Journal Information
Vol. 58. Issue 9.
Pages 635-636 (September 2022)
Download PDF
More article options
Vol. 58. Issue 9.
Pages 635-636 (September 2022)
Full text access
Idiopathic Haemoptysis and Lung Cancer: The Relevance of the Underlying Disease
Avinash Aujayeb
Respiratory Medicine Consultant, Northumbria HealthCare NHS Foundation Trust, Care of Tracy Groom, Northumbria Way, Cramlington, Northumberland NE23 6NZ, United Kingdom
This item has received
Article information
Full Text
Download PDF
Full Text

The Greek words ‘haem’ for blood and ‘ptusis’ for spitting are the origins for haemoptysis. Haemoptysis is when blood is coughed up from an infra-glottic source. This clinical phenomenon is highly variable: It can be blood-streaked sputum to massive bleeding. There are a significant number of aetiologies from thromboembolic disease, lower respiratory infections, pneumonias, lung cancer, vasculitis, toxic gas inhalation and tuberculosis.1–4 As Gonzalez-Barcala et al. found, 12.8% of lung cancer patients present with haemoptysis.5

Haemoptysis is considered a red flag symptom for lung cancer with approximately 19% of patients with lung cancer presenting with haemoptysis.6

Initial investigations are usually a plain chest radiograph [CXR] (within 2 weeks in countries such as the United Kingdom), and subsequent investigations, mostly done through secondary car practitioners, will invariably be cross sectional imaging with computed tomograms (CT). However, CT scanning, which does have a greater than 95% sensitivity or specificity for malignancy can be normal and miss small endobronchial ill-defined tumours in the lower lobes.2 Thus, CT scans are often performed alongside fibreoptic bronchoscopy (FOB) but the value of FOB in patients with non-massive haemoptysis and clear or benign CT findings is unclear.2 Large retrospective data sets suggest that FOB is not worthwhile in these patients and can be resource heavy.7

So, how can we streamline investigations and pathways? This is where the study by Modoni et al. comes in.8 The current study is a subgroup analysis of 606 prospective enrolled patients with haemoptysis from various Italian institutions and the authors must be commended on doing this, as the vast majority of the previous studies have been retrospective.9,10 They followed up everyone where there was no initial diagnosis over 18 months which is a wholly adequate timeframe. The authors have showed that (with univariate analysis) if a patient is male, has a history of smoking, is having more than just mild haemoptysis and has an abnormal CXR, the presentation is highly likely to be of a malignancy. Multivariate analysis revealed age, abnormal CXR and previous airway cancer to be predictive.

Thus, where does this evidence leave the scientific community? One might argue that the above is already known, and some of it is. However, primary and secondary in Europe are facing unprecedented pressures. The COVID-19 pandemic rages on, with fears of winter waves. Charitable campaigns have been intensified to encourage patients to present for further investigations. Lung cancer pickup and survival rates remain abysmal, mostly due to late presentations.11,12 The investigative pathway in someone with haemoptysis that initially eludes diagnosis is thus for further debate and should perhaps be streamlined to reduce pressures on services: this is a call for individualised pathways.13,14

What is probably required, initially, is a thorough initial history and a CXR. Should the CXR be abnormal, then normal investigation such as CT scan and FOB and directed biopsies would be the norm. If no cause if found, anecdotally, patients are often discharged, but this should not apply to all, as if the above risk factors are present, then further follow up is required.

This poses further questions: what is the optimal follow up period? How should patients be followed up? Virtually? Face to face? What investigations should they have? Serial radiographs or cross-sectional imaging? What are the health-economic benefits of implementing such a programme? All these points need to worked up in a large multicentre international randomised trial. A proposal for funding and support for example could be proposed to the European Respiratory Society through their clinical research collaboratives.15

A further final point to raise would be to debate further where the above results lie with the nascent lung cancer screening programmes. These have been very successful at finding early stage cancer, and have enabled curative surgery in many.16 Could those with so called idiopathic haemoptysis be plugged into screening programmes, or should they?

Once again, I congratulate the authors on their initial study, and continuing with various sub group analyses. Implementing their findings in the right setting with the right patients at the right times would have important clinical significance.

Authorship statement

AA wrote the full article.

Ethics statement

Ethics statement is not applicable.


There is no funding.

Conflict of interest

Conflicts do not exist.

T.S. Panchabhai, A.C. Mehta.
Historical perspectives of bronchoscopy. Connecting the dots.
Ann Am Thorac Soc, 12 (2015), pp. 631-641
I.A. Du Rand, J. Blaikley, R. Booton, N. Chaudhuri, V. Gupta, S. Khalid, et al.
British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE.
J. Nascimento, A. Dias, C. Resende, A. Miniero, P. Esteves.
Diffuse alveolar hemorrhage: a case of overlap syndrome of ANCA-associated vasculitis in diffuse systemic sclerosis.
Arch Bronconeumol (Engl Ed), (2021),
M.C. Mendonça, J.B. Abreu, K. Gama.
Diffuse alveolar hemorrhage after orotracheal extubation probably induced by sevoflurane inhalation.
Arch Bronconeumol (Engl Ed), (2021),
F.J. Gonzalez-Barcala, J.A. Falagan, J.M. Garcia-Prim, L. Valdes, J.M. Carreira, A. Pose, et al.
Symptoms and reason for a medical visit in lung cancer patients.
Acta Med Port, 27 (2014), pp. 318-324
Lung and pleural cancers. Recognition and referral [accessed 18.10.21]. Available from:
D.C. Murphy, K. Jackson, R. Johnston, S. Welsh, R. Webster, R. Lapsley, et al.
The value of bronchoscopy in patients with non-massive haemoptysis and a clear or benign computer tomogram scan.
Clin Respir J, 15 (2021), pp. 430-436
Mondoni M, Carlucci P, Cipolla G, Guiseppe C, Nicolo V, Fois A, et al. Predictors of malignancy in patients with haemoptysis. Arch Bronconeumol. DOI:10.1016/j.arbres.2021.11.002I
C. Abdulmalak, J. Cottenet, G. Beltramo, M. Georges, P. Camus, P. Bonniaud, et al.
Haemoptysis in adults: a 5-year study using the French nationwide hospital administrative database.
Eur Respir J, 46 (2015), pp. 503-511
F. Herth, A. Ernst, H.D. Becker.
Long-term outcome and lung cancer incidence in patients with hemoptysis of unknown origin.
Chest, 120 (2001), pp. 1592-1594
Spot the Difference. Roy Castle Lung Cancer Foundation [accessed 18.10.21]. Available from:
Lung Cancer. British Lung Foundation [accessed 18.10.21]. Available from:
A. Aujayeb.
A note on lung cancer in the COVID-19 era.
Respirology, 26 (2021), pp. 510-511
T.L. Leong.
Delayed access to lung cancer screening and treatment during the COVID-19 pandemic: are we headed for a lung cancer pandemic?.
Respirology, 26 (2021), pp. 145-146
Ongoing Clinical Research Collaborations Ongoing Clinical Research Collaborations (ERS). European Respiratory Society [accessed 18.10.21]. Available from:
H. Balata, M. Ruparel, E. O’Dowd, et al.
Analysis of the baseline performance of five UK lung cancer screening programmes.
Lung Cancer, 161 (2021), pp. 136-140
Copyright © 2021. SEPAR
Archivos de Bronconeumología
Article options

Are you a health professional able to prescribe or dispense drugs?