What is the initial workup and management for a patient presenting to the emergency department (ED) with hemoptysis?

Hemoptysis Workup in the Emergency Department

Immediate Severity Assessment and Airway Protection

For any patient presenting with hemoptysis to the ED, immediately assess severity and prioritize airway protection—massive hemoptysis (≥200 mL/24h or any amount causing respiratory compromise) requires immediate intubation with a single-lumen cuffed endotracheal tube and direct progression to bronchial artery embolization without delay. 1

Severity Classification

• Scant hemoptysis (<5 mL): Generally does not require hospital admission unless it is the first episode or persistent 2
• Mild-to-moderate hemoptysis (5-240 mL): Requires admission for monitoring and treatment 2
• Massive hemoptysis (>240 mL/24h or causing respiratory compromise): Life-threatening emergency with mortality up to 59-100% if untreated—demands immediate intervention 1

Critical point: The rate of bleeding correlates more closely with morbidity and mortality than total volume—a patient with rapid bleeding of 50 mL may be at higher risk than one with slow bleeding of 100 mL over 24 hours 1, 3

Initial Stabilization for Massive Hemoptysis

Airway Management

• Intubate immediately with a single-lumen cuffed endotracheal tube (NOT double-lumen) to allow bronchoscopic suctioning and clot removal 1, 4
• Administer high-flow oxygen 1, 4
• Avoid BiPAP entirely—positive pressure ventilation worsens bleeding 1, 4
• Consider selective right or left mainstem intubation to protect the non-bleeding lung 1

Hemodynamic Stabilization

• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation 1, 4
• Obtain baseline labs: complete blood count, PT/aPTT, fibrinogen (Clauss method, NOT derived), type and cross-match 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1, 4

Immediate Medication Management

• Stop all NSAIDs immediately for any hemoptysis ≥5 mL—they impair platelet function and worsen bleeding 2, 1, 4
• Stop anticoagulants immediately during active hemoptysis 4
• Stop all airway clearance therapies immediately in massive hemoptysis to allow clot formation 1, 4
• Stop aerosolized hypertonic saline in massive hemoptysis 1, 4

Diagnostic Workup Based on Clinical Stability

For Clinically UNSTABLE Patients with Massive Hemoptysis

Proceed directly to bronchial artery embolization (BAE) WITHOUT bronchoscopy or CT—delaying BAE significantly increases mortality. 1, 4

• BAE achieves immediate hemostasis in 73-99% of cases 1
• Over 90% of massive hemoptysis originates from bronchial arteries 1
• Do NOT perform bronchoscopy before BAE in unstable patients—this wastes valuable time and increases mortality 1, 4
• Conventional arteriography is performed with therapeutic intent during BAE, not as a diagnostic modality 1

For Clinically STABLE Patients with Significant Hemoptysis

Obtain CT chest with IV contrast as the primary diagnostic test—this is superior to bronchoscopy and arteriography for identifying the cause and location of bleeding. 1

Imaging Algorithm:

1. Chest radiograph is reasonable as initial imaging when confirming benign causes like acute bronchitis or pneumonia 1

   • However, chest radiograph has limited sensitivity (only 26% diagnostic yield) 1, 3
   • Two or more opacified lung quadrants correlate with increased mortality risk 1, 4

2. CT chest with IV contrast is the standard of care for:

   • Determining etiology of nonmassive hemoptysis (77% diagnostic accuracy) 1, 3
   • Arterial planning if BAE is being considered 1
   • Identifying cause and location of bleeding 1

3. Bronchoscopy provides valuable information on anatomic site and side of bleeding in stable patients 1

   • Perform bronchoscopy to identify the source in patients with mild-to-moderate or scant hemoptysis 1
   • For visible central airway lesions, bronchoscopic interventions include: argon plasma coagulation, Nd:YAG laser, electrocautery, tamponade with iced saline, bronchial blockade balloons, and topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate) 1

Medical Management for Mild-to-Moderate Hemoptysis

Antibiotic Therapy

Start antibiotics immediately for any hemoptysis ≥5 mL—bleeding may represent pulmonary exacerbation or superimposed bacterial infection 2, 1, 3

• The American Thoracic Society strongly recommends this (median score 9/10) 2
• For scant hemoptysis without other features of pulmonary exacerbation, antibiotic use is controversial with no consensus 2

Admission Criteria

• Scant hemoptysis (<5 mL): May not require admission unless first episode or persistent 2, 1
• Mild-to-moderate hemoptysis (≥5 mL): Admit to hospital for monitoring and treatment 2, 1
• Massive hemoptysis: Always admit to intensive care for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding 2, 1

Common Etiologies to Consider

• Bronchiectasis: Most common cause in many series 1
• Lung cancer: Common cause; BAE is typically palliative or temporizing before definitive surgery 1
• Active tuberculosis: Common cause, especially in resource-limited areas 1, 5
• Aspergillomas: High recurrence rate (55%) after BAE—definitive surgical treatment recommended following initial BAE 1

Management of Recurrent Hemoptysis

• Recurrence occurs in 10-55% of cases after BAE 1
• Repeat BAE is the primary therapeutic option with no increased risk of morbidity or mortality 1
• Perform CT angiography or CT with IV contrast before repeat BAE for arterial mapping 1
• Recurrence within 3 months is often due to incomplete embolization; after 3 months, it's typically due to vascular collateralization or recanalization 1

Critical Pitfalls to Avoid

• Never delay BAE in unstable patients to perform bronchoscopy first—this significantly increases mortality 1, 4
• Never use double-lumen endotracheal tubes as initial airway management—single-lumen tubes allow better suctioning and clot removal 1, 4
• Never continue NSAIDs or anticoagulants during active hemoptysis—they worsen bleeding 2, 1, 4
• Never use BiPAP in massive hemoptysis—positive pressure worsens bleeding 1, 4
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity 1
• Do not use derived fibrinogen levels—use Clauss fibrinogen instead 1

Post-Intervention Management

• Admit all patients with massive hemoptysis to intensive care 1
• Start venous thromboprophylaxis as soon as bleeding is controlled 1
• Monitor for development of aspiration pneumonitis or ARDS 4
• Resume anticoagulation only after complete resolution of hemoptysis (typically 12-24 hours after last episode) 4