What is the best next step for a patient presenting with acute hemoptysis?

From the Guidelines

The best next step for a patient presenting with acute hemoptysis is to first stabilize the patient by ensuring airway patency, adequate oxygenation, and hemodynamic stability, and then consider early consultation for bronchial artery embolization (BAE) or surgical intervention, as BAE has been shown to be a safe and effective intervention for the treatment of massive hemoptysis, with a high success rate of 75-95% (1).

To achieve this, the following steps should be taken:

• Position the patient with the bleeding lung in the dependent position (affected side down) to prevent blood from spilling into the unaffected lung.
• Obtain immediate laboratory studies including complete blood count, coagulation profile, and type and cross-match for potential blood transfusion.
• Chest imaging with a chest X-ray should be performed promptly, followed by chest CT with IV contrast if the patient is stable enough, as it provides better visualization of mediastinal structures and helps in preprocedural embolization planning (1).
• Bronchoscopy is essential 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 balloon tamponade.
• For massive hemoptysis (>100-200 mL in 24 hours), consider early consultation for BAE or surgical intervention, as the mortality rate for massive hemoptysis due to lung cancer can be as high as 59-100% (1).
• Simultaneously, treat any underlying causes such as infections with appropriate antibiotics, correct coagulopathies with vitamin K, fresh frozen plasma, or platelet transfusions as needed, and manage conditions like pulmonary hypertension or heart failure that may contribute to the bleeding.

This approach prioritizes patient stabilization while rapidly identifying and addressing the source of bleeding to prevent life-threatening complications, and is supported by the most recent and highest quality evidence (1).

From the Research

Diagnosis and Treatment of Hemoptysis

The best next step for a patient presenting with acute hemoptysis involves a series of diagnostic and potentially therapeutic interventions.

• The initial evaluation should include determining the origin of bleeding and identifying any underlying conditions that may be causing the hemoptysis, such as bronchiectasis, chronic bronchitis, or lung cancer 2, 3.
• Chest radiography is recommended as the initial diagnostic test for hemodynamically stable patients with hemoptysis 3.
• Further evaluation with computed tomography (CT) with or without bronchoscopy is recommended in patients with massive hemoptysis, those with abnormal radiographic findings, and those with risk factors for malignancy despite normal radiographic findings 3.
• Multidetector computed tomography (MDCT) angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number, and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding 2.
• Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis and can be used for immediate control of bleeding and locating the source of the hemorrhage 2.

Management of Hemoptysis

• Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis 2, 4.
• Bronchial artery embolization (BAE) is a safe and effective technique for the treatment of massive and recurrent hemoptysis 4.
• Repeated episodes of hemoptysis require prompt repeat BAE after exclusion of extrabronchial systemic and pulmonary artery bleeding sources 4.
• Surgery is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located, due to the high mortality rate associated with surgery in hemodynamically unstable patients with life-threatening hemoptysis 2.

Patient Evaluation and Outcome

• Hemoptysis can be a life-threatening pulmonary emergency with high mortality and requires immediate diagnosis and treatment 4.
• The relative frequency of the different causes of hemoptysis, such as lung cancer, pulmonary embolism, and bronchiectasis, should be evaluated in a tertiary referral hospital 5.
• The outcome of patients with cryptogenic hemoptysis in chronic obstructive pulmonary disease (COPD) is generally favorable when managed with timely angiographic embolization, with low incidence of lung cancer and recurrences of hemoptysis 6.