What is the treatment for massive hemoptysis?

From the Guidelines

The treatment for massive hemoptysis requires immediate intervention with bronchial artery embolization (BAE) as the preferred definitive treatment, with success rates of 70-99% 1.

Initial Management

Initial management includes positioning the patient with the bleeding side down to prevent blood from flooding the unaffected lung, securing the airway, providing supplemental oxygen, and establishing intravenous access for fluid resuscitation.

• Rigid or flexible bronchoscopy should be performed urgently for both diagnostic and therapeutic purposes, allowing for direct visualization of the bleeding source and potential interventions such as cold saline lavage, topical epinephrine application, or endobronchial tamponade using a Fogarty catheter.
• Medical management includes correcting coagulopathies with fresh frozen plasma, platelets, or vitamin K as needed, and treating underlying causes such as infections with appropriate antibiotics.

Definitive Treatment

• Bronchial artery embolization is the preferred definitive treatment for most cases of massive hemoptysis 1, with success rates of 70-99%.
• If embolization fails or is unavailable, surgical resection may be necessary, though it carries higher mortality (up to 40%) 1.
• Tranexamic acid (1g IV followed by 1g every 8 hours) may be used as a temporizing measure.

Rationale

The urgency of treatment is justified by the high mortality rate of untreated massive hemoptysis (50-100%), primarily due to asphyxiation rather than exsanguination 1.

• Recent studies have consistently shown high success rates for BAE in treating massive hemoptysis, making it the preferred treatment option 1.
• The American College of Radiology recommends BAE as the primary treatment for massive hemoptysis 1.

From the FDA Drug Label

Tranexamic acid injection is an antifibrinolytic indicated in patients with hemophilia for short-term use (2 to 8 days) to reduce or prevent hemorrhage and reduce the need for replacement therapy during and following tooth extraction

The treatment for massive hemoptysis is not directly addressed in the provided drug label for tranexamic acid (IV) 2. Key points:

• The label mentions the use of tranexamic acid for reducing or preventing hemorrhage in patients with hemophilia, but it does not specifically mention massive hemoptysis.
• The label does provide dosage and administration information for patients with hemophilia, but this may not be directly applicable to massive hemoptysis. The FDA drug label does not answer the question.

From the Research

Treatment Options for Massive Hemoptysis

• The primary goal of treatment is to secure the airway, stabilize hemodynamics, and control the bleeding 3.
• Intensive care and monitoring with endotracheal intubation are useful in massive hemoptysis, and bronchoscopy should be performed to help localize the bleeding site 4.
• Embolization is a suitable first-line treatment for massive hemoptysis, reserving emergency surgery for cases where the above measures are insufficient to control bleeding 4, 5, 6.
• Bronchial artery embolization is used to treat massive hemoptysis, particularly when an involved artery is noted on computed tomography angiography 5, 6.
• Surgery is indicated if bronchial artery embolization alone is not successful, or for special indications such as traumatic or iatrogenic pulmonary/vascular injury, or refractory aspergilloma 5, 6.

Diagnostic Evaluation

• A thorough diagnostic evaluation is needed to identify the underlying pathology, site of bleeding, and vascular anatomy, so that the appropriate treatment can be planned 3, 5, 6.
• The evaluation should include conventional chest x-rays in two planes, contrast-enhanced multislice computerized tomography, and bronchoscopy 6.
• Computed tomography and computed tomography angiography of the chest with intravenous contrast are the preferred modalities to determine the etiology of bleeding 5.

Management of Hemoptysis

• Mild hemoptysis comprises more than 90% of cases and has a good prognosis, whereas massive hemoptysis has a high mortality rate 5.
• Hemoptysis must be differentiated from pseudohemoptysis, which is blood that originates from nasopharyngeal or gastrointestinal sources 5.
• The initial evaluation includes determining the severity of bleeding and stability of the patient and may require bronchoscopy for airway protection 5.
• Management should include treatment of the underlying etiology because recurrence often takes place in the absence of treatment of the identified cause 5.