Haemoptysis with a normal chest radiograph: how concerned should we be?

In this issue of Thorax ( see page 854 ), Thirumaran and colleagues describe their experience with a consecutive group of patients evaluated for haemoptysis who had a normal chest radiograph.1 Over a 4-year period these investigators identified 270 patients who were evaluated for this problem. They made two important observations. First, they found that 26 of the 270 patients (9.6%) had respiratory tract malignancies as the cause of the haemoptysis. Of these 26 respiratory tract malignancies, 20 were non-small cell lung cancer (NSCLC) and 2 were small cell lung cancer. Secondly, they performed both fibreoptic bronchoscopy (FOB) and chest CT on the majority of the 270 patients evaluated. Overall, at least 269 FOBs and 257 CTs were performed to diagnose these 22 lung cancers. These observations lead to a series of fundamentally important questions for doctors to consider. Why should haemoptysis with a normal chest radiograph be a concern? Haemoptysis can be massive and life-threatening, by causing either airway compromise or haemodynamic insufficiency. Fortunately, haemoptysis is rarely massive. I work in a busy Intensive Care Unit (ICU; 19 beds and >1500 admissions per year) in a large urban hospital (907 beds and about 47 000 admissions per year) and we see probably only 1–2 cases of massive, life-threatening haemoptysis per year. In the study by Thirumaran et al , of the 275 episodes of haemoptysis, none was massive; the majority were described as simply streaks of bleeding. Although doctors should be aware of the risk of massive haemoptysis, most cases of haemoptysis represent minor bleeding which stops spontaneously. The real concern about haemoptysis with a normal chest radiograph is understanding the cause. As Thirumaran and colleagues point out, haemoptysis should be considered a possible signal of an underlying serious illness, particularly lung cancer. Doctors should not be lulled into believing that …