What is the emergency assessment and management plan for a patient presenting with hemoptysis, including airway protection, anticoagulant reversal, diagnostic work‑up, and treatment options?

Emergency Assessment and Management of Hemoptysis

In massive hemoptysis with hemodynamic instability, proceed directly to bronchial artery embolization (BAE) without delay—achieving 73–99% immediate hemostasis—while simultaneously securing the airway with a single-lumen endotracheal tube; bronchoscopy before BAE in unstable patients increases mortality and must be avoided. 1, 2

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Immediate Severity Stratification

Classify hemoptysis by volume and clinical impact to guide your next steps: 1

• Scant: <5 mL/24h—outpatient management acceptable if first episode or non-persistent 1
• Mild-to-moderate: 5–240 mL/24h—requires hospital admission and empiric antibiotics 1
• Massive: >240 mL/24h or any amount causing respiratory compromise—the rate of bleeding predicts mortality more accurately than total volume 1, 3

Two or more opacified lung quadrants on chest radiograph signal increased mortality risk. 1

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Airway Protection and Resuscitation (Massive Hemoptysis)

Immediate Actions

• Intubate with a single-lumen cuffed endotracheal tube (≥8.0 mm) to permit bronchoscopic suctioning and clot removal; double-lumen tubes limit therapeutic access and are contraindicated. 1
• Avoid BiPAP entirely—positive pressure worsens bleeding. 1
• Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation and potential transfusion. 1
• Administer high-flow oxygen and position the patient bleeding-side down (if lateralized) to protect the contralateral lung. 1, 4

Selective Mainstem Intubation

Consider selective right or left mainstem intubation to isolate and protect the non-bleeding lung when the bleeding side is known. 1

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Anticoagulant and Medication Management

Stop all NSAIDs and anticoagulants immediately—NSAIDs impair platelet function and anticoagulants exacerbate hemorrhage. 1, 2, 3

• For pulmonary embolism with hemoptysis, restart anticoagulation only after complete resolution of bleeding (typically 12–24 hours after the last episode). 2
• Do not use vasoactive agents (e.g., epinephrine) for massive bleeding—they are ineffective. 1

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Diagnostic Work-Up by Clinical Stability

Clinically Unstable (Massive Hemoptysis)

Do not delay BAE for CT imaging or bronchoscopy—delays significantly increase mortality. 1, 2, 3

• Obtain a chest radiograph only to assess opacified lung quadrants and verify endotracheal tube placement. 1
• Proceed directly to BAE, which controls bleeding in 73–99% of cases because >90% of massive hemoptysis originates from bronchial arteries. 1, 2, 3

Clinically Stable (Mild-to-Moderate or Persistent Hemoptysis)

• CT chest with IV contrast is the preferred initial test, with 77% diagnostic accuracy—far superior to chest radiograph (26% yield) or bronchoscopy (8% yield) for identifying etiology. 1, 2, 3
• CT angiography (CTA) provides optimal vessel opacification, detects aberrant bronchial arteries in 36% of cases, and identifies pulmonary artery pseudoaneurysms missed on conventional arteriography. 1
• Bronchoscopy is reserved for identifying the anatomic site and side of bleeding (70–80% diagnostic yield) and for therapeutic interventions in visible central airway lesions. 1, 3

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Definitive Treatment Options

Bronchial Artery Embolization (BAE)

BAE is first-line therapy for massive hemoptysis, with immediate success rates of 73–99%. 1, 2, 3

• In unstable patients, perform BAE without preceding bronchoscopy. 1, 2
• For the ~10% with pulmonary arterial bleeding, pulmonary artery embolization achieves 88–90% success. 1
• Recurrence occurs in 10–55% of cases, with higher rates in aspergillomas (55%), malignancy, and sarcoidosis. 1, 3
• Recurrence within 3 months suggests incomplete embolization; after 3 months, suspect vascular collateralization or recanalization. 1
• Repeat BAE carries no increased morbidity or mortality and is the primary option for recurrent bleeding. 1

Bronchoscopic Interventions (Visible Central Airway Lesions)

Use bronchoscopy for both diagnosis and therapy in stable patients with visible lesions: 1, 3

• Tamponade: wedge the bronchoscope tip into the bleeding bronchus 1
• Iced saline instillation to constrict blood vessels 1
• Bronchial blockade balloons for temporary control 1
• Topical hemostatic tamponade with oxidized regenerated cellulose mesh—98% success rate 1, 3
• Thermal ablation: argon plasma coagulation (100% success at 3 months), Nd:YAG laser (~60% response), or electrocautery 1

External Beam Radiation Therapy (EBRT)

For unresectable lung cancer with non-massive hemoptysis, EBRT provides 81–86% hemoptysis relief. 1, 3

• No survival difference between 30 Gy/10 fractions vs. 40 Gy/20 fractions, or 17 Gy/2 fractions vs. 30 Gy/10 fractions. 1
• Combined high-dose rate brachytherapy with EBRT improves symptom relief but carries a 7–22% fatal hemoptysis rate. 1

Surgical Resection

Surgery is reserved as a final option when BAE fails or for surgically resectable tumors in stable patients. 1

• Surgical mortality for massive hemoptysis is 16%, associated with blood aspiration into the contralateral lung and pneumonectomy. 1
• Definitive surgery is recommended for aspergillomas after initial BAE due to 55% recurrence rates. 1

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Medical Management (Mild-to-Moderate Hemoptysis)

• Admit all patients with ≥5 mL hemoptysis for monitoring and treatment. 1
• Administer empiric antibiotics (e.g., amoxicillin-clavulanate for 14 days per British Thoracic Society guidelines) for any hemoptysis ≥5 mL, as bleeding may represent pulmonary infection or exacerbation. 1, 2, 3
• Stop all airway clearance therapies immediately in massive hemoptysis to allow clot formation; continue in scant hemoptysis. 1
• Stop aerosolized hypertonic saline in massive hemoptysis—it exacerbates bleeding. 1

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Post-Intervention ICU Management

• Admit all patients with massive hemoptysis to ICU for monitoring of coagulation parameters, hemoglobin, blood gases, and ongoing bleeding. 1
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy. 1
• Start venous thromboprophylaxis as soon as bleeding is controlled. 1
• Do not rely on single hematocrit measurements—use a combination of clinical and laboratory parameters. 1
• Use Clauss fibrinogen (not derived fibrinogen) to assess coagulation status. 1

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Common Etiologies by Setting

• Outpatient/primary care: acute respiratory infections, COPD, malignancy, bronchiectasis 1
• Tertiary centers (North America/Europe): bronchiectasis (most common), respiratory infections, lung carcinoma 1, 5
• Developing countries: tuberculosis and its sequelae 1
• Other notable causes: sarcoidosis, autoimmune capillaritis, coagulopathies, pulmonary arteriovenous malformations, pulmonary embolism (uncommon), cryptogenic (~20% of cases) 1

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Critical Pitfalls to Avoid

• Never perform bronchoscopy before BAE in unstable patients—this delay increases mortality. 1, 2, 3
• Never use BiPAP in massive hemoptysis—positive pressure worsens bleeding. 1
• Never delay airway protection for diagnostic procedures when respiratory distress is present. 1
• Never continue NSAIDs or anticoagulants during active bleeding. 1, 2, 3
• Never use double-lumen endotracheal tubes—they limit bronchoscope access. 1