What are the appropriate evaluation and treatment steps for a patient presenting with hemoptysis (coughing blood)?

Evaluation and Management of Hemoptysis

For patients presenting with hemoptysis, immediately assess severity and airway stability—if massive hemoptysis (≥200 mL/24h or causing respiratory compromise) is present, intubate with a single-lumen endotracheal tube and proceed directly to bronchial artery embolization without delay, as this achieves 73-99% immediate hemostasis and delaying intervention significantly increases mortality. 1, 2

Initial Severity Assessment and Risk Stratification

The first priority is determining whether the patient has massive versus non-massive hemoptysis, as this dictates the entire management pathway 1, 3:

• Massive hemoptysis is defined as bleeding placing the patient at high risk for asphyxiation or exsanguination (traditionally ≥200 mL in 24 hours), though the rate of bleeding correlates more closely with mortality than total volume 1, 3, 2
• Non-massive hemoptysis includes scant (<5 mL/24h) to moderate amounts without respiratory compromise 1, 4
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 1, 3
• Mortality from massive hemoptysis ranges from 59-100% if untreated, primarily from asphyxiation rather than exsanguination 1, 5

Management of Massive Hemoptysis (Life-Threatening)

Immediate Airway Management

Intubate immediately with a single-lumen cuffed endotracheal tube (not double-lumen) to allow bronchoscopic suctioning and removal of large obstructing clots, which are the most common cause of death from asphyxiation 1, 2:

• The larger diameter enables rapid removal of obstructing clots 1, 2
• Double-lumen tubes are more difficult to place, have smaller lumens, and do not permit therapeutic bronchoscopy 2
• Consider selective right or left mainstem intubation to protect the non-bleeding lung if the bleeding side is identified 1, 2

Critical Actions and Pitfalls to Avoid

• Avoid BiPAP entirely—positive pressure ventilation worsens bleeding 1, 2
• Stop all airway clearance therapies immediately to allow clot formation 1, 2
• Stop aerosolized hypertonic saline as it can exacerbate bleeding 1, 2
• Stop all NSAIDs immediately due to platelet dysfunction that worsens bleeding 3, 2
• Stop all anticoagulants during active hemoptysis 2
• Establish large-bore IV access (ideally 8-Fr central line) for resuscitation 1, 2

Definitive Treatment: Bronchial Artery Embolization

For clinically unstable patients, proceed directly to bronchial artery embolization (BAE) without bronchoscopy or other diagnostic delays 1, 3, 2:

• BAE achieves immediate hemostasis in 73-99% of cases, as over 90% of massive hemoptysis originates from systemic bronchial arteries 6, 1, 3, 2
• Delaying BAE in unstable patients significantly increases mortality 1, 3, 2
• Never perform bronchoscopy before BAE in unstable patients—this delay is associated with increased mortality 1, 2
• CT angiography is the standard of care for arterial planning if time permits in stable patients 1, 2

Bronchoscopic Temporizing Measures (If Immediately Available)

While preparing for BAE, bronchoscopic interventions can provide temporary hemostasis 1, 2:

• Tamponade by wedging the bronchoscope tip into the bleeding bronchus 1, 2
• Iced saline instillation to constrict blood vessels 1, 2
• Bronchial blockade balloons (may require 24-48 hours in place) 1, 2
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate) 1, 3, 2
• Thermal ablation using argon plasma coagulation, Nd:YAG laser, or electrocautery for visible central lesions 1, 2

Intensive Care Management

Admit all patients to intensive care for monitoring 1, 2:

• Monitor coagulation parameters, hemoglobin, blood gases, and ongoing bleeding 1, 2
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1, 2
• Start venous thromboprophylaxis as soon as bleeding is controlled 1, 2

Management of Non-Massive Hemoptysis (Stable Patients)

Initial Diagnostic Approach

For clinically stable patients, obtain CT chest with IV contrast as the preferred initial diagnostic test to identify cause and location of bleeding 1, 3, 2:

• CT has diagnostic accuracy of 80-90% and is superior to bronchoscopy for identifying etiology (77% vs 8% diagnostic yield) 1, 3, 2
• Chest radiograph is reasonable for confirming benign causes like acute bronchitis or pneumonia, but has limited sensitivity (suggests etiology in only 26% of cases) 6, 1
• CT angiography provides arterial mapping if BAE is being considered 1, 2

Bronchoscopy Indications

Perform bronchoscopy for both diagnostic and therapeutic purposes in stable patients 1, 3, 2:

• Provides information on anatomic site, side of bleeding, nature of source, and severity (diagnostic yield 70-80%) 3, 2
• Particularly indicated in smokers with hemoptysis even when chest radiograph is normal, as this suggests possible airway involvement by malignancy 6
• Can perform therapeutic interventions for visible central airway lesions 1, 3

Medical Management

• Administer antibiotics for any hemoptysis ≥5 mL, as bleeding may represent pulmonary exacerbation or superimposed bacterial infection 1, 3, 2
• Stop NSAIDs immediately due to platelet dysfunction 1, 3, 2
• Admit to hospital for any hemoptysis ≥5 mL for monitoring and treatment 1
• Scant hemoptysis (<5 mL/24h) may not require hospital admission 1

When to Consider BAE for Non-Massive Hemoptysis

BAE is increasingly utilized for non-massive hemoptysis when conservative medical therapy fails or for palliation 6, 1:

• Immediate bleeding cessation in 93% of patients 6
• Success rates similar between non-massive and massive hemoptysis 6
• Particularly effective when repeated episodes prevent normal daily activities 6
• 87% and 58% of patients remain free of hemoptysis at 1 and 3 years, respectively 6

Common Etiologies by Geographic Region

In developed countries, the most common causes are 4, 5:

• Acute respiratory infections (most common overall) 4
• Bronchiectasis 6, 1
• Lung cancer (17.4% of cases; higher in smokers >40 years) 6, 7
• Chronic obstructive pulmonary disease 4
• Cryptogenic (20-50% of cases have no identified cause) 6, 4

In resource-limited areas, tuberculosis remains the leading cause 6, 5

Management of Recurrent Hemoptysis

• Recurrence occurs in 10-55% of cases after BAE, requiring close follow-up 1, 3
• Higher recurrence rates are associated with chronic pulmonary aspergillomas (55%), malignancy, and sarcoidosis 1, 3
• Repeat BAE is the primary therapeutic option for recurrent hemoptysis, with no increased risk of morbidity or mortality 1, 2
• Recurrence within 3 months is often due to incomplete embolization; after 3 months, it's typically due to vascular collateralization or recanalization 1
• For aspergillomas causing hemoptysis, definitive surgical treatment following initial BAE is recommended due to high recurrence rates 1

Special Considerations for Malignancy-Related Hemoptysis

• External beam radiation therapy (EBRT) provides hemoptysis relief in 81-86% of patients with unresectable lung cancer 1, 3
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone, though fatal hemoptysis rates range from 7-22% 1
• BAE for malignancy is typically palliative or a temporizing measure prior to definitive surgery 1
• Surgery may be considered for surgically resectable tumors in stable patients (50-70% survival rates), but carries 16% mortality when performed for massive hemoptysis 1

Surgical Management

Surgery is reserved as a final therapeutic option when BAE fails or is not feasible 1, 2:

• Indicated for surgically resectable tumors in stable patients 1
• For stage I and II non-small cell lung cancer causing cough/hemoptysis, surgery is the treatment of choice 6
• Surgical management of massive hemoptysis carries 16% mortality, associated with blood aspiration into contralateral lung and pneumonectomy 1