What is the immediate management for a patient presenting with massive haemoptysis (coughing up large amounts of blood)?

Immediate Management of Massive Haemoptysis

For a patient presenting with massive haemoptysis, immediately secure the airway with endotracheal intubation if there is any danger of airway compromise, as death occurs from asphyxiation rather than hemorrhagic shock, then proceed with bronchoscopy for localization followed by bronchial artery embolization as first-line definitive treatment. 1, 2

Initial Resuscitation and Stabilization

Airway Management (Priority #1)

• Intubate electively and early if there is any danger of airway compromise – in published series, 84% of patients with massive haemoptysis required intubation 2
• Administer high FiO2 immediately to all patients 3
• Patients die from asphyxiation, not hemorrhagic shock, making airway protection the absolute priority 1

Vascular Access and Hemodynamic Support

• Establish large-bore IV access (largest bore possible, including central access if needed) 3
• If the patient is conscious, talking, and has a peripheral pulse present, blood pressure is adequate – do not aggressively normalize blood pressure initially 3
• Avoid vasopressors in the acute phase 3

Baseline Investigations

• Obtain immediate baseline bloods: full blood count, prothrombin time, activated partial thromboplastin time, Clauss fibrinogen (not derived fibrinogen), and cross-match 3
• Perform near-patient testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available 3

Localization of Bleeding Source

Bronchoscopy (Essential Step)

• Perform fiberoptic bronchoscopy urgently to localize the bleeding site – bronchoscopy identifies the site in 90% of cases compared to only 64% with chest X-ray alone 2
• Bronchoscopy should be performed to help guide definitive treatment decisions 2, 4

Imaging

• Obtain computed tomography to assist with localization and treatment planning 5

Definitive Hemorrhage Control

Treatment Algorithm (in order of preference):

First-Line: Bronchial Artery Embolization

• Embolization is the superior first-line treatment for massive haemoptysis – successfully controls bleeding in 51% of patients and is significantly better than medical treatment alone at immediate cessation of haemoptysis 2, 6
• Nonsurgical control of hemorrhage is superior to surgery in the acute situation 1
• Coordinate early with interventional radiology for urgent embolization 5

Second-Line: Medical Management

• Medical therapy alone stops bleeding in only 26% of patients with massive haemoptysis 2
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 3

Last Resort: Emergency Surgery

• Reserve emergency surgery only for cases where embolization and medical measures are insufficient to control bleeding 2, 4
• Only 13% of patients require emergency surgery, with higher mortality risk 2
• Surgery may need to be limited to "damage control" procedures 3

Multidisciplinary Team Activation

• Immediately activate a coordinated multidisciplinary team consisting of pulmonologists, critical care physicians/anesthesiologists, interventional radiologists, and thoracic surgeons 1, 5
• Early activation and coordinated response is critical for survival 1

Post-Stabilization Management

Critical Care Monitoring

• Admit all patients to intensive care unit for continued monitoring after hemorrhage control 3, 2
• Monitor coagulation parameters, hemoglobin, blood gases, and assess for ongoing bleeding 3
• Serial assessment for signs of rebleeding (22% of survivors experience recurrent hemoptysis during follow-up) 2

Venous Thromboprophylaxis

• Commence standard venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state following massive hemorrhage 3, 7
• Consider temporary inferior vena cava filtration if necessary 3, 7

Common Pitfalls to Avoid

• Do not delay intubation – waiting for respiratory compromise increases mortality risk; intubate electively when massive haemoptysis is confirmed 2
• Do not rely on chest X-ray alone for localization – bronchoscopy is far superior 2
• Do not rush to emergency surgery – embolization has better outcomes in the acute setting 1, 6
• Do not use derived fibrinogen levels – these are misleading; only Clauss fibrinogen is reliable 3