Single-center experience with hemoptysis in geriatric patients.

Introduction
Hemoptysis is defined as the expectoration of blood, either mixed with mucus or alone, originating from the lower respiratory tract [1, 2]. The differential diagnosis of hemoptysis is extensive, with etiologies varying by geographic region and healthcare settings [3–6]. Globally, the most common cause of hemoptysis is tuberculosis [7]. In underdeveloped countries, hemoptysis often results from acute respiratory tract infections, cancer, and bronchiectasis [7–9]. However, in 20%-50% of cases, no underlying cause can be identified through computed tomography (CT) or bronchoscopy, classifying these cases as cryptogenic hemoptysis.
Management strategies for hemoptysis range from conservative to interventional approaches, including emergency surgery, bronchial artery embolization (BAE), flexible bronchoscopy (FB), and rigid bronchoscopy (RB). These interventions should be considered only after ensuring hemodynamic stabilization and evaluating the patient’s clinical history [10, 11]. While surgery was historically the primary treatment modality, emergency surgical interventions for hemoptysis carry significantly higher mortality rates (up to 40%) compared to elective procedures [12]. FB allows direct visualization of the bronchial tree and localizes bleeding in 73%-93% of massive hemoptysis cases, although its effectiveness decreases in mild-to-moderate bleeding [13–16]. RB, on the other hand, provides superior image-guided bleeding control, facilitates airway clearance, and enhances visualization when used in combination with FB [17].
Over the past 50 years, the global population aged 65 and older has tripled, and projections estimate that nearly 30% of Europe’s population will exceed age 65 within the next 40 years [18]. Aging induces both structural and functional changes in the respiratory system, leading to a decline in pulmonary function test (PFT) parameters, including forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and maximal voluntary ventilation (MVV). Additionally, impaired mucociliary clearance, delayed cough reflexes, and alterations in swallowing function weaken the lungs’ protective mechanisms [19]. Comorbidities, malnutrition, and psychological or cognitive impairments further complicate surgical and interventional procedures, increasing the risk of perioperative complications [20]. As a result, the approach to hemoptysis in geriatric patients may differ from that in younger individuals.
Early diagnosis and effective management of hemoptysis in specialized centers significantly reduce mortality and complications. As a reference center, we designed this study to share our experience in managing hemoptysis in patients aged 65 years and older and to provide a resource for clinicians caring for this population.

Methods
The study is a single-center, retrospective observational analysis. Patients aged 65 years and older who were admitted to our hospital with hemoptysis between January 2012 and January 2022 were identified through the hospital information management system (HBYS). Clinical trial number: not applicable.
A total of 1383 patients aged 65 and older were included in the study, selected from approximately 7500 patients who presented to the hospital due to hemoptysis during the study period.

Hemoptysis management in our hospital
Patients admitted to our hospital’s chest diseases outpatient clinic or emergency department continued their follow-up and treatment in the chest diseases department after hemodynamic stabilization. Initial management in the emergency department included adrenaline nebulization, application of cold compresses in localizable cases, and intravenous tranexamic acid administration, depending on the patient’s clinical presentation. Fresh frozen plasma and platelet infusions were administered when necessary in patients with coagulation disorders. Platelet levels > 70,000/L and International Normalized Ratio (INR) values ​​<1:30, with an activated partial thromboplastin time (aPTT) not more than twice the control value, were considered within normal limits. After clinical stabilization was achieved in hospitalized patients, interventional procedures such as FB, RB, and BAE were performed according to patient groups and clinician experience to investigate etiologic causes and control bleeding. Complete blood count (CBC) data for the patients included in the study were analyzed using the Sysmex XT4000i device, and biochemical tests were performed using the Beckman Coulter AU2700 device in the hospital laboratory.

Recorded data
Patients’ demographic information, vital signs, comorbid diseases, dates of presentation with hemoptysis, dates of hospitalization, and invasive procedures performed during hospitalization were documented. Complete blood count, platelet count (Plt), International Normalized Ratio, liver function tests (alanine aminotransferase [ALT], aspartate aminotransferase [AST]), kidney function tests, and sodium and potassium values ​​recorded at hospital admission were documented. The amount of bleeding during the reference hospital admission for all patients was classified.

Definitions
Hemoptysis severity was classified as follows [5–8, 11]:

Massive hemoptysis: 300–1000 ml of bleeding within 24 h,

Moderate hemoptysis: 100–300 ml of bleeding within 24 h,

Minimal hemoptysis: Less than 100 ml of bleeding.

Study design
The causes of hemoptysis, interventional procedures, hospital stay durations, and biochemical parameters potentially associated with mortality were investigated in patients aged 65 years and older who presented to our hospital with hemoptysis. The relationship between interventional procedures and underlying diseases, as well as whether the procedures performed constituted independent factors affecting mortality, was analyzed and interpreted.

Statistical analysis
The Statistical Package for the Social Sciences version 23.0 (SPSS Inc.; Chicago, IL, USA) was used for statistical evaluation of the data. Descriptive analyses were conducted to provide information about the general characteristics of the study population. Continuous variables are presented as mean ± standard deviation, and categorical variables as n (%). Comparisons of age groups with respect to demographic characteristics, clinical findings, comorbidities, and procedures performed was assessed using the Chi-square test. The Kolmogorov-Smirnov test was used to assess the normal distribution of continuous variables. Comparisons of selected biochemical parameters, number of admissions, and length of hospitalization across age groups was performed using the Kruskal-Wallis H test or One-Way Analysis of Variance (ANOVA), depending on the normal distribution status. Pairwise comparisons following significant group differences were conducted using the Bonferroni or Dunn test. A binary logistic regression model was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for in-hospital mortality. Independent variables included age (modeled both as a continuous variable and with restricted cubic splines to capture nonlinear effects), sex, comorbidities, use of anticoagulant/antiplatelet agents, etiology, bleeding severity, and interventional procedures (fiberoptic bronchoscopy, rigid bronchoscopy, bronchial artery embolization, and surgery). Model performance was evaluated using the Hosmer–Lemeshow goodness-of-fit test, Nagelkerke R², and the area under the receiver operating characteristic curve (AUC) to assess discrimination. In statistical decisions, a p value of less than 0.05 was accepted to indicate a statistically significant difference.

Results
A total of 1,383 the study: 1064 (76.9%) male and 319 (23.1%) female. The mean age was 72.66 ± 6.04 years (minimum 65, maximum 93). The age group distribution was as follows: 938 young-old (65–74 years; 67.8%), 377 middle-old (75–84 years; 27.3%), and 68 old-old (> 85 years; 4.9%). Figure 1 illustrates the gender distribution across age groups.

Regarding smoking status, 35.6% of the patients had no history of smoking, 54.7% were current smokers, and 9.4% were former smokers. During the follow-up period, 1243 (89.1%) patients were alive and 140 patients (10.1%) had died. A total of 768 patients (55.5%) had at least one comorbidity. The most common comorbidities were hypertension (HT) (23.6%, n = 327), chronic obstructive pulmonary disease (COPD) (22.6%, n = 312), lung cancer (13.9%, n = 192), heart diseases (such as cardiac arrhythmia, congestive heart failure, ischemic heart disease) (13.7%, n = 190), sequelae tuberculosis and active tuberculosis infection (7.6%, n = 105), acute and chronic renal failure (6.8%, n = 94), and bronchiectasis (5.9%, n = 81). There were 117 patients (8.5%) using antiplatelet drugs and 125 patients (9%) using anticoagulant drugs that predispose to bleeding. Regarding interventional procedures performed for hemoptysis, surgery was performed in 291 patients (21.04%), including 259 wedge resections (18.73%), 24 lobectomies (1.74%), and eight pneumonectomies (0.58%). BAE was performed in 517 patients (37.38%), RB in 489 patients (35.36%), and FB in 1,088 patients (78.67%).
A statistically significant difference was found in gender distribution, anticoagulant use, and antiaggregant drug use across age groups (p < 0.001). While the proportion of male patients decreased with increasing age, the use of anticoagulant and antiaggregant drugs increased in the older age groups (Table 1).

Comparisons between age groups and comorbid conditions showed that the prevalence of comorbid diseases, including heart disease, coronary artery disease (CAD), heart failure (HF), atrial fibrillation, cerebrovascular disease, and renal failure increased with age, with statistically significant differences observed between age groups (p < 0.001) (Table 2).

When biochemical parameters were compared across age groups, statistically significant differences were found in red blood cell (RBC) count, hemoglobin (HGB), hematocrit (HCT), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width – standard deviation (RDW-SD), lymphocyte (LY) count, glucose, and albumin levels ​​(p < 0.001). The mean values of RBC, HGB, HCT, MCHC, LY, and albumin ​​decreased with increasing age, whereas RDW-SD and blood urea nitrogen (BUN) ​​values increased with age. Table 3 presents the comparison of biochemical parameters across age groups.

There was no statistically significant correlation between biochemical parameters and either the amount of bleeding or the length of hospital stay (p > 0.05). Additionally, no statistically significant differences were found between biochemical parameters and the procedures performed or mortality outcomes.
No statistically significant differences were observed when comparing the amount of bleeding with interventional procedures, whether performed alone or in combination (p > 0.05). When bleeding severity was compared across comorbid conditions, a statistically significant association was found only for HT (p = 0.020). No statistically significant relationships were identified between the amount of bleeding and other diseases (p > 0.05). There was a statistically significant difference in both the number of admissions and the length of hospital stay across age groups (p < 0.05). In terms of admission frequency, older age groups generally had fewer hospital admissions. A difference in length of stay was observed between the 65–74 and 75–84 age groups, and between the 75–84 and 85-and-above age groups. Specifically, the 75–84 age group had fewer admissions than the 65–74 group, whereas the 85-and-above age group had more admissions than the 75–84 group. When evaluating recurrent hospital visits, no statistically significant difference was found in relation to gender, amount of bleeding, additional diseases, age groups, biochemical parameters, or anticoagulant and antiaggregant drug use (p > 0.05). Table 4 presents the comparison of the number of hospital visits and length of stay by age group.

A statistically significant difference was observed in the comparison of interventional procedure combinations across age groups (p < 0.001). The number of procedures performed in combination decreased in the older age groups. Table 5 presents the comparison of interventional procedure combinations by age group, and Table 6 shows the distribution of interventional procedures according to age group and bleeding severity.

When gender groups were compared in relation to comorbidities, conditions such as CAD, asthma, COPD, renal failure, bronchiectasis, and lung cancer were found to be statistically significantly more common in male patients (p < 0.001). No statistically significant association was found between smoking history and bleeding severity (p > 0.05).

When 192 patients diagnosed with lung cancer were analyzed, 164 (85.4%) were male, and the mean age was 73.21 years. The age distribution was as follows: 121 (63%) were young-old (65–74 years), 62 (32.3%) were middle-old (75–84 years), and nine (4.7%) were old-old (≥ 85). A total of 36 patients (18.8%) died during follow-up. Regarding the amount of bleeding, 100 patients (51.2%) had minimal bleeding, 87 (45.3%) had moderate bleeding, and two (2.6%) had massive bleeding. Among these patients, 38 (19.8%) underwent surgery (33 wedge resections), 143 (74.5%) underwent FB, 69 (35.9%) underwent RB, and 72 (37.5%) underwent BAE. When 104 patients diagnosed with active pulmonary tuberculosis and sequelae tuberculosis were analyzed, 80 (76.9%) were male, and the mean age was 72.95 years. The age distribution was as follows: 73 (70.2%) were young-old (65–74 years), 24 (23.1%) were middle-old (75–84 years), and seven (6.7%) were old-old (≥ 85 years). Nineteen patients (18.3%) died during follow-up. Based on the amount of bleeding, 46 patients (44.2%) had minimal bleeding, 56 (53.8%) had moderate bleeding, and two (1.9%) had massive bleeding. Additionally, 18 patients (17.3%) underwent surgery (15 wedge resections), 84 (80.8%) underwent FB, 28 (26.9%) underwent RB, and 46 (44.2%) underwent BAE.
When 164 patients with heart disease were analyzed, 134 (81.7%) were male, and the mean age was 73.63 years. The age distribution was as follows: 96 (58.5%) were young-old (65–74 years), 41 (25%) were middle-old (75–84 years), and 27 (16.5%) were old-old (≥ 85 years). Fourteen patients (8.5%) died during follow-up. Regarding bleeding severity, 77 patients (47%) had minimal bleeding, 81 (49.4%) had moderate bleeding, and six (3.7%) had massive bleeding. It was observed that 38 patients (23.2%) underwent surgery (31 wedge resections), 133 patients (81.1%) underwent FB, 62 patients (37.8%) underwent RB, and 50 patients (30.2%) underwent BAE.
When the 125 patients using antiaggregants were analyzed, 105 (84%) were male and 20 (16%) were female. A total of nine patients (7.2%) died during follow-up. Regarding the distribution according to the amount of bleeding, 59 patients (47.2) had minimal bleeding, 61 (48.8%) had moderate bleeding, and five [4] had massive bleeding. It was observed that 31 patients (24.8%) underwent surgery (24 wedge resections), 102 (81.6) underwent FB, 48 (38.4%) underwent RB, and 37 (29.6%) underwent BAE.
When 117 patients using anticoagulants were analyzed, 99 (84.6%) were male and 18 (15.4%) were female. A total of 20 patients (17.1%) died during follow-up. Based on the amount of bleeding, 60 patients (51.3) had minimal bleeding, 54 (46.2%) had moderate bleeding, and three (2.6) had massive bleeding. It was observed that 26 patients (22.2%) underwent surgery (21 wedge resections), 93 (79.5) underwent FB, 51 (43.6%) underwent RB, and 35 (29.9%) underwent BAE.

Discussion
This study provides valuable insights into the management of hemoptysis in geriatric patients, emphasizing that age alone does not determine bleeding severity or mortality. By analyzing a large patient cohort, we found no statistically significant relationship between bleeding volume, mortality, biochemical parameters, comorbidities, or anticoagulant use. Interventional pulmonary procedures were performed at similar rates across all age groups, suggesting that age should not restrict treatment decisions. Our findings emphasize that chronological age should not be considered an isolated predictor of hemoptysis outcomes. Recent geriatric research has highlighted that frailty, functional capacity, and nutritional status have stronger prognostic implications than chronological age alone, suggesting that future studies should incorporate frailty indices into risk assessment models.
Hemoptysis is defined as the expectoration of blood from the lower respiratory tract and may result from multiple underlying causes; however, 20%-50% of cases remain cryptogenic [1, 2]. Although most cases are mild and self-limited, hemoptysis can become a life-threatening medical emergency. These cases are associated with mortality rates exceeding 50%, primarily due to asphyxia. Management strategies are guided by severity: outpatient care is appropriate for clinically stable patients with non-life-threatening hemoptysis, whereas intensive interventions, such as BAE or surgical resection, are reserved for patients with high-risk features or life-threatening hemoptysis [21]. Aging is associated with structural and functional respiratory changes, reduced physiological reserve, and increased risks related to interventional procedures. These factors complicate hemoptysis management in elderly patients. In many countries, limited access to specialized centers further exacerbates these challenges. As a reference center, our study aims to share clinical experience and offer guidance on geriatric hemoptysis management.

Gender and smoking
Previous studies have reported that hemoptysis is approximately twice as common in men [8]. Our study found a male-to-female ratio of 3.3:1, likely due to the higher prevalence of bronchiectasis and lung cancer among men, as well as comorbid conditions such as coronary artery disease and renal failure, which predispose patients to bleeding. Consistent with the literature, we found no statistically significant relationship between hemoptysis and smoking history, despite 64% of patients reporting a history of smoking [22].

Bleeding severity and comorbidities
Minimal bleeding was the most common presentation across all age groups, with no statistically significant differences observed as age increased. This finding suggests that age does not influence bleeding severity. Furthermore, no statistically significant correlation was found between bleeding volume and interventional procedures, whether performed individually or in combination. Among comorbid conditions, only hypertension demonstrated a statistically significant association with bleeding severity (p = 0.020).
A major clinical concern is that increased comorbidities and the use of anticoagulant or antiplatelet medications may elevate the risk of bleeding and mortality in elderly patients. However, our study found no association between these factors and either mortality or bleeding volume. Interventional procedures were also performed at similar rates across all age groups, further supporting the safety of these interventions in older adults.
Despite the growing use of anticoagulant and antiplatelet medications in the elderly, our study did not demonstrate any correlation between these medications and bleeding severity or mortality. This underscores the importance of individualized treatment rather than the XXXroutine discontinuation of such therapies.

Etiology and causes of hemoptysis
In European populations, up to 50% of hemoptysis cases remain of unknown origin [4, 22, 23]. Among identifiable causes, airway infections, bronchial carcinomas, metastases, bronchiectasis, and tuberculosis are most frequently reported. In our study, lung cancer was the most common etiology in geriatric patients, followed by tuberculosis sequelae and bronchiectasis. This may be due to our hospital’s role as a specialized pulmonary center, which results in a higher referral rate for suspected lung cancer cases. Additionally, lung cancer incidence increases with age, with the average age at diagnosis being approximately 70 years [24, 25]. Given that our study population consisted exclusively of patients aged 65 and older, it was expected that malignancy would be the leading etiology.

Mortality and risk factors
Hemoptysis-related mortality varies significantly depending on the severity of bleeding. Previous studies have reported mortality rates of 0.3% in mild cases, rising to as high as 50% in massive hemoptysis [26]. Lim et al. identified significant associations between age, heart failure, and mortality in bronchiectasis-related hemoptysis [27]. Similarly, Lee et al. reported mortality rates of 13.4% and 13.5% among patients with moderate and massive hemoptysis, respectively, with no statistically significant difference between the groups [28]. In our study, the overall mortality rate was 10%, and no significant relationships were found between age, comorbidities, biochemical parameters, bleeding volume, and mortality. These findings suggest that age alone is not a major risk factor for mortality in hemoptysis. Our study also contributes to the limited literature examining the role of biochemical parameters in hemoptysis-related mortality, particularly in geriatric populations.
Interestingly, mortality among patients with malignancy-related hemoptysis was not statistically significantly higher than in other etiologic groups. This contrasts with previous studies identifying malignancy as an independent predictor of death, possibly reflecting the benefits of early intervention and multidisciplinary management in specialized centers.

Interventional pulmonary
Flexible bronchoscopy is widely recognized as the preferred interventional method for hemoptysis due to its diagnostic and therapeutic advantages [29–31]. In our study, it was the most frequently used procedure across all age groups and bleeding severities (78%). Its widespread use in elderly patients may be attributed to its minimal procedural risks, the absence of a need for general anesthesia, and its broad availability.
Rigid bronchoscopy is favored in cases of massive hemoptysis because it allows for airway protection, removal of large clots, and therapeutic interventions such as thermal ablation or cautery [31, 32]. In our study, RB was performed in 35% of cases, with similar rates across all age groups and bleeding severities. These findings support its safety and efficacy in geriatric patients.
Bronchial artery embolization has been reported to achieve success rates of up to 90% in hemoptysis management [11, 33]. In our study, BAE was performed in 37% of cases, primarily in patients with minimal or moderate bleeding, and most commonly in combination with FB. Although BAE is often considered the first-line intervention for massive hemoptysis, our study found that it was used in only 31% of massive cases, whereas FB (77%) and RB (44%) were more frequently utilized. BAE is a frequently used intervention in the treatment of hemoptysis and has a high success rate. A 2022 study demonstrated that patients treated with BAE for hemoptysis secondary to bronchiectasis achieved a three-year recurrence-free survival rate of 66.2%, compared to only 2.5% in those managed conservatively [34]. Furthermore, a 2020 study emphasized that multidetector CT angiography provides high accuracy in identifying the bleeding source during pre-BAE planning and plays an important role in predicting recurrence risk [35]. An artificial neural network-based nomogram developed in the same year predicted hemoptysis recurrence after BAE and demonstrated potential utility in clinical decision-making [36]. These findings are particularly relevant for geriatric patients. Although BAE has been shown to be effective in controlling acute bleeding, the absence of long-term follow-up data limits the ability to fully assess recurrence risk. Previous studies have reported recurrence rates ranging from 10% to 30%, highlighting the need for longitudinal studies specifically focused on geriatric cohorts.
Additionally, we observed a decline in the use of combined interventional procedures with increasing patient age. This could reflect concerns regarding procedural risks in older individuals or a preference for less invasive management strategies. However, our findings suggest that interventional pulmonary procedures remain viable and safe options for geriatric patients when performed by experienced specialists.
The limitations of this study include its retrospective single-center design and the lack of long-term follow-up data, which may affect generalizability. Furthermore, frailty and functional scores were not recorded, preventing an evaluation of their potential role as predictors of clinical outcomes.

Key contributions of this study
While previous studies have suggested that advanced age increases complications in hemoptysis management, our findings demonstrate that age alone is not a determinant of mortality or bleeding volume. Although interventional procedures were performed less frequently in older patients, this did not translate into higher mortality rates.
Contrary to reports proposing that biochemical parameters may predict hemoptysis severity and mortality, our study found no such associations. This suggests that commonly used biochemical markers in hemoptysis risk assessment for elderly patients need to be reconsidered.
Despite concerns regarding elevated procedural risks in the elderly, our study found that FB, RB, and BAE can be safely performed, with success rates comparable to those seen in younger populations.
Unlike global data suggesting tuberculosis as the leading cause of hemoptysis, our study found lung cancer to be the most common etiology in geriatric patients. This highlights the importance of malignancy screening in elderly individuals presenting with hemoptysis.
Previous studies have reported high mortality rates in cases of massive hemoptysis. However, our study observed an overall mortality rate of approximately 10%, with no statistically significant relationship between bleeding volume and mortality. These findings suggest that general health status, comorbidities, and treatment strategies play a more critical role in determining patient outcomes.
Given the large cohort and multidimensional dataset, our findings could contribute to the development of risk stratification models tailored specifically for geriatric patients with hemoptysis, incorporating age, comorbidities, and procedural tolerance.

Conclusion
This study provides more comprehensive and detailed data than previous research on the management of hemoptysis in geriatric patients. It demonstrates that age alone is not a determinant of outcomes, that interventional procedures are safe and effective, and that biochemical parameters may not be associated with hemoptysis severity. We believe that these findings will help shape the clinical management of hemoptysis in geriatric patients and serve as an important guide for future research.

Supplementary Information