The approaches to assess and treat hemoptysis are shown in Fig. 35-1. History should determine whether the bleeding source is likely the respiratory tract or an alternative source (e.g., nasopharynx, upper GI tract). The quantity of expectorated blood should be estimated, because it influences the urgency of evaluation and treatment. Massive hemoptysis, variably defined as 200-600 mL within 24 h, requires emergent care. The presence of purulent or frothy secretions should be assessed. History of previous hemoptysis episodes and cigarette smoking should be ascertained. Fever and chills should be assessed as potential indicators of acute infection. Recent inhalation of illicit drugs and other toxins should be determined.

Physical examination should include assessment of the nares for epistaxis, and evaluation of the heart and lungs. Pedal edema could indicate congestive heart failure if symmetric, and deep-vein thrombosis with pulmonary embolism if asymmetric. Clubbing could indicate lung cancer or bronchiectasis. Assessment of vital signs and oxygen saturation can provide information about hemodynamic stability and respiratory compromise.

Radiographic evaluation with a chest x-ray should be performed. Chest CT may be helpful to assess for bronchiectasis, pneumonia, lung cancer, and pulmonary embolism. Laboratory studies include a complete blood count and coagulation studies; renal function and urinalysis should be assessed, with additional blood tests including antineutrophil cytoplasmic antibody (ANCA), anti-GBM (glomerular basement membrane), and ANA if DAH is suspected. Sputum should be sent for Gram's stain and routine culture as well as acid-fast bacillus (AFB) smear and culture.

Bronchoscopy is often required to complete the evaluation. In massive hemoptysis, rigid bronchoscopy may be necessary.