One of the most hair-raising presentations to the emergency department (ED) can be  massive hemoptysis with respiratory failure. While life-threatening hemoptysis represents a minority of hemoptysis cases seen in the ED, it is imperative we have an efficient and organized approach to management, as respiratory failure and death can occur rapidly. The definition of massive hemoptysis is variable across publications with expectorated blood volumes ranging from 100 to 1,000 mL per 24 hours, as these volumes are difficult to estimate for any given patient. A more practical definition of massive or life-threatening hemoptysis is that which causes signs of worsening respiratory distress, hemodynamic instability, abnormal gas exchange, or airway obstruction.¹ However, it is important to understand that death from hemoptysis is almost always due to hypoxia or asphyxiation (blood impedes gas exchange in the lungs, typically because of bleeding from high-pressure bronchial arteries into the lungs) as opposed to hemodynamic instability.² Death from hemoptysis is akin to drowning, so airway considerations usually take precedence over hemodynamic considerations. A common clinical pitfall is assuming that a patient who is coughing up a small amount of blood is not at risk for respiratory failure. Some patients accumulate blood in the lungs without voluminous expectoration, as reflected by hypoxemia and respiratory distress. These patients are at imminent risk of respiratory failure.

1. Differentiate hemoptysis from upper respiratory tract and GI sources

Hemoptysis has a different management algorithm from upper respiratory tract bleeding and gastrointestinal bleeding, underlying the importance of this first step. Patients with a chief complaint of hemoptysis are often incorrect with regards to the source of bleeding, so relying on the patient’s history of hemoptysis alone is a pitfall. Coffee-ground appearance, nausea, vomiting, melena, abdominal pain and known gastric and/or liver disease suggest a gastrointestinal source. Concomitant epistaxis, blood in the nares, or sensation of blood dripping in the posterior pharynx suggests an upper respiratory tract source. A thorough nasopharyngeal and oral exam is recommended; nasopharyngoscopy may be necessary to rule out an upper respiratory source of bleeding. True hemoptysis is usually bright red and/or foamy blood, and is associated with respiratory symptoms as well as a sensation of warmth in the chest.³ Individuals at risk for massive hemoptysis include those with a history of lung cancer, bronchiectasis, and tuberculosis.⁴

2. Maintain adequate oxygenation and ventilation

The decision to intubate is often a difficult one, as securing the airway removes the cough reflex and may increase the rate of blood pooling in the lungs leading to even worse gas exchange. The majority of patients with massive hemoptysis can effectively clear the blood out of the lungs with vigorous coughing. In fact, patients’ ability to clear the airway is often more effective than endotracheal intubation and suctioning.⁵ If a patient with massive hemoptysis is able to maintain adequate oxygenation with coughing, intubation is not recommended. Indications for endotracheal intubation in patients with massive hemoptysis include impending or worsening respiratory failure with hypoxemia and dyspnea, hemodynamic instability, low Glasgow coma score with poor airway protection, ineffective cough with inability to clear adequate volume of blood from the lungs, and expected worsening clinical course if patient needs to be sent outside of the ED for a CT scan or definitive procedure.6 Position the patient with the head of the bed at 30 to 45 degrees during intubation whenever possible, and use an 8.5 or 9 size endotracheal tube to allow for bronchoscopy and/or endobronchial blocker placement whenever necessary.⁷ Rapid sequence intubation with video laryngoscopy or ketamine-assisted awake intubation are this author’s recommended first-attempt airway strategies in patients with massive hemoptysis who require airway control.

Adequate suctioning of blood from the airway is necessary to provide clear visualization during endotracheal intubation. A single standard suction catheter such as a Yankhauer catheter can easily be overwhelmed, becoming ineffective in some patients with massive hemoptysis. Suggestions for adequate suctioning to ensure visualization during endotracheal intubation in this setting include employing a meconium aspirator attached to the endotracheal tube, or the suction assisted laryngoscopy and airway decontamination, or SALAD, technique with a DuCanto aspirator.^8,9 If blood overwhelms the ability of the catheter to clear the blood enough to allow visualization to facilitate endotracheal intubation, do not hesitate to move quickly to performing a cricothyrotomy.

If it is determined that the bleeding originates from one lung it is recommended to position the patient in lateral decubitus with the bleeding lung down to avoid contamination of the contralateral lung. Portable chest X-ray may help determine from which lung the bleeding originates.

3. Early consultation with ICU, interventional radiology, interventional pulmonology, thoracic surgery, and/or anesthesia (depending on local practice and underlying cause)

The definitive management of life-threatening hemoptysis involves source control, which usually requires a procedure, most commonly bronchial artery embolization performed by interventional radiology, bronchoscopy with local instillation of tranexamic acid (TXA), or epinephrine by interventional pulmonology or surgical resection by thoracics.^10–12

4. Administer nebulized tranexamic acid

Inhaled nebulized TXA has been shown in one small, randomized control trial (RCT) and one retrospective study to hasten resolution of non-massive hemoptysis.^13,14 The typical regimen is 500 mg three times daily. Larger doses of 1 to 2 g for massive hemoptysis have shown promise based on several case reports.^15–17 One RCT compared nebulized TXA with intravenous TXA and showed that resolution occurred in 30 minutes in 72 percent of patients in the nebulized group compared to 51 percent in the intravenous group, with a lower admission rate and lower volume of hemoptysis in the nebulized group.¹⁸ Larger RCTs are required before recommending TXA for patients with massive hemoptysis, however this author recommends its use in this setting, as the potential benefit likely outweighs the rare harms of nebulized tranexamic acid.

5. Reverse coagulopathies, if present

If patients with massive hemoptysis have recently taken an oral anticoagulant, they should receive specific reversal agents or prothrombin complex concentrates with or without Vitamin K, depending on the specific agent.¹⁹ If the patient has severe thrombocytopenia, consideration should be given to platelet transfusions, to target a platelet count greater than 50 x 109/L.²⁰ (If the fibrinogen is less than 150 mg/dL, consider giving fibrinogen concentrate.⁵

6. Search for underlying cause or source of bleeding with imaging

Chest x-ray can localize the side of bleeding in patients with massive hemoptysis in approximately 50 percent of patients and suggest an etiology in about 33 percent. However, the sensitivity is poor with up to 50 percent of patients with normal chest x-ray having positive findings on CT.21 CT should be obtained in high-risk patients even with mild hemoptysis, and all patients with moderate to severe bleeding, even if the chest x-ray is unremarkable. The diagnostic yield of CT is superior to that of bronchoscopy while the yield in localizing the lesion is comparable at 75 percent.⁷ CT is generally recommended prior to bronchoscopy for this reason. The mnemonic BATTLECAMP may be used to recall the important causes of hemoptysis: Bronchiectasis, Aspergilloma/AV malformation, Tuberculosis, Tracheo-innominate fistula, Lung cancer or abscess, Pulmonary embolism, Cocaine/Coagulopathy/Catemenial/Cystic Fibrosis, Autoimmune (vasculitis, systemic lupus erythematosus), Alveolar hemorrhage, Mitral stenosis, Pneumonia.

7. Arrange for definitive management

Depending on the underlying cause, definitive management may include bronchial artery embolization, a bronchial blocker, surgical resection, or even heparinization or embolectomy in the case of pulmonary embolism. So next time you are faced with a patient with massive hemoptysis heading for respiratory failure in your ED, take an organized approach such as this seven-step one to maximize your patient’s chance of survival with good neurologic outcome.

A special thanks to Drs. Bourke Tillmann and Scott Weingart for their expertise on the EM Cases podcast that inspired this column.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, division of emergency medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of Emergency Medicine Cases podcast and website.

References

1. Deshwal H, Sinha A, Mehta AC. Life-threatening hemoptysis. Semin Respir Crit Care Med. 2021;42(1):145-159.
2. Atchinson PRA, Hatton CJ, Roginski MA, et al. The emergency department evaluation and management of massive hemoptysis. Am J Emerg Med. 2021;50:148-155.
3. Ittrich H, Bockhorn M, Klose H, et al. The diagnosis and treatment of hemoptysis. Dtsch Arztebl Int. 2017;114(21):371-381.
4. Li H, Ding X, Zhai S, et al. A retrospective study on the management of massive hemoptysis by bronchial artery embolization: risk factors associated with recurrence of hemoptysis. BMC Pulm Med. 2023;23(1):87.
5. Kathuria H, Hollingsworth HM, Vilvendhan R, et al. Management of life-threatening hemoptysis. J Intensive Care. 2020;8:23.
6. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086.
7. Davidson K, Shojaee S. Managing massive hemoptysis. Chest. 2020;157(1):77-88.
8. Kei J, Mebust DP. Comparing the effectiveness of a novel suction set-up using an adult endotracheal tube connected to a meconium aspirator vs. a traditional Yankauer suction instrument. J Emerg Med. 2017;52(4):433-437.
9. Weingart S. EMCrit 196 – Having a vomit SALAD with Dr. Jim DuCanto – airway management techniques during massive regurgitation, emesis, or bleeding. EMCrit blog website. Published April 3, 2017. Accessed October 11, 2023.
10. Lopez JK, Lee HY. Bronchial artery embolization for treatment of life-threatening hemoptysis. Semin Intervent Radiol. 2006;23(3):223-9.
11. Fekri MS, Hashemi-Bajgani SM, Shafahi A, et al. Comparing adrenaline with tranexamic acid to control acute endobronchial bleeding: A randomized controlled trial. Iran J Med Sci. 2017;42(2):129-135.
12. Yun JS, Song SY, Na KJ. Surgery for hemoptysis in patients with benign lung disease. J Thorac Dis. 2018;10(6):3532-3538.
13. Wand O, Guber E, Guber A, et al. Inhaled tranexamic acid for hemoptysis treatment: A randomized controlled trial. Chest. 2018;154(6):1379-1384.
14. O‘Neil ER, Schmees LR, Resendiz K, et al. Inhaled tranexamic acid as a novel treatment for pulmonary hemorrhage in critically ill pediatric patients: An observational study. Crit Care Explor. 2020;2(1):e0075.
15. Sanghvi S, Van Tuyl A, Greenstein J, et al. Tranexamic acid for treatment of pulmonary hemorrhage after tissue plasminogen activator administration for intubated patient. Am J Emerg Med. 2019;37(8):1602.e5-1602.e6.
16. Komura S, Rodriguez RM, Peabody CR. Hemoptysis? Try inhaled tranexamic acid. J Emerg Med. 2018;54(5):e97-e99.
17. Hankerson MJ, Raffetto B, Mallon WK, et al. Nebulized tranexamic acid as a noninvasive therapy for cancer-related hemoptysis. J Palliat Med. 2015;18(12):1060-2.
18. Gopinath B, Mishra PR, Aggarwal P, et al. Nebulized vs IV tranexamic acid for hemoptysis: a pilot randomized controlled trial. Chest. 2023;163(5):1176-1184.
19. Tomaselli GF, Mahaffey KW, Cuker A, et al. 2020 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: A report of the American College of Cardiology solution set oversight committee. J Am Coll Cardiol. 2020;76(5):594-622.
20. Santoshi RK, Patel R, Patel NS, et al. A comprehensive review of thrombocytopenia with a spotlight on intensive care patients. Cureus. 2022;14(8):e27718.
21. Thirumaran M, Sundar R, Sutcliffe IM, et al. Is investigation of patients with haemoptysis and normal chest radiograph justified? Thorax. 2009;64(10):854-6.