What is the management approach for a patient presenting with haemoptysis (coughing up blood)?

Management of Haemoptysis

Immediately secure the airway with a single-lumen cuffed endotracheal tube in massive haemoptysis, and proceed directly to bronchial artery embolization (BAE) without delay in unstable patients, as this achieves 73-99% immediate hemostasis and delaying intervention significantly increases mortality. 1, 2

Initial Assessment and Severity Stratification

Massive haemoptysis is defined as bleeding causing high risk for asphyxiation or exsanguination (traditionally ≥200 mL/24 hours), though the rate of bleeding correlates more closely with mortality than total volume—patients die from asphyxiation, not exsanguination. 1, 2, 3

• Scant haemoptysis (<5 mL/24h) may not require hospital admission 1
• Mild-to-moderate haemoptysis (5-240 mL/24h) requires hospital admission and monitoring 1
• Massive haemoptysis (>240 mL/24h or any amount causing respiratory compromise) demands immediate intervention with mortality risk up to 59-100% if untreated 1

Immediate Management of Massive Haemoptysis

Airway Protection (First Priority)

Intubate immediately with a single-lumen cuffed endotracheal tube (NOT double-lumen)—the larger diameter allows bronchoscopic suctioning and rapid removal of obstructing clots, which is the most common cause of death. 4, 2

• Selective right or left mainstem intubation can protect the non-bleeding lung if the bleeding side is identified 4, 2
• Never use double-lumen tubes—they are difficult to place, have smaller lumens, and prevent therapeutic bronchoscopy 4, 2
• Avoid BiPAP entirely—positive pressure ventilation worsens bleeding 1, 2

Resuscitation and Stabilization

• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation 4, 1, 2
• Administer high-flow oxygen to maintain adequate oxygenation 4
• Obtain baseline labs: CBC, PT/aPTT, Clauss fibrinogen (not derived), and type/cross-match 4, 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 4, 2

Critical Medical Management

Stop NSAIDs immediately—they impair platelet function and worsen bleeding 1, 2

• Stop all anticoagulants during active haemoptysis 2
• Stop all airway clearance therapies immediately to allow clot formation 1, 2
• Stop aerosolized hypertonic saline—it can exacerbate bleeding 1, 2
• Administer antibiotics for haemoptysis ≥5 mL, as bleeding may represent pulmonary exacerbation or superimposed infection 1, 2

Definitive Management Pathway

For Clinically Unstable Patients

Proceed directly to bronchial artery embolization (BAE) without bronchoscopy—delaying BAE significantly increases mortality. 1, 2

• BAE achieves immediate hemostasis in 73-99% of cases, as over 90% of massive haemoptysis originates from bronchial arteries 1, 2
• Never delay airway protection for diagnostic procedures when respiratory distress is present 1, 2
• Never perform bronchoscopy before BAE in unstable patients—this delay increases mortality 2

For Clinically Stable Patients

Obtain CT chest with IV contrast as the preferred initial diagnostic test—it has 80-90% diagnostic accuracy and is superior to bronchoscopy for identifying cause and location. 1, 2

• Chest radiograph is reasonable for confirming benign causes (acute bronchitis, pneumonia) but has limited sensitivity (26%) 1
• CT angiography (CTA) is the standard of care for arterial planning if BAE is being considered 1, 2

Perform bronchoscopy to identify the anatomic site and side of bleeding (70-80% diagnostic yield) and for therapeutic intervention. 1, 2

Bronchoscopic Management Techniques

When bronchoscopy identifies the bleeding source, use the following sequential approach:

1. Tamponade: Wedge the bronchoscope tip tightly into the bleeding bronchus 4, 1, 2
2. Iced saline instillation: Constrict blood vessels (stops bleeding in many patients) 4, 1, 2
3. Bronchial blockade balloons: May require 24-48 hours in place 4, 1, 2
4. Topical hemostatic tamponade: Oxidized regenerated cellulose mesh arrests haemoptysis in 98% of cases 4, 1, 2
5. Thermal ablation: Argon plasma coagulation (100% control at 3 months), Nd:YAG laser (60% response), or electrocautery for visible central airway lesions 4, 1

Do not instill vasoactive agents like epinephrine if bleeding is brisk—they are unlikely to help. 2

Management of Non-Massive Haemoptysis

For mild-to-moderate haemoptysis in stable patients:

• Admit to hospital for monitoring and treatment 1
• Stop NSAIDs immediately 1, 2
• Administer antibiotics 1, 2
• Perform bronchoscopy to identify the bleeding source 1
• Continue aerosol therapies (except hypertonic saline) 1
• Continue airway clearance therapies in scant haemoptysis—active cycle of breathing and autogenic drainage are least concerning 1

For unresectable lung cancer with non-massive haemoptysis:

• External beam radiation therapy (EBRT) provides palliation in ~60% of patients, with haemoptysis relief in 81-86% 4, 1
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone 4, 1

Management of Recurrent Haemoptysis

Recurrence occurs in 10-55% of cases after BAE, requiring close follow-up. 1, 2

• Repeat BAE is the primary therapeutic option—recent studies show no increased risk of morbidity or mortality for repeat interventions 1, 2
• Obtain CTA or CT with IV contrast before repeat BAE for arterial mapping 1
• Recurrence within 3 months is often due to incomplete/missed embolization; after 3 months, it's due to vascular collateralization or recanalization 1

Higher recurrence rates are associated with:

• Chronic pulmonary aspergillomas (55% recurrence) 1
• Malignancy 1
• Sarcoidosis 1

For aspergillomas causing haemoptysis, definitive surgical treatment following initial BAE is recommended due to high recurrence rates. 1

Surgical Management

Surgery is reserved as a final therapeutic option when BAE fails or for surgically resectable tumors in stable patients. 1, 2

• Surgical management carries 16% mortality, associated with blood aspiration into contralateral lung and pneumonectomy 1
• Lung resection should only be performed after other measures (BAE, bronchoscopic interventions) have failed 1
• For surgically resectable tumors in stable patients, surgery achieves 50-70% survival rates 1

Post-Intervention Care

Admit all patients to intensive care for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding. 1, 2

• Start venous thromboprophylaxis as soon as bleeding is controlled—patients rapidly develop a prothrombotic state 4, 2
• Continue active warming 2
• Monitor wound drains to identify overt or covert bleeding 4

Common Etiologies

The most common causes of haemoptysis include:

• Bronchiectasis (most common in many series) 1
• Lung cancer 1
• Active tuberculosis 1
• Chronic pulmonary aspergillomas 1

Critical Pitfalls to Avoid

• Never delay airway protection for diagnostic procedures when respiratory distress is present 1, 2
• Never use double-lumen endotracheal tubes in massive haemoptysis 4, 2
• Never perform bronchoscopy before BAE in unstable patients 2
• Never use BiPAP in massive haemoptysis 1, 2
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity 1
• Do not use derived fibrinogen levels—use Clauss fibrinogen 4, 1
• Never continue NSAIDs or anticoagulants during active haemoptysis 1, 2