How should I manage a patient presenting with hemoptysis?

Management of Hemoptysis

Immediately assess the severity of bleeding and protect the airway—for massive hemoptysis (>240 mL/24h or causing respiratory compromise), intubate with a single-lumen endotracheal tube and proceed directly to bronchial artery embolization without delay, as delaying definitive intervention significantly increases mortality. 1

Initial Severity Stratification

Classify hemoptysis by volume and clinical stability to guide management:

• Scant hemoptysis: <5 mL in 24 hours 2, 3
• Mild-to-moderate hemoptysis: 5-240 mL in 24 hours 2, 3
• Massive hemoptysis: >240 mL in 24 hours OR any amount causing respiratory compromise or hemodynamic instability 1, 3

The rate of bleeding correlates more closely with mortality than total volume—rapid bleeding is more dangerous regardless of quantity. 1, 4 Two or more opacified lung quadrants on chest radiograph indicate increased mortality risk. 4, 3

Management Algorithm by Severity

For Massive Hemoptysis (Life-Threatening)

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 is the most common cause of death from asphyxiation. 1
• Consider selective right or left mainstem intubation to protect the non-bleeding lung if the bleeding side is identified. 1, 4
• Never use BiPAP or positive pressure ventilation, as this worsens bleeding. 1, 4

Immediate Resuscitation:

• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation. 1, 4
• Obtain baseline labs: complete blood count, PT/aPTT, Clauss fibrinogen (not derived), type and cross-match. 4
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy. 4, 3

Definitive Treatment Pathway:

• For clinically unstable patients, proceed directly to bronchial artery embolization (BAE) without bronchoscopy or CT imaging, as delaying BAE significantly increases mortality. 1, 4
• BAE achieves immediate hemostasis in 73-99% of cases, as over 90% of massive hemoptysis originates from bronchial arteries. 1, 4, 3
• For the remaining ~10% with pulmonary arterial bleeding, pulmonary artery embolization achieves 88-90% success rates. 4, 3

Medical Management:

• Stop all NSAIDs immediately, as they impair platelet function and worsen bleeding. 1, 4
• Stop all anticoagulants during active hemoptysis. 1, 3
• Stop all airway clearance therapies immediately to allow clot formation. 1, 4
• Stop aerosolized hypertonic saline, as it can exacerbate bleeding. 4
• Administer antibiotics, as bleeding may represent a pulmonary exacerbation or superimposed bacterial infection. 1, 4, 3

Intensive Care Monitoring:

• Admit all patients to intensive care for monitoring of coagulation parameters, hemoglobin levels, blood gases, and ongoing bleeding. 1, 3
• Start venous thromboprophylaxis as soon as bleeding is controlled. 1, 3

For Clinically Stable Patients with Massive Hemoptysis

Diagnostic Evaluation:

• CT chest with IV contrast is the preferred initial diagnostic test, with diagnostic accuracy of 80-90% and superior to bronchoscopy. 1, 4
• CT angiography is the standard of care for arterial planning if BAE is being considered. 1, 4
• Perform bronchoscopy to identify the anatomic site and side of bleeding, with diagnostic yield of 70-80%. 1, 3

Bronchoscopic Temporizing Measures:

• Wedge the bronchoscope tip tightly into the bleeding bronchus for tamponade. 1, 4
• Instill iced saline solution to constrict blood vessels. 1, 4
• Use bronchial blockade balloons for tamponade, potentially requiring 24-48 hours in place. 1, 4
• Bronchoscopic-guided topical hemostatic tamponade therapy using oxidized regenerated cellulose mesh immediately arrests hemoptysis in 98% of patients. 1, 4

For Mild-to-Moderate Hemoptysis (5-240 mL/24h)

When to Contact Healthcare Provider:

• The patient with at least mild hemoptysis (>5 mL) should contact their healthcare provider immediately. 2

Hospital Admission:

• Admit to hospital for monitoring and treatment for any hemoptysis ≥5 mL. 2, 4, 3

Medical Management:

• Administer antibiotics for any hemoptysis ≥5 mL, as bleeding may represent pulmonary exacerbation or superimposed bacterial infection. 2, 1, 4, 3
• Stop all NSAIDs immediately due to their effect on platelet function that worsens bleeding. 2, 1, 4
• Stop anticoagulants during active hemoptysis. 1, 3

Diagnostic Evaluation:

• Perform bronchoscopy to identify the bleeding source. 4, 3
• CT chest with IV contrast has 77% diagnostic accuracy for determining etiology. 4, 3

Airway Clearance Modifications:

• Active cycle of breathing and autogenic drainage are least concerning and may be continued. 4
• Stop aerosolized hypertonic saline. 4
• General aerosol therapies (except hypertonic saline) may be continued with caution. 4

For Scant Hemoptysis (<5 mL/24h)

When to Contact Healthcare Provider:

• The patient with scant hemoptysis should contact their healthcare provider if it is the first-ever episode or if it is persistent. 2

Hospital Admission:

• Scant hemoptysis may not require hospital admission. 2, 4, 3

Medical Management:

• For scant hemoptysis without other features of pulmonary exacerbation, antibiotics are not routinely required. 2
• Stop NSAIDs even with scant hemoptysis. 2
• Continue airway clearance therapies and aerosol therapies (except hypertonic saline). 4

Management of Recurrent Hemoptysis

Recurrence occurs in 10-55% of cases after initial BAE, with higher rates in chronic pulmonary aspergillomas (55%), malignancy, and sarcoidosis. 1, 4, 3

For recurrent hemoptysis:

• Repeat BAE is the primary therapeutic option, with no increased risk of morbidity or mortality for repeat interventions. 1, 4, 3
• Perform CT angiography or CT with IV contrast before repeat BAE for arterial mapping. 4
• Recurrence within 3 months is often due to incomplete or missed embolization; after 3 months, it's typically due to vascular collateralization or recanalization. 4

Surgical Management

Surgery is reserved as a final therapeutic option when BAE fails or for surgically resectable tumors in stable patients. 4, 3

Specific indications:

• BAE unsuccessful in controlling bleeding 3
• Surgically resectable tumors in stable patients (50-70% survival rates) 4
• Aspergillomas causing recurrent hemoptysis after initial BAE (due to 55% recurrence rate) 4

Surgery for massive hemoptysis carries 16% mortality, associated with blood aspiration into the contralateral lung and pneumonectomy. 4, 3

Radiation Therapy for Malignancy-Related Hemoptysis

For unresectable lung cancer with hemoptysis:

• External beam radiation therapy (EBRT) provides palliation in approximately 60% of patients, with hemoptysis being the best-palliated symptom (81-86% relief rates). 4, 3
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone, though fatal hemoptysis rates range from 7-22%. 4
• BAE for malignancy is typically palliative or a temporizing measure prior to definitive surgery. 4

Critical Pitfalls to Avoid

• Never delay airway protection in favor of diagnostic procedures when respiratory distress is present. 1, 4
• Never perform bronchoscopy before BAE in clinically unstable patients with massive hemoptysis, as this delay significantly increases mortality. 1, 4
• Never use double-lumen endotracheal tubes, as they are more difficult to place, have smaller lumens, and do not permit therapeutic bronchoscopy. 1, 4
• Do not instill vasoactive agents like epinephrine if bleeding is brisk, as they are unlikely to help. 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity. 4
• Do not use derived fibrinogen levels; use Clauss fibrinogen to assess coagulation status. 4