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ACR Appropriateness Criteria® Hemoptysis

Ketai, Loren H. MD*; Mohammed, Tan-Lucien H. MD; Kirsch, Jacobo MD; Kanne, Jeffrey P. MD§; Chung, Jonathan H. MD; Donnelly, Edwin F. MD; Ginsburg, Mark E. MD#; Heitkamp, Darel E. MD**; Henry, Travis S. MD††; Kazerooni, Ella A. MD‡‡; Lorenz, Jonathan M. MD§§; McComb, Barbara L. MD∥∥; Ravenel, James G. MD¶¶; Saleh, Anthony G. MD##; Shah, Rakesh D. MD***; Steiner, Robert M. MD†††; Suh, Robert D. MD‡‡‡Expert Panel on Thoracic Imaging

doi: 10.1097/RTI.0000000000000084
Web Exclusive Content—ACR Appropriateness Criteria® Review

Although hemoptysis is often self-limited and benign in origin, it can be an indicator of serious disease including bronchiectasis, granulomatous infection, and malignancy. Hemoptysis severity can be graded on the basis of the quantity of expectorated blood: <30 mL of hemoptysis as minor, 30 to 300 mL as moderate to severe (major), and >300 to 400 mL in 24 hours as massive. Among patients with hemoptysis, chest radiographs are often abnormal and can guide evaluation. The overall risk for malignancy in patients with normal radiographs is low but may be as much as 5% to 10% in patients with >30 mL of hemoptysis and those who are above 40 years of age and have significant smoking history. A combination of negative computed tomography and bronchoscopy results predicts a very low likelihood of lung malignancy diagnosis over medium-term follow-up (2 to 3 y). Bronchial and nonbronchial systemic arteries are much more frequent sources of hemoptysis than pulmonary arteries. Major or massive hemoptysis can usually be stopped acutely by bronchial arterial embolization. Recurrences, however, are common and often require repeat embolization. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

*Department of Radiology, University of New Mexico, Albuquerque, NM

Virginia Mason Medical Center, Seattle, WA

Cleveland Clinic, Weston

∥∥Mayo Clinic, Jacksonville, FL

§Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI

National Jewish Health, Denver, CO

Vanderbilt University Medical Center, Nashville, TN

#Department of Surgery, Society of Thoracic Surgeons, Columbia University, New York

##The American College of Chest Physicians, New York Methodist Hospital, Brooklyn

***North Shore University Hospital, Manhasset, NY

**Department of Radiology, Indiana University, Indianapolis, IN

††Emory University Hospital, Atlanta, GA

‡‡University of Michigan Medical Center, Ann Arbor, MI

§§University of Chicago Hospital, Chicago, IL

¶¶Medical University of South Carolina, Charleston, SC

†††Department of Radiology, Temple University, Philadelphia, PA

‡‡‡Ronald Regan UCLA Medical Center, Los Angeles, CA

This article is a summary of the complete version of this topic, which is available on the ACRWebsite at Practitioners are encouraged to refer to the complete version.

Reprinted with permission of the American College of Radiology.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria®through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

Jeffrey P. Kanne is a consultant at PTC Therapeutics. Robert M. Steiner is a consultant and course director at Education Symposium Inc. and a consultant at John and Johnson.

Reprint: Loren H. Ketai, MD, Department of Radiology, 1 University of New Mexico # 105530 Albuquerque, NM 87131-0001 (e-mail:

© 2014 by Lippincott Williams & Wilkins