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## Complete Summary

#### GUIDELINE TITLE

Hemoptysis.

#### BIBLIOGRAPHIC SOURCE(S)

Winer-Muram HT, Kahn A, Aquino SL, Batra PV, Gurney JW, Haramati LB,
MacMahon H, Mohammed TL, Rozenshtein A, Vydareny KH, Washington L,
Woodard PK, Kaiser L, Raoof S, Expert Panel on Thoracic Imaging.
Hemoptysis. \[online publication\]. Reston (VA): American College of
Radiology (ACR); 2006. 6 p. \[18 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Fleishon H, Westcott J, Davis
SD, Gefter WB, Henschke CI, McLoud TC, Pugatch RD, Sostman HD, Tocino I,
White CS, Yankelevitz D, Bode FR, Goodman LR. Hemoptysis. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215 (Suppl):631-5.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Hemoptysis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Pulmonary Medicine\
Radiology

#### INTENDED USERS

Health Plans\
Hospitals\
Managed Care Organizations\
Physicians\
Utilization Management

#### GUIDELINE OBJECTIVE(S)

To evaluate the appropriateness of initial radiologic examinations for
patients with hemoptysis

#### TARGET POPULATION

Patients with hemoptysis

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  X-ray, chest

2.  Computed tomography (CT), chest, with or without contrast

3.  CT angiography (CTA), chest

4.  Multidetector CT (MDCT) angiography

5.  Invasive (INV), lung, bronchial artery embolization

#### MAJOR OUTCOMES CONSIDERED

Utility of radiologic examinations in differential diagnosis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The guideline developer performed literature searches of peer-reviewed
medical journals and the major applicable articles were identified and
collected.

#### NUMBER OF SOURCE DOCUMENTS

The total number of source documents identified as the result of the
literature search is not known.

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Not Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not stated

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

One or two topic leaders within a panel assume the responsibility of
developing an evidence table for each clinical condition, based on
analysis of the current literature. These tables serve as a basis for
developing a narrative specific to each clinical condition.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Since data available from existing scientific studies are usually
insufficient for meta-analysis, broad-based consensus techniques are
needed for reaching agreement in the formulation of the appropriateness
criteria. The American College of Radiology (ACR) Appropriateness
Criteria panels use a modified Delphi technique to arrive at consensus.
Serial surveys are conducted by distributing questionnaires to
consolidate expert opinions within each panel. These questionnaires are
distributed to the participants along with the evidence table and
narrative as developed by the topic leader(s). Questionnaires are
completed by participants in their own professional setting without
influence of the other members. Voting is conducted using a scoring
system from 1-9, indicating the least to the most appropriate imaging
examination or therapeutic procedure. The survey results are collected,
tabulated in anonymous fashion, and redistributed after each round. A
maximum of three rounds is conducted and opinions are unified to the
highest degree possible. Eighty percent agreement is considered a
consensus. This modified Delphi technique enables individual, unbiased
expression, is economical, easy to understand, and relatively simple to
conduct.

If consensus cannot be reached by the Delphi technique, the panel is
convened and group consensus techniques are utilized. The strengths and
weaknesses of each test or procedure are discussed and consensus reached
whenever possible. If \"No consensus\" appears in the rating column,
reasons for this decision are added to the comment sections.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Criteria developed by the Expert Panels are reviewed by the American
College of Radiology (ACR) Committee on Appropriateness Criteria.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**ACR Appropriateness Criteria®**

**Clinical Condition: Hemoptysis**

**Variant 1: Two risk factors (\>40 years old and \>40 pack-year
history).**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                   Baseline. Repeat chest x-rays when
                                           clinically indicated. In certain
                                           clinical settings, may not need to
                                           proceed to CT imaging.

  CT, chest, with or   9                   Without contrast may be performed
  without contrast                         to simply localize bleeding site
                                           prior to bronchoscopy. With
                                           contrast--may show source of
                                           bleeding and not need CTA.

  CTA, chest           5                   To evaluate source of bleeding
                                           (i.e., systemic or pulmonary
                                           artery vascular supply). If
                                           contrast enhanced MDCT is
                                           performed, CTA may not be needed.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 2: Persistent/recurrent hemoptysis and two risk factors (\>40
years old, \>40 pack-year history).**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                   Baseline. Repeat chest x-rays when
                                           clinically indicated, (e.g.,
                                           during episodes of recurrent
                                           hemoptysis). In certain clinical
                                           settings, may not need to proceed
                                           to CT imaging (e.g., diagnosis of
                                           chronic bronchitis).

  CT, chest, with or   9                   Without contrast - to localize
  without contrast                         bleeding site prior to
                                           bronchoscopy. With contrast - may
                                           show source of bleeding and not
                                           need CTA.

  CTA, chest           6                   With contrast - to evaluate source
                                           of bleeding (i.e., systemic or
                                           pulmonary artery vascular supply).
                                           If contrast enhanced MDCT is
                                           performed, CTA may not be needed.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Variant 3: Massive hemoptysis without cardiopulmonary compromise.**

  ---------------------------------------------------------------------------
  **Radiologic         **Appropriateness   **Comments**
  Procedure**          Rating**            
  -------------------- ------------------- ----------------------------------
  X-ray, chest         9                   Portable if patient unstable.

  INV, lung, bronchial 8                   If clinically feasible.
  artery embolization                      

  CT, chest, with or   9                   If clinically feasible. Contrast
  without contrast                         preferred if not contraindicated.
                                           With contrast -- may show source
                                           of bleeding and not need CTA.

  CTA, chest           5                   If clinically feasible, to
                                           evaluate source of bleeding (i.e.,
                                           systemic or pulmonary artery
                                           vascular supply), especially
                                           before bronchial artery
                                           embolization. If contrast enhanced
                                           MDCT is performed, CTA may not be
                                           needed.

  ***Appropriateness                       
  Criteria Scale*\                         
  1 2 3 4 5 6 7 8 9\                       
  1 = Least                                
  appropriate 9 = Most                     
  appropriate**                            
  ---------------------------------------------------------------------------

Note: Abbreviations used in the tables are listed at the end of the
\"Major Recommendations\" field.

**Summary of Literature Review**

Hemoptysis is defined as the expectoration of blood that originates from
the tracheobronchial tree or pulmonary parenchyma. Life-threatening
hemoptysis is rare. Most cases are benign, self-limiting events.
However, the presentation of hemoptysis may be a harbinger of
significant underlying tracheopulmonary pathology. Common causes of
hemoptysis include chronic bronchitis, bronchiectasis, pneumonia, fungal
infections, tuberculosis, and malignancy.

The majority of patients will have an identifiable source and etiology
for the bleeding at the time of initial diagnosis. Cryptogenic
hemoptysis, for which no cause can be identified, is responsible for
3.0%--42.2% of episodes of hemoptysis, particularly in smokers. It is a
diagnosis of exclusion and might be expected to decrease in prevalence
with more systematic use of computed tomography (CT).

**Bronchoscopy versus CT**

There is controversy in the literature regarding the use of CT vs.
bronchoscopy when further study is indicated. This controversy is
further compounded by the lack of a consistent clinical approach for
evaluating patients with hemoptysis. Bronchoscopy, performed with either
a rigid or a flexible fiberoptic endoscope, is useful in identifying a
specific site of bleeding, diagnosing active hemorrhage, and controlling
the airway in patients with catastrophic hemorrhage. However, its
capacity to help localize the site of bleeding is equivalent to that of
radiography or CT, and it is less useful in detecting an underlying
disease process. The airways are often filled with blood at the time of
bronchoscopy, making evaluation of the distal airways difficult.

Several articles have cited cases of hemoptysis with negative chest
radiograph and bronchoscopy in which CT subsequently showed
malignancies. In addition, CT can establish the diagnosis of
bronchiectasis. Refer to the original guideline document for a brief
review of some of the pertinent studies along with their varying
conclusions.

*Guidelines*

Several articles have addressed the need for further evaluation of
patients with negative or nonlocalizing chest radiographs. The overall
diagnostic yield in this category of patients is low. However, there is
a well-recognized 3%--10% incidence of malignancy in this population.
One study reported that almost one-quarter of patients presenting with
acute hemoptysis secondary to malignancy had normal chest radiographic
findings, yet, clear guidelines for the initial workup and follow-up in
patients without a definitive diagnosis are missing.

A review study of 119 cases of hemoptysis with negative chest
radiographs recommended that patients younger than 40 years old who had
negative chest radiographs be managed with observation only.

Another study with 196 patients with negative chest radiographs and
subsequent bronchoscopy found by univariate and discriminant analysis
three predictors of malignancy. Risk factors were found to include: sex
(male), age 50 years or older, and \>40 pack year smoking history. If
the criteria of two to three risk factors or bleeding, in excess of 30
mL over a period of 24 hours were met, 100% of the cancers would have
been found with an overall diagnostic yield of 82%. The use of
bronchoscopy would have been reduced by 28%.

In another study, 119 bronchoscopies performed in patients with
hemoptysis and negative or nonlocalizing findings on chest radiographs
were evaluated. There was no significant difference in the rate of
cancers or diagnostic yield at bronchoscopy between patients with normal
chest radiograph versus those with nonlocalizing findings. The authors
recommended an initial approach of observation and reserving
bronchoscopy for persistent hemoptysis, development of focal chest
radiograph findings or those at risk for malignancy. They suggested
using the risk factors mentioned above but with the lower age limit
changed to 40 years.

Another group of researchers reported that for smokers with hemoptysis
of unknown origin who are \>40 years of age, approximately 6% of them
will have a lung cancer that manifests within 3 years. The authors
recommend additional follow-up testing in patients presenting with
hemoptysis in which the underlying cause was not detected at initial
radiography.

In certain cases, it may be useful or even necessary to perform
follow-up CT several months after the episode of hemoptysis to study the
evolution of underlying parenchymal lung abnormalities or to exclude the
possibility that a small malignancy may have been missed at initial CT.

Because of increasing frequency of lung cancer in women (the chance that
a man will develop lung cancer is 1 in 13 and for a woman, it is 1 in
17), male gender should not be considered one of the risk factors.

*Imaging*

The imaging modalities pertinent to the evaluation of hemoptysis include
chest radiograph, CT, multidetector CT (MDCT), and thoracic
aortography--bronchial artery embolization. There is uniform recognition
of the efficacy of chest radiograph in the initial stages of evaluation.
Radiography can help lateralize the bleeding with a high degree of
certainty and can often help detect underlying parenchymal and pleural
abnormalities.

Conditions such as bronchiectasis, lung malignancy, tuberculosis, and
chronic fungal infection are some of the most common underlying causes
of hemoptysis and are easily detected with CT.

MDCT angiography permits noninvasive, rapid, and accurate assessment of
the cause and consequences of hemorrhage into the airways and helps
guide subsequent management. Contrast-enhanced MDCT can demonstrate the
site of bleeding as accurately as bronchoscopy and detect underlying
disease with high sensitivity. MDCT provides for high-resolution
angiographic studies of the thoracic and upper abdominal vasculature,
which are useful prior to anticipated bronchial artery embolization or
surgical intervention.

**Bronchial Artery Embolization**

Bronchial artery embolization has been shown to be an effective therapy
in the control of massive hemoptysis. Nonsurgical interventions for
hemoptysis may be used as an interim solution before surgery or may
constitute definitive therapy in a patient who is a not a candidate for
surgery. In over 90% of cases of hemoptysis requiring intervention with
arterial embolization or surgery, the bronchial arteries are responsible
for the bleeding. Failure to recognize the presence of a nonbronchial
systemic arterial supply in patients with massive hemoptysis may result
in recurrent bleeding after successful bronchial artery embolization.

Peripheral pulmonary artery pseudoaneurysms occur in up to 11% of
patients undergoing bronchial angiography for hemoptysis. Occlusion of
the pulmonary artery pseudoaneurysm may require embolization of
bronchial or nonbronchial systemic arteries or pulmonary artery
branches.

Bronchoscopy before bronchial artery embolization is unnecessary in
patients with hemoptysis of known causation if the site of bleeding can
be determined from radiographs or CT and no bronchoscopic airways
management is needed.

The following guidelines are recommended:

1.  Initial evaluation of patients with hemoptysis should include a
    chest radiograph.

2.  Patients at high risk for malignancy (\>40 years old, \>40 pack-year
    smoking history) with negative chest radiograph, CT scan, and
    bronchoscopy can be followed with observation for the following 3
    years. Radiography and CT are recommended imaging modalities for the
    follow-up. Bronchoscopy may complement imaging during the period of
    observation.

3.  In patients who are at high risk for malignancy and have suspicious
    chest radiograph findings, CT is suggested for initial evaluation.

4.  Massive hemoptysis can be effectively treated with either surgery or
    percutaneous embolization. Contrast enhanced MDCT prior to
    embolization or surgery will define the source of hemoptysis to be
    bronchial systemic, nonbronchial systemic and/or pulmonary arterial.
    Percutaneous embolization may be used initially to halt the
    hemorrhage prior to definitive surgery.

**Abbreviations**

-   CT, computed tomography

-   CTA, computed tomographic angiography

-   INV, invasive

-   MDCT, multidetector computed tomography

#### CLINICAL ALGORITHM(S)

Algorithms were not developed from criteria guidelines.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The recommendations are based on analysis of the current literature and
expert panel consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Selection of appropriate radiologic imaging procedures for evaluation of
patients with hemoptysis

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

An American College of Radiology (ACR) Committee on Appropriateness
Criteria and its expert panels have developed criteria for determining
appropriate imaging examinations for diagnosis and treatment of
specified medical condition(s). These criteria are intended to guide
radiologists, radiation oncologists, and referring physicians in making
decisions regarding radiologic imaging and treatment. Generally, the
complexity and severity of a patient\'s clinical condition should
dictate the selection of appropriate imaging procedures or treatments.
Only those exams generally used for evaluation of the patient\'s
condition are ranked. Other imaging studies necessary to evaluate other
co-existent diseases or other medical consequences of this condition are
not considered in this document. The availability of equipment or
personnel may influence the selection of appropriate imaging procedures
or treatments. Imaging techniques classified as investigational by the
U.S. Food and Drug Administration (FDA) have not been considered in
developing these criteria; however, study of new equipment and
applications should be encouraged. The ultimate decision regarding the
appropriateness of any specific radiologic examination or treatment must
be made by the referring physician and radiologist in light of all the
circumstances presented in an individual examination.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Winer-Muram HT, Kahn A, Aquino SL, Batra PV, Gurney JW, Haramati LB,
MacMahon H, Mohammed TL, Rozenshtein A, Vydareny KH, Washington L,
Woodard PK, Kaiser L, Raoof S, Expert Panel on Thoracic Imaging.
Hemoptysis. \[online publication\]. Reston (VA): American College of
Radiology (ACR); 2006. 6 p. \[18 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1995 (revised 2006)

#### GUIDELINE DEVELOPER(S)

American College of Radiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Radiology (ACR) provided the funding and the
resources for these ACR Appropriateness Criteria®.

#### GUIDELINE COMMITTEE

Committee on Appropriateness Criteria, Expert Panel on Thoracic Imaging

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Panel Members*: Helen T. Winer-Muram, MD; Arfa Khan, MD; Suzanne L.
Aquino, MD; Poonam V. Batra MD; Jud W. Gurney, MD; Linda B. Haramati,
MD; Heber MacMahon, MD; Tan-Lucien H. Mohammed, MD; Anna Rozenshtein,
MD; Kay H.Vydareny, MD; Lacey Washington, MD; Pamela K. Woodard, MD;
Larry Kaiser, MD; Suhail Raoof, MBBS

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Fleishon H, Westcott J, Davis
SD, Gefter WB, Henschke CI, McLoud TC, Pugatch RD, Sostman HD, Tocino I,
White CS, Yankelevitz D, Bode FR, Goodman LR. Hemoptysis. American
College of Radiology. ACR Appropriateness Criteria. Radiology 2000
Jun;215 (Suppl):631-5.

The appropriateness criteria are reviewed annually and updated by the
panels as needed, depending on introduction of new and highly
significant scientific evidence.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American College of Radiology (ACR) Web
site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonThoracicImaging/HemoptysisDoc4.aspx).

ACR Appropriateness Criteria® *Anytime*, *Anywhere*™ (PDA application).
Available from the [ACR Web
site](http://www.acr.org/SecondaryMainMenuCategories/ACRStore/FeaturedCategories/QualityandSafety/ac_pda.aspx).

Print copies: Available from the American College of Radiology, 1891
Preston White Drive, Reston, VA 20191. Telephone: (703) 648-8900.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   ACR Appropriateness Criteria®. Background and development. Reston
    (VA): American College of Radiology; 2 p. Electronic copies:
    Available in Portable Document Format (PDF) from the [American
    College of Radiology (ACR) Web
    site](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/background_dev.aspx).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on April 27, 2007.

#### COPYRIGHT STATEMENT

Instructions for downloading, use, and reproduction of the American
College of Radiology (ACR) Appropriateness Criteria® may be found on the
[ACR Web
site.](http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ACRAppropriatenessCriteriaTermsandConditionsDoc1.aspx)

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008