What is the acute inpatient management of massive hemoptysis?

From the Guidelines

The acute inpatient management of massive hemoptysis requires immediate stabilization and a multidisciplinary approach, with bronchial artery embolization being the preferred definitive intervention for most cases, as it has a high success rate of 70-90% 1.

Initial Management

First, position the patient with the bleeding lung in the dependent position to prevent aspiration into the unaffected lung.

• Secure the airway with endotracheal intubation using a large-bore tube (7.5-8.5 mm) to facilitate bronchoscopy and blood clearance.
• Administer supplemental oxygen and maintain hemodynamic stability with IV fluids and blood products as needed, targeting hemoglobin >7-8 g/dL.
• Correct any coagulopathy with fresh frozen plasma, platelets, or specific factor replacement.
• Tranexamic acid (1g IV over 10 minutes, followed by 1g over 8 hours) may help stabilize clots.

Diagnostic and Therapeutic Interventions

• Perform urgent bronchoscopy for localization and potential intervention, such as cold saline lavage, epinephrine (1:10,000) application, or endobronchial blockers for temporary tamponade.
• Arrange for urgent CT angiography to identify the bleeding source and plan definitive treatment.
• Bronchial artery embolization is the preferred definitive intervention for most cases, with success rates of 70-90% 1.
• If embolization fails or is unavailable, surgical resection may be necessary.

Supportive Care

Throughout management, continue supportive care including broad-spectrum antibiotics if infection is suspected, and maintain close monitoring in an ICU setting.

• This approach addresses the immediate threat while preparing for definitive treatment to stop the bleeding.
• The use of antibiotics is recommended for patients with at least mild (>5 ml) hemoptysis, as it may be a manifestation of a pulmonary exacerbation or infection 1.

From the Research

Acute Inpatient Management of Massive Hemoptysis

The management of massive hemoptysis requires a swift and multidisciplinary approach to stabilize the patient and control the bleeding.

• The initial evaluation should focus on determining the severity of bleeding and the stability of the patient, which may require bronchoscopy for airway protection 2.
• The management of massive hemoptysis involves airway and hemodynamic stabilization, maintenance of oxygenation and ventilation, and treatment of the underlying cause 3, 4.
• Diagnostic testing, such as chest radiography, computed tomography (CT), and CT angiography, can help identify the etiology of bleeding and guide treatment 2.
• Bronchial arterial embolization is a treatment option for massive hemoptysis, particularly when an involved artery is noted on CT angiography 2, 4.
• Surgery is reserved for patients whose medical treatment and embolization are not effective 2.
• The use of tranexamic acid, either systemically or via nebulization, has been suggested as a potential treatment for hemoptysis, although its effectiveness is still being studied 5, 6, 4.

Treatment Options

• Bronchial arterial embolization: a minimally invasive procedure that can help control bleeding in patients with massive hemoptysis 2, 4.
• Surgery: reserved for patients whose medical treatment and embolization are not effective 2.
• Tranexamic acid: a medication that can be used to help control bleeding, although its effectiveness in treating hemoptysis is still being studied 5, 6, 4.
• Supportive medical treatment: includes maintaining oxygenation and ventilation, and treating any underlying conditions that may be contributing to the hemoptysis 3, 4.

Multidisciplinary Approach

• A multidisciplinary approach is essential in the management of massive hemoptysis, involving intensivists, consultative services, and radiologists 4.
• An algorithmic management strategy can help guide the treatment of patients with massive hemoptysis, incorporating diagnostic and therapeutic methods 4.