Management of Hemoptysis
The management of hemoptysis requires immediate assessment of severity, with massive hemoptysis necessitating hospital admission, airway protection, and consideration for bronchial artery embolization, while non-massive hemoptysis can often be managed conservatively with antibiotics and discontinuation of NSAIDs. 1, 2
Initial Assessment and Classification
- Hemoptysis should be classified based on severity: scant (<5 ml), mild-to-moderate (5-240 ml), and massive (>240 ml) 1
- Patients with at least mild hemoptysis (>5 ml) should contact their healthcare provider 1
- Patients with scant hemoptysis (<5 ml) should contact their healthcare provider if it is the first-ever episode or if it is persistent 1
- Massive hemoptysis is considered a medical emergency that can lead to asphyxiation rather than exsanguination 2, 3
Management Based on Severity
Massive Hemoptysis
- Patients with massive hemoptysis should always be admitted to the hospital 1
- Initial management priorities include:
- Airway protection and optimal oxygenation, often requiring endotracheal intubation 1, 2
- Single-lumen cuffed endotracheal tube is generally preferred over double-lumen tubes to allow for bronchoscopic suctioning 1
- Selective right or left mainstem intubation can be performed to protect the non-bleeding lung 1, 2
- Diagnostic evaluation:
- Therapeutic interventions:
- Bronchial artery embolization (BAE) is the first-line therapy for clinically unstable patients with massive hemoptysis 1, 4, 2
- BAE has immediate success rates of 73-99% in controlling bleeding 4, 2
- Bronchoscopic management techniques include tamponade of bleeding segment, instillation of cold saline, and use of bronchial blockade balloons 1, 2
- Delaying BAE in clinically unstable patients significantly increases mortality 4, 2
- Performing bronchoscopy before BAE in unstable patients is not recommended as it wastes valuable time 4
Mild-to-Moderate Hemoptysis
- Hospital admission may not always be necessary, though there was no consensus on a specific threshold volume for admission 1
- Patients with mild-to-moderate hemoptysis should always be treated with antibiotics 1, 4
- Patients should stop NSAIDs as they may worsen bleeding due to effects on platelet function 1, 4, 5
- CT chest with IV contrast is recommended as the initial diagnostic test 1
- For persistent bleeding despite conservative management, bronchial artery embolization can be considered 1
- Recent studies show BAE is a viable therapeutic option for non-massive hemoptysis, especially in cases of palliation or failure of medical therapy 1
Scant Hemoptysis
- Hospital admission is generally not required 1
- Antibiotic treatment is not always necessary, especially without other features of pulmonary exacerbation 1
- Consider antibiotics only in the presence of other findings, such as first episode, persistent bleeding, or history of progressive increase in bleeding 1
Special Considerations
- Recurrence of bleeding occurs in 10-55% of cases after BAE, requiring close follow-up 4, 2
- For patients with lung cancer and hemoptysis, BAE has shown immediate cessation of hemoptysis in 81% of cases 1
- Cryptogenic hemoptysis has demonstrated high success rates with BAE, with 97% of patients remaining free of hemoptysis at 20 months 1
- NSAIDs and anticoagulants should be discontinued during episodes of hemoptysis 1, 4, 5
Common Pitfalls and Caveats
- Delaying intervention in massive hemoptysis significantly increases mortality 4, 2
- Small amounts of blood can significantly impair oxygenation and ventilation, leading to cardiovascular collapse 6, 3
- Continuing NSAIDs or anticoagulants during active hemoptysis can worsen bleeding 4
- A multidisciplinary approach involving intensivists, pulmonologists, interventional radiologists, and thoracic surgeons is essential for optimal management 6, 7