What is the appropriate evaluation and management of a patient presenting with hemoptysis (coughing up blood)?

Hemoptysis: Evaluation and Management

Immediate Severity Assessment and Stabilization

For patients presenting with massive hemoptysis (≥200 mL/24 hours or any amount causing respiratory compromise), immediately intubate with a single-lumen cuffed endotracheal tube and proceed directly to bronchial artery embolization (BAE) without delay, as delaying for diagnostic procedures significantly increases mortality. 1, 2

Defining Severity

• 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, 2
• Mild-to-moderate hemoptysis is ≥5 mL but <200 mL per 24 hours 1
• Scant hemoptysis is <5 mL per 24 hours and may not require hospital admission 1
• Mortality from massive hemoptysis ranges from 9-59% if untreated, primarily from asphyxiation rather than exsanguination 1, 3

Critical First Steps for Massive Hemoptysis

Airway Management:

• Intubate immediately with a single-lumen cuffed endotracheal tube (NOT double-lumen), as the larger diameter allows bronchoscopic suctioning and rapid removal of obstructing clots, which is the most common cause of death 1, 2
• Consider selective right or left mainstem intubation to protect the non-bleeding lung if the bleeding side is identified 1, 2
• Never use BiPAP in massive hemoptysis, as positive pressure ventilation worsens bleeding 1, 2

Resuscitation:

• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation and potential transfusion 1, 2
• Obtain baseline labs: complete blood count, PT/aPTT, Clauss fibrinogen (not derived fibrinogen, which is misleading), and type and cross-match 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1, 2

Medical Management:

• Stop all NSAIDs immediately, as they impair platelet function and worsen bleeding 1, 2
• Stop all anticoagulants during active hemoptysis 2
• Stop all airway clearance therapies immediately to allow clot formation 1, 2
• Stop aerosolized hypertonic saline, as it can exacerbate bleeding 1, 2

Diagnostic Algorithm Based on Patient Stability

For Clinically Unstable Patients with Massive Hemoptysis

Proceed directly to BAE without bronchoscopy or CT imaging, as delaying BAE significantly increases mortality. 1, 2, 4

• BAE achieves immediate hemostasis in 73-99% of cases, as over 90% of massive hemoptysis originates from bronchial arteries 5, 1, 2
• Never perform bronchoscopy before BAE in unstable patients, as this delay is associated with increased mortality 1, 2, 4
• Conventional arteriography is performed with therapeutic intent (embolization), not as a diagnostic modality 1

For Clinically Stable Patients with Significant Hemoptysis

CT chest with IV contrast is the preferred initial diagnostic test, determining etiology in 77-94% of cases and superior to both chest radiograph and bronchoscopy. 1, 2, 4

Diagnostic Pathway:

• CT chest with IV contrast identifies the cause and location of bleeding with 77-94% accuracy, far superior to chest radiograph (26% diagnostic yield) 5, 1, 4
• CT angiography (CTA) is the standard of care for arterial planning if BAE is being considered, providing better vessel opacification, detecting aberrant bronchial arteries in 36% of cases, and identifying pulmonary artery pseudoaneurysms 1
• Bronchoscopy should be performed immediately in stable patients to identify the anatomic site and side of bleeding, with diagnostic yield of 70-80% 2
• Chest radiograph is reasonable only when confirming benign causes like acute bronchitis or pneumonia, but has limited sensitivity 1

Key Diagnostic Findings:

• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 1
• CT is superior to bronchoscopy for diagnosing lung cancer (17 vs 15 positive cases) and definitive staging (48% vs 14%) 5

Bronchoscopic Management Techniques

Temporizing Measures During Bronchoscopy

• Tamponade by wedging the bronchoscope tip tightly into the bleeding bronchus 1, 2
• Iced saline instillation to constrict blood vessels and stop bleeding 1, 2
• Bronchial blockade balloons to tamponade the bronchus, potentially requiring 24-48 hours in place 1, 2
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh arrests hemoptysis in 98% of cases 1, 2
• Do not instill vasoactive agents like epinephrine if bleeding is brisk, as they are unlikely to help 2

Definitive Bronchoscopic Interventions for Visible Central Airway Lesions

• Thermal ablation using argon plasma coagulation, Nd:YAG laser, or electrocautery achieves 80-90% success rates for visible central airway lesions 1
• For distal or parenchymal lesions not amenable to bronchoscopic intervention, external beam radiation therapy (EBRT) achieves 81-86% hemoptysis relief rates 1
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone, though fatal hemoptysis rates range from 7-22% 1

Management of Mild-to-Moderate Hemoptysis (≥5 mL but <200 mL/24h)

Admit to hospital for monitoring and treatment, administer antibiotics, and stop all NSAIDs immediately. 1

• Admit to hospital for any hemoptysis ≥5 mL for monitoring and treatment 1
• Administer antibiotics, as bleeding may represent pulmonary exacerbation or superimposed bacterial infection 1, 2
• Stop all NSAIDs immediately due to their effect on platelet function 1, 2
• Continue aerosol therapies (except hypertonic saline) in scant hemoptysis 1
• For mild-to-moderate hemoptysis, active cycle of breathing and autogenic drainage are least concerning 1
• BAE is increasingly utilized when conservative medical therapy fails or for palliation, with immediate bleeding cessation in 93% of patients 1, 4

Bronchial Artery Embolization: Efficacy and Outcomes

Success Rates by Etiology

• Overall immediate success rate: 73-99% across all etiologies 5, 1, 2
• Tuberculosis-related hemoptysis: 95% immediate success, 90% success at one month, 76% free of hemoptysis at 1 year 5
• Bronchiectasis: 22-29% of cases, with similar success rates to tuberculosis 5
• Malignancy: 75-80% immediate success rate, though 6-month mortality remains high at 55% 5
• Cryptogenic hemoptysis: 100% immediate success rate, with recurrence rates (12%) similar to known causes (25%) 5

Pulmonary Artery Embolization

• For the ~10% of massive hemoptysis originating from pulmonary arteries, pulmonary artery embolization achieves 88-90% success rates 5, 1
• Pulmonary artery pseudoaneurysms are identified in approximately 3.5% of patients presenting with massive hemoptysis 5

Management of Recurrent Hemoptysis

Repeat BAE is the primary therapeutic option for recurrent hemoptysis, with no increased risk of morbidity or mortality for repeat interventions. 1, 2

• Recurrence occurs in 10-55% of cases after initial BAE, requiring close follow-up 1, 2
• Higher recurrence rates are associated with chronic pulmonary aspergillomas (55%), malignancy, and sarcoidosis 1
• Recurrence within 3 months is often due to incomplete or missed embolization of bleeding arteries 1
• Recurrence after 3 months is most likely due to vascular collateralization or recanalization 1
• Perform CTA or CT with IV contrast before repeat BAE for arterial mapping 1

Definitive Management for Specific Etiologies

• Aspergillomas: Definitive surgical treatment following initial BAE is recommended due to 55% recurrence rate 1
• Malignancy: BAE is typically palliative or a temporizing measure prior to definitive surgery 1
• Surgically resectable tumors: Surgery may be considered in stable patients with 50-70% survival rates, though surgical management carries 16% mortality associated with blood aspiration into contralateral lung and pneumonectomy 1

Intensive Care Monitoring

• 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 1, 2
• Avoid hyperventilation and excessive positive end-expiratory pressure in hypovolemic patients, as this worsens hemodynamics 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity 1

Critical Pitfalls to Avoid

• Never delay airway protection in favor of diagnostic procedures when respiratory distress is present 1, 2, 4
• Never perform bronchoscopy before BAE in clinically unstable patients with massive hemoptysis 1, 2, 4
• Never use double-lumen endotracheal tubes, as they are more difficult to place, have smaller lumens, and do not permit therapeutic bronchoscopy 2
• Never continue NSAIDs or anticoagulants during active hemoptysis 1, 2
• Never use BiPAP in massive hemoptysis 1, 2
• Never use derived fibrinogen levels; always use Clauss fibrinogen 1