What is the recommended evaluation and management for a patient presenting with hemoptysis?

Management and Evaluation of Hemoptysis

Immediate Assessment and Stabilization

The first priority is immediate severity assessment and airway protection, with massive hemoptysis requiring intubation using a single-lumen cuffed endotracheal tube to allow bronchoscopic suctioning and clot removal. 1

Severity Classification

• Assess severity immediately: scant (<5 mL/24h), mild-to-moderate (5-240 mL/24h), or massive (>240 mL/24h or any amount causing respiratory compromise), recognizing that the rate of bleeding correlates more closely with mortality than total volume 2, 1
• Massive hemoptysis carries mortality risk up to 59-100% if untreated, with death typically from asphyxiation rather than exsanguination 3, 1

Airway Management

• Intubate immediately with a single-lumen cuffed endotracheal tube (not double-lumen) to permit bronchoscopic suctioning and removal of large obstructing clots 1
• Position the patient with the bleeding lung in the dependent position to protect the non-bleeding lung, if the bleeding side is known 2
• Consider selective right or left mainstem intubation to isolate and protect the non-bleeding lung 3, 1
• Avoid BiPAP entirely in massive hemoptysis, as positive pressure ventilation worsens bleeding 3, 1

Hemodynamic Stabilization

• Administer high-flow oxygen immediately 2
• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation and potential transfusion 3, 1
• Obtain baseline labs: complete blood count, PT/aPTT, Clauss fibrinogen (not derived fibrinogen, which is misleading), and type and cross-match 3
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 3, 1

Diagnostic Evaluation

Imaging Strategy

For clinically stable patients, CT chest with IV contrast is the preferred initial diagnostic test, identifying the cause and location of bleeding with 77-80% diagnostic accuracy, superior to chest radiograph which suggests etiology in only 26% of cases 2, 3

• CT angiography (CTA) is the standard of care for arterial planning if bronchial artery embolization (BAE) is being considered, detecting aberrant bronchial arteries in 36% of cases and identifying pulmonary artery pseudoaneurysms missed on conventional arteriography 3
• Chest radiograph is reasonable only when confirming benign causes like acute bronchitis or pneumonia, but has limited sensitivity 3
• Two or more opacified lung quadrants on chest radiograph correlate with increased mortality risk 3

Bronchoscopy

• Perform bronchoscopy immediately in stable patients with mild-to-moderate hemoptysis to identify the anatomic site and side of bleeding, with diagnostic yield of 70-80% 1
• In clinically unstable patients with massive hemoptysis, proceed directly to BAE without bronchoscopy, as delaying BAE significantly increases mortality 3, 1

Medical Management

Immediate Interventions

• Administer antibiotics empirically for any hemoptysis ≥5 mL, as bleeding may represent pulmonary exacerbation or superimposed bacterial infection 2, 3
• Stop all NSAIDs immediately due to their effect on platelet function that worsens bleeding 3, 1
• Stop all anticoagulants during active hemoptysis unless absolutely necessary for another indication 2, 1
• Consider tranexamic acid as adjunct therapy to reduce bleeding 2

Airway Clearance Modifications

• Stop all airway clearance therapies immediately in massive hemoptysis to allow clot formation 3, 1
• Stop aerosolized hypertonic saline in massive hemoptysis, as it can exacerbate bleeding 3
• Continue airway clearance therapies in scant hemoptysis; for mild-to-moderate hemoptysis, active cycle of breathing and autogenic drainage are least concerning 3

Interventional Management

Bronchial Artery Embolization (BAE)

BAE has become the first-line therapy for massive hemoptysis with immediate success rates of 73-99%, as over 90% of massive hemoptysis originates from bronchial arteries. 3, 1

• For clinically unstable patients, proceed directly to BAE without delay—delaying BAE for CT imaging or bronchoscopy significantly increases mortality 3, 1
• For stable patients with significant hemoptysis, BAE achieves immediate bleeding cessation in 93% of patients 3
• Recurrence occurs in 10-55% of cases after initial BAE, with higher rates in chronic pulmonary aspergillomas (55%), malignancy, and sarcoidosis 3, 1
• Repeat BAE shows no increased risk of morbidity or mortality for recurrent hemoptysis 3, 1

Bronchoscopic Interventions

For visible central airway lesions in stable patients, bronchoscopic interventions include: 3, 1

• Tamponade by wedging the bronchoscope tip into the bleeding bronchus
• Instillation of iced saline solution to constrict blood vessels
• Bronchial blockade balloons (may require 24-48 hours in place)
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate)
• Thermal ablation using argon plasma coagulation, Nd:YAG laser, or electrocautery (80-90% success rates)

Pulmonary Artery Embolization

• For the ~10% of cases with pulmonary arterial bleeding, pulmonary artery embolization achieves 88-90% success rates 3

Radiation Therapy

• External beam radiation therapy (EBRT) provides hemoptysis relief in 81-86% of patients with distal or parenchymal lesions not amenable to bronchoscopic intervention 3
• Combined high-dose rate brachytherapy with EBRT provides better symptom relief than EBRT alone, though fatal hemoptysis rates range from 7-22% 3

Surgical Management

• Surgery is reserved as a final therapeutic option when BAE is unsuccessful, or for surgically resectable tumors in stable patients (50-70% survival rates) 3
• Surgery for massive hemoptysis carries 16% mortality, associated with blood aspiration into contralateral lung and pneumonectomy 3
• For aspergillomas causing hemoptysis, definitive surgical treatment following initial BAE is recommended due to 55% recurrence rates 3

Monitoring and Admission Criteria

Intensive Care Admission

• Admit to intensive care if hemoptysis is massive or the patient is unstable, monitoring coagulation parameters, hemoglobin, arterial blood gases, and ongoing bleeding 2, 1
• Start venous thromboprophylaxis as soon as bleeding is controlled 1

Hospital Admission

• Admit to hospital for any hemoptysis ≥5 mL for monitoring and treatment 3
• For mild-to-moderate hemoptysis, admit to a monitored bed with close observation for progression, as bleeding can unpredictably worsen 2
• Scant hemoptysis (<5 mL/24h) may not require hospital admission 3

Critical Pitfalls to Avoid

• Never delay airway protection in favor of diagnostic procedures when respiratory distress is present 2, 1
• Never perform bronchoscopy before BAE in unstable patients with massive hemoptysis, as this wastes valuable time and increases mortality 2, 3, 1
• Never use double-lumen endotracheal tubes, as they are more difficult to place, have smaller lumens, and do not permit therapeutic bronchoscopy 1
• Do not rely on chest radiograph alone for diagnosis due to limited sensitivity 2
• Do not use derived fibrinogen levels—always use Clauss fibrinogen to accurately assess coagulation status 2, 3
• Do not instill vasoactive agents like epinephrine if bleeding is brisk, as they are unlikely to help 1
• Avoid hyperventilation and excessive positive end-expiratory pressure in hypovolemic patients, as this worsens hemodynamics 3

Common Etiologies

• Bronchiectasis is the most common cause of hemoptysis in many series 3
• Infectious and inflammatory airway diseases account for 25.8% of cases 4
• Lung cancer accounts for 17.4% of cases; BAE for malignancy is typically palliative or a temporizing measure prior to definitive surgery 3, 4
• Active tuberculosis is another common cause 3
• The cause remains unknown in approximately 50% of cases 4