Urgent considerations

See Differentials for more details

Massive haemoptysis

Massive haemoptysis is a medical emergency and requires immediate treatment. Massive haemoptysis is defined as the expectoration of blood from a source below the glottis exceeding 600 mL of blood over a 24-hour period or 150 mL of blood (which may flood the lung dead space) over a 1-hour period.

Alternatively, massive haemoptysis can be diagnosed by clinical features of: airway compromise (obstruction, aspiration, hypoxaemia, need for intubation); haemodynamic instability or requirement for blood transfusion.[3]

Experts recommend a stepwise approach to treat massive haemoptysis:

1. Initial stabilisation

Initial priorities are assessment of the need for intubation or mechanical ventilation, and protection of the non-bleeding lung. Attending to ABC (Airway, Breathing, and Circulation) is paramount. Coagulopathy, thrombocytopenia, and platelet dysfunction should be identified and reversed immediately, and blood products should be readily available.

2. Protection of the non-bleeding lung

If haemoptysis is active and unilateral, there is risk of blood spillage into the non-bleeding lung, and rapid action should be taken to protect the non-bleeding lung. The patient may be placed in a lateral decubitus position with the bleeding lung downward in a dependent position.[5] Alternatively, the non-bleeding lung may be selectively intubated with the largest endotracheal tube available. A double-lumen endotracheal tube has a very limited role in managing massive haemoptysis due to the complexity of its proper placement, the need for significant operator experience, and the small lumen sizes, which do not allow room for therapeutic bronchoscopy.[5]

3. Airway intervention and control of bleeding

Once the patient has been stabilised and the non-bleeding lung has been protected, early bronchoscopy should be performed. Airway control can be attained by flexible bronchoscopy through a large-bore endotracheal tube or through the barrel of a rigid bronchoscope. Rigid bronchoscopy is a safe, effective way of securing the airway with therapeutic control of bleeding.[7][28][29][30] An endobronchial blocker or Fogarty balloon may be placed into the bleeding bronchus for tamponade of the bleeding site.

Bronchial arteriography with embolisation of the source of bleeding can be used as a diagnostic and therapeutic intervention when available, but the recurrence rate may be high.[31][32][33]​​​​

4. Surgical consideration

For patients who do not respond to embolisation or other minimally invasive techniques, surgical intervention should be considered. Some causes of haemoptysis, such as mitral stenosis, leaking aortic aneurysm, iatrogenic pulmonary artery rupture, traumatic injury to the chest, tracheo-innominate fistula, focal bronchiectasis, or aspergilloma resistant to other therapies, should be treated surgically.[5] The thoracic surgeon should be involved early in the care of patients with massive haemoptysis, and a multi-disciplinary approach is needed to optimise the outcome.[34]

5. Other

Bridging therapies with potential to reduce bleeding severity include nebulised or bronchoscopic tranexamic acid, cold saline lavage, local epinephrine, bronchoscopic fibrinogen-thrombin injection, and tissue glue.[35][36][37][38][39][40][41][42]

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