How to manage hemoptysis in pulmonary embolism (pulmonary thromboembolism)?

From the Guidelines

Management of hemoptysis in pulmonary embolism requires prompt intervention with a focus on treating the underlying embolism while supporting respiratory function, and according to the most recent evidence 1, bronchial artery embolization is recommended in the majority of cases of massive hemoptysis.

Initial Management

First, administer anticoagulation therapy with either low molecular weight heparin (such as enoxaparin 1 mg/kg twice daily) or unfractionated heparin (80 units/kg bolus followed by 18 units/kg/hour infusion) to prevent clot propagation, as recommended by the European Society of Cardiology 1.

• Oxygen supplementation should be provided to maintain oxygen saturation above 92%.
• For significant hemoptysis, position the patient with the affected side down to prevent blood from flowing into the unaffected lung.
• Avoid cough suppressants as expectoration of blood helps maintain airway patency.

Severe Hemoptysis

If hemoptysis is severe (>100 mL in 24 hours), consider tranexamic acid (1g IV every 8 hours) to reduce bleeding.

• In cases of massive hemoptysis with hemodynamic instability, urgent interventional procedures such as bronchial artery embolization or surgical intervention may be necessary, as recommended by the American College of Radiology 1.
• Hemoptysis in pulmonary embolism occurs due to pulmonary infarction with subsequent necrosis of lung tissue and erosion into bronchial vessels, or from pulmonary hypertension causing rupture of bronchial vessels.

Monitoring and Adjustment

Regular monitoring of vital signs, hemoglobin levels, and coagulation parameters is essential, and anticoagulation may need adjustment if bleeding worsens.

• The use of thrombolytic therapy should be considered in patients with high-risk pulmonary embolism presenting with cardiogenic shock and/or persistent arterial hypotension, as recommended by the European Society of Cardiology 1.
• Surgical pulmonary embolectomy is a recommended therapeutic alternative in patients with high-risk pulmonary embolism in whom thrombolysis is absolutely contraindicated or has failed 1.

From the FDA Drug Label

Heparin Sodium Injection is indicated for: • Prophylaxis and treatment of venous thrombosis and pulmonary embolism;

The management of hemoptysis in pulmonary embolism is not directly addressed in the provided drug label for heparin (IV) 2.

• The label discusses the use of heparin for the treatment of pulmonary embolism, but it does not provide information on managing hemoptysis specifically.
• Hemoptysis is a serious condition that requires immediate medical attention, but the provided label does not offer guidance on its management in the context of pulmonary embolism treated with heparin.

From the Research

Management of Hemoptysis in Pulmonary Embolism

• Hemoptysis is a potentially life-threatening symptom that requires immediate management 3
• In patients with pulmonary embolism (PE) and hemoptysis, anticoagulation should be stopped and an inferior vena cava filter may be justified 3
• The optimal management regarding the use of specific reversal agents or prothrombotic plasma concentrates remains uncertain and weakly documented 3
• After hemoptysis has been resolved, there is uncertainty on restarting anticoagulation modalities 3

Treatment of Pulmonary Embolism

• Anticoagulant therapy with intravenous unfractionated heparin or subcutaneous low molecular weight heparin followed by oral anticoagulant treatment for at least 3 months is the treatment of choice for most patients with PE 4
• Direct oral anticoagulants such as apixaban, edoxaban, rivaroxaban, or dabigatran are noninferior for treating PE and have a lower rate of bleeding compared to heparin combined with a vitamin K antagonist 5
• Low molecular weight heparin is at least as effective as unfractionated heparin in the treatment of PE, with a similar risk of bleeding 6

Management of Massive Hemoptysis

• Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management 7
• Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram 7
• Bronchial artery embolization with interventional radiology has become the mainstay of treatment for massive hemoptysis 7