Name: Hemoptysis — bulletproof documentation — ER Toolkit
Creator: Kim Trinh, MD

Most hemoptysis is minor, but massive hemoptysis kills by drowning, not bleeding out — the airway is the emergency. The defensible chart documents the volume/rate, the airway plan, and that the dangerous causes — PE, malignancy, and TB — were considered.

01What's at stake

In massive hemoptysis the lethal mechanism is asphyxiation from blood flooding the airways, so airway protection and positioning (bleeding side down) come before the diagnostic workup. Even small-volume hemoptysis matters because it can herald malignancy (in a smoker), active TB (a public-health/isolation issue), or PE — misses that surface later.

02Can't-miss differential

Massive hemoptysis — an airway/asphyxiation emergency regardless of cause.
Pulmonary embolism — hemoptysis can be the presenting sign.
Malignancy — especially a smoker or new mass; needs imaging and follow-up.
Active tuberculosis — risk factors/exposure → airborne isolation and testing.
Diffuse alveolar hemorrhage / vasculitis (e.g., anti-GBM, ANCA) and bronchiectasis, AVM, mitral stenosis.
Distinguish true hemoptysis from hematemesis and nasopharyngeal (pseudo-) hemoptysis.

03History & exam

Estimate volume and rate, and whether it's worsening. → massive vs minor
Smoking, weight loss, prior cancer? → malignancy
TB risk/exposure, travel, night sweats, immunosuppression? → TB (isolate)
Pleuritic pain, dyspnea, VTE risk, unilateral leg swelling? → PE
Anticoagulation/bleeding history; hematuria + hemoptysis (pulmonary-renal syndrome). → coagulopathy / vasculitis

Skip the typing

Work the case in the Hemoptysis Workup — it records the airway assessment, imaging, and the PE assessment, and assembles an MDM that documents the airway plan and the can't-miss causes considered.

04Workup & management

Airway first in massive hemoptysis — high-flow O₂, position bleeding-side-down to protect the good lung, large-bore access, reverse coagulopathy; early ENT/pulmonology/IR and consideration of bronchial artery embolization.
Imaging: chest x-ray, then CT chest (CT angiography if PE or a bleeding vessel is suspected); bronchoscopy for localization/control.
PE assessment with pretest probability when the story fits.
TB: airborne isolation and testing when risk factors are present.
Labs: CBC, coagulation studies, type & screen for significant bleeding; renal function/urinalysis if vasculitis suspected.

05What to document

▼ weak

"Coughing up some blood, CXR normal, discharged with antibiotics."

▲ defensible

"Small-volume hemoptysis (streaks, ~5 mL, not worsening); airway patent, stable gas exchange. 40-pack-year smoker — malignancy considered, chest imaging obtained and outpatient CT/pulmonology follow-up arranged. PE considered (pretest probability assessed); no TB risk factors. Coagulation studies normal. Return precautions for large-volume bleeding or breathing difficulty. (If massive: airway protection, bleeding-side-down, IR/bronchoscopy and ICU.)"

06Where charts fail

Treating massive hemoptysis as a diagnostic problem before securing/protecting the airway.
Not documenting an estimate of volume/rate or the airway plan.
Discharging a smoker's hemoptysis without imaging and a CT/pulmonology follow-up plan.
Missing PE, or not isolating/testing possible TB.
Mistaking hematemesis or nasopharyngeal bleeding for hemoptysis (or vice versa).

07Sources

Ittrich H, Bockhorn M, Klose H, Simon M. The diagnosis and treatment of hemoptysis. Dtsch Arztebl Int. 2017;114(21):371-381.
Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration. 2010;80(1):38-58.
Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am Fam Physician. 2005;72(7):1253-1260.
Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086.

Hemoptysis: documentation that holds up