Internal and Emergency Medicine

, Volume 13, Issue 3, pp 397–404 | Cite as

Management of patients presenting with haemoptysis to a Tertiary Care Italian Emergency Department: the Florence Haemoptysis Score (FLHASc)

  • Simone VanniEmail author
  • Simone Bianchi
  • Sofia Bigiarini
  • Claudia Casula
  • Marco Brogi
  • Stefano Orsi
  • Manlio Acquafresca
  • Lorenzo Corbetta
  • Stefano Grifoni


We analysed the clinical features and diagnostic workup of patients presenting with haemoptysis to an Italian teaching hospital to derive an easy-to-use clinical score to guide risk stratification and initial management in the emergency department (ED). We retrospectively reviewed clinical records of consecutive patients with haemoptysis over 1 year. A pre-specified set of variables, including demographic data, vital signs, type of expectorate (pure blood vs. blood-streaked sputum), comorbidities, and diagnostic tests and treatments was originally registered. The primary outcome was a composite of any of the following: death from any cause, invasive or non-invasive ventilation, Intensive Care Unit admission, blood transfusions or invasive haemostatic procedures. We investigated associations between the pre-specified clinical variables and the primary outcome using a logistic regression analysis. Finally, we derived a score (the Florence Haemoptysis Score, FLHASc) giving a proportional weight to each variable according to the Odds Ratios (OR). We included 197 patients with a median age of 60 years. The first radiological study was a plain chest X-ray in 128 patients (65%). For 33 (17%) patients, a chest computer tomography (CT scan) was the first radiological study. The most common diagnosis was lung malignancy (19% of cases). The diagnosis remained undetermined in one-third of patients. The primary outcome was met by 11.2% of the study population. Systolic blood pressure <100 mmHg (OR 9.7), a history of malignancy (OR 3), the expectoration of pure blood (OR 2.8), and more than 2 episodes of haemoptysis in the prior 24 h (OR 2.5) are found as independent predictors of the primary outcome. The FLHASc ranges from 0 to 6 with a prognostic accuracy of 78% (IC 95%, 68–88%). The primary outcome incidence is 2.4% (IC 95%, 0.2–8.2%) in patients with a FLHASc equal to zero (n = 85, 43%) versus 13.4% (IC 95% 7.8–21.1%) in patients with a FLHASc > 0 (p < 0.01). Among patients with a FLHASc equal to zero, a negative chest X-ray study identifies patients who may be safely discharged. Patients who presented to the ED with haemoptysis experience a heterogeneous management. We derive a simple clinical prognostic score that may rationalize their diagnostic workup.


Haemoptysis Diagnosis Prognosis Clinical score Emergency department 



The authors gratefully acknowledge the contribution of Sarah McLean in correcting the manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

All procedures performed involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Sakr L, Dutau H (2010) Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration 80(1):38–58CrossRefPubMedGoogle Scholar
  2. 2.
    Jean-Baptiste E (2005) Management of haemoptysis in emergency department. Hospital Physician, pp 53–59Google Scholar
  3. 3.
    Milani GF, Pivirotto F., Leporini C (2013) Emottisi: il ruolo della broncoscopia nella diagnosi e terapia. Standard operativi e linee guida in endoscopia toracica. 2° Consensus Conference Nazionale. Bologna (16 April 2013)Google Scholar
  4. 4.
    Larici AR, Franchi P, Occhipinti M, Contegiacomo A, del Ciello A, Calandriello L et al (2014) Diagnosis and management of hemoptysis. Diagn Interv Radiol 20(4):299–309CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Jean-Baptiste E (2000) Clinical assessment and management of massive hemoptysis. Crit Care Med 28(5):1642–1647CrossRefPubMedGoogle Scholar
  6. 6.
    Thirumaran M, Sundar R, Sutcliffe IM, Currie DC (2009) Is investigation of patients with haemoptysis and normal chest radiograph justified? Thorax 64(10):854–856CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Fartoukh M (2010) Severe haemoptysis: indications for triage and admission to hospital or intensive care unit. Rev Mal Respir 27(10):1243–1253CrossRefPubMedGoogle Scholar
  8. 8.
    Ketai LH, Mohammed TL, Kirsch J, Kanne JP, Chung JH, Donnelly EF et al (2014) ACR appropriateness criteria(R) hemoptysis. J Thorac Imaging 29(3):W19–W22CrossRefPubMedGoogle Scholar
  9. 9.
    Ibrahim WH (2008) Massive haemoptysis: the definition should be revised. Eur Respir J 32(4):1131–1132CrossRefPubMedGoogle Scholar
  10. 10.
    Rugarli C (2015) Medicina interna sistematica. Edizione 7. 2015Google Scholar
  11. 11.
    Ministero della Salute (2016) Ministero della Salute—Assistenza, ospedale e territorio—118 e Pronto Soccorso—I codici colore gravità (triage)Google Scholar
  12. 12.
    Fabbian Fabio, Melandri Roberto, Borsetti Gabriella, Micaglio Emanuele, Pala Marco, De Giorgi Alfredo, Menegatti Alessandra Mellozzi, Boccafogli Arrigo, Manfredini Roberto (2012) Color-coding triage and allergic reactions in an Italian ED. Am J Emerg Med 30(5):826–829CrossRefPubMedGoogle Scholar
  13. 13.
    Lipley N (2005) Updated Manchester triage system published this month. Emerg Nurse 13(7):3CrossRefGoogle Scholar
  14. 14.
    Dweik RA, Stoller JK (1999) Role of bronchoscopy in massive hemoptysis. Clin Chest Med 20(1):89–105CrossRefPubMedGoogle Scholar
  15. 15.
    Flume PA, Yankaskas JR, Ebeling M, Hulsey T, Clark LL (2005) Massive hemoptysis in cystic fibrosis. Chest 128(2):729–738CrossRefPubMedGoogle Scholar
  16. 16.
    Ong TH, Eng P (2003) Massive hemoptysis requiring intensive care. Intensive Care Med 29(2):317–320CrossRefPubMedGoogle Scholar
  17. 17.
    Khalil A, Soussan M, Mangiapan G, Fartoukh M, Parrot A, Carette MF (2007) Utility of high-resolution chest CT scan in the emergency management of haemoptysis in the intensive care unit: severity, localization and aetiology. Br J Radiol 80(949):21–25CrossRefPubMedGoogle Scholar
  18. 18.
    Garzon AA, Cerruti MM, Golding ME (1982) Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 84(6):829–833PubMedGoogle Scholar
  19. 19.
    Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC (2005) Bronchoscopy-guided topical hemostatic tamponade therapy for the management of life-threatening hemoptysis. Chest 127(6):2113–2118CrossRefPubMedGoogle Scholar
  20. 20.
    Holsclaw DS, Grand RJ, Shwachman H (1970) Massive hemoptysis in cystic fibrosis. J Pediatr 76(6):829–838CrossRefPubMedGoogle Scholar
  21. 21.
    Bobrowitz ID, Ramakrishna S, Shim YS (1983) Comparison of medical v surgical treatment of major hemoptysis. Arch Intern Med 143(7):1343–1346CrossRefPubMedGoogle Scholar
  22. 22.
    Vanni S, Jimenez D, Nazerian P, Morello F, Parisi M, Daghini E et al (2015) Short-term clinical outcome of normotensive patients with acute PE and high plasma lactate. Thorax 70(4):333–338CrossRefPubMedGoogle Scholar
  23. 23.
    Adriell RS, Jaqueline LS, Fábio FA (2013) SaO2/FiO2 ratio as risk stratification for patients with sepsis. Crit Care 17(suppl 14):51Google Scholar
  24. 24.
    Thompson AB, Teschler H, Rennard SI (1992) Pathogenesis, evaluation, and therapy for massive hemoptysis. Clin Chest Med 13(1):69–82PubMedGoogle Scholar
  25. 25.
    Bidwell JL, Pachner RW (2005) Hemoptysis: diagnosis and management. Am Fam Phys 72(7):1253–1260Google Scholar
  26. 26.
    Fartoukh M, Khoshnood B, Parrot A, Khalil A, Carette MF, Stoclin A et al (2012) Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis. Respiration 83(2):106–114CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2017

Authors and Affiliations

  • Simone Vanni
    • 1
    Email author
  • Simone Bianchi
    • 1
  • Sofia Bigiarini
    • 1
  • Claudia Casula
    • 1
  • Marco Brogi
    • 2
  • Stefano Orsi
    • 3
  • Manlio Acquafresca
    • 4
  • Lorenzo Corbetta
    • 5
  • Stefano Grifoni
    • 1
  1. 1.Emergency DepartmentAzienda Ospedaliero Universitaria CareggiFlorenceItaly
  2. 2.General Laboratory Unit, Medical Services DepartmentAzienda Ospedaliero Universitaria CareggiFlorenceItaly
  3. 3.Bronchoscopy Unit, Diagnostic and Operative Bronchology DepartmentAzienda Ospedaliero Universitaria CareggiFlorenceItaly
  4. 4.Radiology UnitAzienda Ospedaliero Universitaria CareggiFlorenceItaly
  5. 5.Interventional Pulmonology UnitAzienda Ospedaliero Universitaria CareggiFlorenceItaly

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