you are arranging a CXR and making firm arrangements for follow-up.
- Any smoker with significant haemoptysis should have a CXR – particularly if there are other sinister features such as shortness of breath, weight loss, persistent cough or clubbing.
- PE causes sudden onset of shortness of breath with pleuritic pain. Consider this diagnosis if there is no other obvious explanation for the symptoms, especially if the patient has a tachycardia. Signs of DVT may only appear later, or sometimes never at all.
- TB is on the increase in the UK. Consider this possibility in the elderly, immigrants and vagrants. It often mimics malignancy.
- If haemoptysis persists, arrange referral even if the CXR is clear – some lesions may not appear on the X-ray, or may only develop after some time has elapsed. Other investigations may be required.