What is the initial approach for a patient presenting with hemoptysis?

Initial Approach to Hemoptysis

Immediately assess severity and prioritize airway protection—massive hemoptysis (≥200 mL/24 hours or any amount causing respiratory compromise) requires emergent intubation with a single-lumen cuffed endotracheal tube and direct progression to bronchial artery embolization (BAE) without delay for bronchoscopy, as delaying intervention significantly increases mortality. 1, 2

Immediate Stabilization (First 15 Minutes)

For Massive/Life-Threatening Hemoptysis

• Intubate immediately with a single-lumen cuffed endotracheal tube (not double-lumen) to allow bronchoscopic suctioning and clot removal 1
• Administer high-flow oxygen and establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation 1, 2
• Obtain baseline labs: complete blood count, PT/aPTT, Clauss fibrinogen (not derived fibrinogen, which is misleading), and type and cross-match 1
• Proceed directly to BAE without bronchoscopy in clinically unstable patients—BAE achieves immediate hemostasis in 73-99% of cases and is now first-line therapy 1, 2
• Consider selective right or left mainstem intubation to protect the non-bleeding lung 1

Critical Pitfalls to Avoid

• Never delay BAE for diagnostic bronchoscopy in unstable patients—this significantly increases mortality 1, 2
• Avoid BiPAP in massive hemoptysis, as positive pressure can worsen bleeding 1
• Stop all airway clearance therapies immediately to allow clot formation 1
• Do not continue NSAIDs or anticoagulants during active hemoptysis 1

For Stable/Non-Massive Hemoptysis

Diagnostic Algorithm

1. Chest radiograph is reasonable as initial imaging, especially when confirming benign causes like acute bronchitis or pneumonia 3, 1
2. CT chest with IV contrast is the preferred diagnostic test for stable patients with significant hemoptysis:
   • Provides 80-90% diagnostic accuracy 2
   • Superior to bronchoscopy for identifying malignancy (77% vs 8% diagnostic yield) 2
   • Identifies both bleeding source and underlying pathology 3, 1, 2
3. Bronchoscopy provides valuable information on anatomic site and side of bleeding, and allows tissue diagnosis 1

When to Escalate to BAE

• BAE is increasingly utilized for non-massive hemoptysis when conservative medical therapy fails, achieving immediate bleeding cessation in 93% of patients 1
• CTA has become the standard of care for arterial planning before BAE 3, 1, 2

Bronchoscopic Management Techniques (For Visible Central Lesions)

When bronchoscopy is performed in stable patients, the following interventions achieve 80-90% success rates 1:

• Tamponade with iced saline instillation 1
• Bronchial blockade balloons 1
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate) 1
• Thermal ablation: argon plasma coagulation, Nd:YAG laser, or electrocautery 1

Management of Recurrent Hemoptysis

• Recurrence occurs in 10-55% of cases after initial BAE, with higher rates in specific conditions 1:
  • Chronic pulmonary aspergillomas: 55% recurrence rate 3, 1
  • Malignancy 3, 1
  • Sarcoidosis 3, 1
• Recurrence within 3 months is typically due to incomplete or missed embolization of bleeding arteries 3
• Recurrence after 3 months is most likely due to vascular collateralization or recanalization 3
• Repeat BAE shows no increased risk of morbidity or mortality 3, 1
• For aspergillomas causing hemoptysis, definitive surgical treatment following initial BAE is recommended due to high recurrence rates 3, 1

Post-Intervention Management

• Admit all patients with massive hemoptysis to intensive care for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1
• Start venous thromboprophylaxis as soon as bleeding is controlled 1
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 1

Special Considerations

For Malignancy-Related Hemoptysis

• BAE is typically palliative or temporizing before definitive treatment, with 75-80% immediate success rates 2
• 6-month mortality for malignancy-related hemoptysis is 55% 2
• External beam radiation therapy (EBRT) provides hemoptysis relief in 81-86% of cases 1
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone 1

Surgical Management

• Reserved as final therapeutic option when BAE is unsuccessful or for surgically resectable tumors in stable patients 1
• Surgery for massive hemoptysis carries 16% mortality, associated with blood aspiration into contralateral lung and pneumonectomy 1
• For aspergillomas, definitive surgical treatment is recommended after initial BAE stabilization 3, 1