What is the treatment for severe hemoptysis?

Treatment of Severe Hemoptysis

For severe hemoptysis, immediately secure the airway with a single-lumen cuffed endotracheal tube and proceed directly to bronchial artery embolization (BAE) in unstable patients, while stable patients should undergo CT angiography followed by BAE or bronchoscopic intervention based on bleeding source. 1

Immediate Airway Management

Intubate immediately with a single-lumen cuffed endotracheal tube rather than a double-lumen tube to allow bronchoscopic suctioning and removal of large obstructing clots, which is the most common cause of death from asphyxiation in massive hemoptysis. 1 Double-lumen tubes are more difficult to place, have smaller lumens, and do not permit therapeutic bronchoscopy through each side. 1

• Perform selective right or left mainstem intubation to protect the nonbleeding lung if the bleeding side is identified. 1
• Avoid BiPAP entirely, as positive pressure ventilation can worsen bleeding. 1
• Establish large-bore IV access for resuscitation immediately. 1

Risk Stratification and Treatment Algorithm

For Clinically Unstable Patients with Massive Hemoptysis

Proceed directly to bronchial artery embolization (BAE) without delay, as delaying BAE significantly increases mortality. 1, 2 Do not perform bronchoscopy before BAE in unstable patients, as this delay increases mortality. 1

• BAE achieves immediate hemostasis in 73-99% of cases, as over 90% of massive hemoptysis originates from systemic arterial supply. 1, 3
• The rate of bleeding correlates more closely with mortality than total volume. 1, 2

For Clinically Stable Patients

Obtain CT chest with IV contrast as the preferred initial diagnostic test, with diagnostic accuracy of 80-90% and superior to bronchoscopy. 1, 2 CT angiography is the standard of care for arterial planning if BAE is being considered. 1

• Perform bronchoscopy immediately in stable patients to identify the anatomic site and side of bleeding, with diagnostic yield of 70-80%. 1, 2
• Bronchoscopy provides information on the nature of the bleeding source, severity, and therapeutic feasibility. 4, 2

Bronchoscopic Therapeutic Interventions

Bronchoscopic-guided topical hemostatic tamponade therapy using oxidized regenerated cellulose mesh can immediately arrest hemoptysis in 98% of patients. 1

• Wedge the bronchoscope tip tightly into the bleeding bronchus for tamponade, followed by instillation of iced saline solution to constrict blood vessels. 1
• Use bronchial blockade balloons to tamponade the bronchus, potentially requiring 24-48 hours in place. 1
• For visible central airway lesions, use endobronchial management options including argon plasma coagulation, Nd:YAG laser, or electrocautery with 80-90% success rate. 5

Medical Management

Stop NSAIDs immediately in patients with severe hemoptysis, as they impair platelet function and worsen bleeding. 1, 2

• Stop all anticoagulants during active hemoptysis. 1, 5
• Stop all airway clearance therapies immediately in massive hemoptysis to allow clot formation. 1
• Administer antibiotics for patients with at least mild hemoptysis, as bleeding may represent a pulmonary exacerbation or superimposed bacterial infection. 1, 2

Bronchial Artery Embolization Details

BAE has a pooled technical success of 97.22% and pooled clinical success of 92.46%. 3 However, recurrence of bleeding occurs in 10-55% of cases after BAE, requiring close follow-up. 1, 2 Repeat BAE shows no increased risk of morbidity or mortality. 1

• Higher recurrence rates are associated with chronic pulmonary aspergillomas, malignancy, and sarcoidosis. 2
• Prompt repeat embolization is advised in patients with recurrent hemoptysis to identify nonbronchial systemic and pulmonary arterial sources of bleeding. 6

Cancer-Specific Management

For patients with lung cancer and significant hemoptysis, external beam radiation therapy (EBRT) is recommended for non-massive hemoptysis in patients with unresectable lung cancer, with hemoptysis relief rates of 81-86%. 2, 5

• For surgically resectable tumors in stable patients, surgical resection of the bleeding lobe or entire lung may be appropriate, with 50-70% survival rates. 5
• Surgery for massive hemoptysis carries 16% mortality, associated with blood aspiration into contralateral lung and pneumonectomy. 5
• Most patients with lung cancer and massive hemoptysis have advanced disease and are not surgical candidates. 4

Intensive Care Monitoring

Admit all patients to intensive care for monitoring of coagulation parameters, hemoglobin levels, blood gases, and ongoing bleeding. 1, 5

• Actively warm the patient and all transfused fluids. 1
• Start venous thromboprophylaxis as soon as bleeding is controlled. 1

Critical Pitfalls to Avoid

Never delay airway protection in favor of diagnostic procedures when respiratory distress is present. 1 The mortality rate of massive hemoptysis may be as high as 59-100% in patients with bronchogenic carcinoma. 4

• Do not instill vasoactive agents like epinephrine if bleeding is brisk, as they are unlikely to help. 1
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk. 2