What are the initial steps for managing a patient presenting with hemoptysis (coughing up blood)?

Initial Management of Hemoptysis

Immediately assess airway patency, hemodynamic stability, and oxygenation status as the absolute first priority, then rapidly determine if the patient has massive hemoptysis requiring emergent intervention versus non-massive hemoptysis allowing for diagnostic evaluation. 1, 2

Immediate Assessment and Stabilization

Define Severity

• Massive hemoptysis is defined as bleeding placing the patient at high risk for asphyxiation or exsanguination, where the rate of bleeding correlates more closely with mortality than total volume (traditionally ≥200 mL in 24 hours). 1, 2
• Look for signs of respiratory distress (hypoxia, tachypnea, inability to clear secretions) and hemodynamic instability (hypotension, tachycardia, altered mental status). 2
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk. 1, 2

Airway Protection and Resuscitation

• Administer high-flow oxygen immediately to maintain adequate oxygenation. 2
• Intubate immediately with a single-lumen cuffed endotracheal tube if the patient has massive hemoptysis with respiratory distress—this allows bronchoscopic suctioning and clot removal. 1, 2
• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation and potential transfusion. 3, 2
• Avoid BiPAP in massive hemoptysis, as positive pressure can worsen bleeding. 2
• Stop all airway clearance therapies immediately in massive hemoptysis to allow clot formation. 2

Initial Laboratory and Imaging

• Obtain baseline labs: complete blood count, PT/aPTT, fibrinogen (Clauss method, not derived), and type and cross-match. 3
• If the patient is conscious and talking with a palpable peripheral pulse, blood pressure is likely adequate—do not delay intervention for precise BP measurement. 3
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy. 3, 2

Management Algorithm Based on Clinical Stability

For Clinically UNSTABLE Patients with Massive Hemoptysis

Proceed directly to bronchial artery embolization (BAE) without delay—do NOT perform bronchoscopy first, as delaying BAE significantly increases mortality. 1, 2

• BAE achieves immediate hemostasis in 73-99% of cases, as over 90% of massive hemoptysis originates from bronchial arteries. 1, 2
• If BAE is not immediately available, use bronchoscopic tamponade techniques: iced saline instillation, bronchial blockade balloons, or topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate). 1, 2
• Consider selective right or left mainstem intubation to protect the non-bleeding lung if the bleeding side is known. 2
• Admit to ICU for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding. 2

For Clinically STABLE Patients with Significant Hemoptysis

Obtain CT chest with IV contrast as the preferred initial diagnostic test to identify cause and location of bleeding—CT has diagnostic accuracy of 80-90% and is superior to bronchoscopy for identifying etiology (77% vs 8%). 1, 2

• Chest radiograph is reasonable if confirming benign causes like acute bronchitis or pneumonia, but has limited sensitivity (suggests etiology in only 26% of cases). 2
• Perform bronchoscopy for both diagnostic and therapeutic purposes if CT does not identify the source or if there is a visible central airway lesion—bronchoscopy provides information on anatomic site, side of bleeding, and severity with 70-80% diagnostic yield. 1, 2
• CT angiography (CTA) has become the standard of care for arterial planning if BAE is being considered. 2

Medical Management for Non-Massive Hemoptysis

• Stop NSAIDs immediately, as they impair platelet function and worsen bleeding. 1, 4
• Administer antibiotics for patients with at least mild hemoptysis, as bleeding may represent a pulmonary exacerbation. 1
• Do NOT continue anticoagulants or antiplatelet medications during active hemoptysis—these can worsen bleeding. 2
• Avoid hyperventilation and excessive positive end-expiratory pressure in hypovolemic patients, as this can worsen hemodynamics. 3

Bronchoscopic Interventions for Visible Lesions

For visible central airway lesions causing hemoptysis, bronchoscopic interventions include:

• Topical hemostatic tamponade with oxidized regenerated cellulose mesh (arrests hemoptysis in 98% of cases). 1, 2
• Thermal ablation using argon plasma coagulation, Nd:YAG laser, or electrocautery (80-90% success rates). 2
• Iced saline instillation and bronchial blockade balloons for tamponade. 1, 2

Common Pitfalls to Avoid

• Do NOT delay airway protection in favor of diagnostic procedures when the patient has respiratory distress. 2
• Do NOT perform bronchoscopy before BAE in clinically unstable patients with massive hemoptysis—this significantly increases mortality. 2
• Do NOT rely on single hematocrit measurements as an isolated marker for bleeding severity. 3
• Do NOT use derived fibrinogen levels—they are misleading; use Clauss fibrinogen instead. 3

Recurrence and Follow-Up

• Recurrence of bleeding occurs in 10-55% of cases after BAE, requiring close follow-up. 1, 2
• Higher recurrence rates are associated with chronic pulmonary aspergillomas (55%), malignancy, and sarcoidosis. 1, 2
• Recurrence within 3 months is often due to incomplete embolization; after 3 months, it's typically due to vascular collateralization or recanalization. 2
• Repeat BAE is the primary therapeutic option for recurrent hemoptysis, with no increased risk of morbidity or mortality for repeat interventions. 2

Definitive Management Considerations

• For unresectable lung cancer with non-massive hemoptysis, external beam radiation therapy (EBRT) provides hemoptysis relief in 81-86% of cases. 1, 2
• Surgery is reserved for patients with surgically resectable tumors in stable patients (50-70% survival rates) or when BAE is unsuccessful, but carries 16% mortality associated with blood aspiration and pneumonectomy. 2
• For aspergillomas, definitive surgical treatment following initial BAE is recommended due to high recurrence rates. 2