What is the management approach for a patient presenting with hemoptysis (expectoration of blood from the lungs)?

Management of Hemoptysis

Immediate Assessment and Airway Protection

For massive hemoptysis (≥200 mL/24h or any amount causing respiratory distress), immediately secure the airway with endotracheal intubation using a single-lumen cuffed endotracheal tube (not double-lumen) to allow bronchoscopic suctioning and rapid removal of large obstructing clots. 1, 2

• Massive hemoptysis is defined as bleeding placing the patient at high risk for asphyxiation or exsanguination, with the rate of bleeding more closely associated with mortality than total volume 1
• Death occurs primarily from asphyxiation due to airway obstruction by blood clots, not exsanguination 1, 3
• Consider selective right or left mainstem intubation to protect the non-bleeding lung if the bleeding side is known 4, 1
• Avoid BiPAP entirely in massive hemoptysis, as positive pressure ventilation worsens bleeding 1
• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation 1
• Administer high-flow oxygen and obtain baseline labs including CBC, PT/aPTT, Clauss fibrinogen (not derived), and type and cross-match 1

Risk Stratification

Proceed directly to bronchial artery embolization (BAE) without bronchoscopy in clinically unstable patients with massive hemoptysis, as delaying BAE significantly increases mortality. 1, 2

• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 1
• Mortality in massive hemoptysis ranges from 59-100% in lung cancer patients if untreated 2
• Stop all NSAIDs and anticoagulants immediately, as continuing these during active hemoptysis worsens bleeding 1
• Stop all airway clearance therapies immediately in massive hemoptysis to allow clot formation 1
• Stop aerosolized hypertonic saline specifically, as it exacerbates bleeding 1

Diagnostic Approach for Stable Patients

For clinically stable patients with significant hemoptysis, obtain CT chest with IV contrast as the preferred initial diagnostic test to identify the cause and location of bleeding, with diagnostic accuracy of 80-90%. 1, 2

• Chest radiograph is reasonable for initial imaging when confirming benign causes like acute bronchitis or pneumonia, but has limited sensitivity (50-70%) and suggests etiology in only 26% of cases 1, 2
• CTA has become the standard of care for arterial planning if BAE is being considered 1
• Bronchoscopy provides valuable information on the anatomic site, side of bleeding, nature of the source, and severity, with diagnostic yield of 70-80% 1, 2

Bronchoscopic Management

Use bronchoscopy for both diagnostic and therapeutic purposes, employing tamponade of the bleeding segment by tightly inserting the bronchoscope tip into the bronchus, followed by instillation of iced saline solution to constrict blood vessels. 4, 1

• If bleeding persists despite bronchoscopic wedging and cold saline lavage, use bronchoscopic-guided topical hemostatic tamponade with oxidized regenerated cellulose mesh, which arrests hemoptysis in 98% of cases 4, 1
• Bronchial blockade balloons can tamponade the bronchus and may need to remain in place for 24-48 hours 4, 1
• For bronchoscopically visible lesions causing bleeding, use thermal ablation techniques including argon plasma coagulation (100% control at 3-month follow-up), Nd:YAG laser photocoagulation (60% response rate), or electrocautery 4, 1
• Instillation of vasoactive agents like epinephrine is unlikely to help if bleeding is brisk 4

Bronchial Artery Embolization

BAE is the first-line therapy for massive hemoptysis with immediate success rates of 73-99%, as over 90% of massive hemoptysis originates from bronchial arteries. 1, 2

• Perform BAE without delay in clinically unstable patients; delaying BAE significantly increases mortality 1
• For non-massive hemoptysis, BAE is increasingly utilized when conservative medical therapy fails, with immediate bleeding cessation in 93% of patients 1
• Recurrence of bleeding occurs in 10-55% of cases after BAE, requiring close follow-up 1, 2
• Higher recurrent hemoptysis rates are associated with chronic pulmonary aspergillomas (55% recurrence), malignancy, and sarcoidosis 1
• Recurrence within 3 months is often due to incomplete or missed embolization, while failure after 3 months is due to vascular collateralization or recanalization 1
• Recent studies show no increased risk of morbidity or mortality for repeat BAE interventions 1

Radiation Therapy for Non-Massive Hemoptysis

For non-massive hemoptysis in patients with unresectable lung cancer, use external beam radiation therapy (EBRT), which provides symptom relief in approximately 60% of patients, with hemoptysis being the best-palliated symptom (81-86% relief). 4, 1, 2

• A prospective study randomizing 409 patients to either 30 Gy in 10 fractions or 40 Gy in 20 fractions showed no significant differences in outcomes, with median survival of 6 months 4
• Hypofractionated regimens (17 Gy in 8.5-Gy fractions weekly vs 30 Gy in 10 fractions over 2 weeks) showed no difference in survival or palliation 4
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone, though fatal hemoptysis rates range from 7-22% 1

Surgical Management

Reserve surgery as a final therapeutic option for massive hemoptysis when BAE fails, or for surgically resectable tumors in stable patients, with survival rates of 50-70%. 1, 2

• Surgery for massive hemoptysis carries 16% mortality, associated with blood aspiration into the contralateral lung and pneumonectomy 1
• For aspergillomas causing hemoptysis, definitive surgical treatment following initial BAE is recommended due to high recurrence rates (55%) 1
• BAE for malignancy is typically palliative or a temporizing measure prior to definitive surgery 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
• Avoid hyperventilation and excessive positive end-expiratory pressure in hypovolemic patients, as this worsens hemodynamics 1

Common Pitfalls to Avoid

• Do not delay airway protection in favor of diagnostic procedures when the patient has respiratory distress 1
• Do not use double-lumen endotracheal tubes, as they have smaller lumens and do not permit therapeutic bronchoscope passage 4
• Do not perform bronchoscopy before BAE in unstable patients 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity 1
• Do not use derived fibrinogen levels, as they are misleading; use Clauss fibrinogen instead 1
• For mild-to-moderate hemoptysis, continue airway clearance therapies (active cycle of breathing and autogenic drainage are least concerning) and aerosol therapies except hypertonic saline 1