Urgent considerations

See Differentials for more details

Massive hemoptysis

Massive hemoptysis is a medical emergency and requires immediate treatment. Massive hemoptysis is defined as the expectoration of blood from a source below the glottis exceeding 600 mL of blood over a 24-hour period or 150 mL of blood (which may flood the lung dead space) over a 1-hour period.

Alternatively, massive hemoptysis can be diagnosed by clinical features of: airway compromise (obstruction, aspiration, hypoxemia, need for intubation); hemodynamic instability or requirement for blood transfusion.[3]

Experts recommend a stepwise approach to treat massive hemoptysis:

1. Initial stabilization

Initial priorities are evaluation of the need for intubation or mechanical ventilation, and protection of the nonbleeding lung. Attending to ABC (Airway, Breathing, and Circulation) is paramount. Coagulopathy, thrombocytopenia, and platelet dysfunction should be identified and reversed immediately, and blood products should be readily available.

2. Protection of the nonbleeding lung

If hemoptysis is active and unilateral, there is a risk of blood spillage into the nonbleeding lung, and rapid action should be taken to protect the nonbleeding lung. The patient may be placed in a lateral decubitus position with the bleeding lung downward in a dependent position.[5] Alternatively, the nonbleeding lung may be selectively intubated with the largest endotracheal tube available. A double-lumen endotracheal tube has a very limited role in managing massive hemoptysis due to the complexity of its proper placement, the need for significant operator experience, and the small lumen sizes, which do not allow room for therapeutic bronchoscopy.[5]

3. Airway intervention and control of bleeding

Once the patient has been stabilized and the nonbleeding lung has been protected, early bronchoscopy should be performed. Airway control can be attained by flexible bronchoscopy through a large-bore endotracheal tube or through the barrel of a rigid bronchoscope. Rigid bronchoscopy is a safe, effective way of securing the airway with therapeutic control of bleeding.[7][28][29][30] An endobronchial blocker or Fogarty balloon may be placed into the bleeding bronchus for tamponade of the bleeding site.

Bronchial arteriography with embolization of the source of bleeding can be used as a diagnostic and therapeutic intervention when available, but the recurrence rate may be high.[31][32][33]​​​​

4. Surgical consideration

For patients who do not respond to embolization or other minimally invasive techniques, surgical intervention should be considered. Some causes of hemoptysis, such as mitral stenosis, leaking aortic aneurysm, iatrogenic pulmonary artery rupture, traumatic injury to the chest, tracheo-innominate fistula, focal bronchiectasis, or aspergilloma resistant to other therapies, should be treated surgically.[5] The thoracic surgeon should be involved early in the care of patients with massive hemoptysis, and a multidisciplinary approach is needed to optimize the outcome.[34]

5. Other

Bridging therapies with potential to reduce bleeding severity include nebulized or bronchoscopic tranexamic acid, cold saline lavage, local epinephrine, bronchoscopic fibrinogen-thrombin injection, and tissue glue.[35][36][37][38][39][40][41][42]

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