Evaluation and Treatment of Massive Hemoptysis

Massive hemoptysis is more appropriately defined as life-threatening hemoptysis that causes airway obstruction, respiratory failure, and/or hypotension. Patients with this condition die from asphyxiation, not hemorrhagic shock. Any patient who presents with life-threatening hemoptysis requires immediate treatment to secure the airway and stabilize the patient. Early activation and coordinated response from a multidisciplinary team is critical. Once the airway is secure and appropriate resuscitation is initiated, priorities are to localize the source of the bleeding and gain hemorrhage control. Nonsurgical control of hemorrhage is superior to surgery in the acute situation. Most of these patients will require ICU level care. Immediate actions to stabilize the patient and secure the airway include placement of the patient in the decubitus position with bleeding lung down, intubation with greater than or equal to 8 mm endotracheal tube, blood product transfusion and reversal of coagulopathies, bronchoscopy (to aid in securing the airway via suction, isolation of the bleeding lung via bronchial blocker or placement of the endotracheal tube in the main stem bronchus, and application of hemostatic adjuncts), engagement of a multidisciplinary team (including ICU, interventional radiology, thoracic surgery, interventional pulmonology, anesthesiology), and placement of the patient in the ICU. Diagnostic options include chest radiography, CT, and bronchoscopy. Chest radiography is a quick, bedside tool that may be able to identify the side of the bleed. Both CT and bronchoscopy are capable of localizing the source of the bleed, and the combination of the 2 is more effective than each alone. CT is also capable of providing insight into the underlying cause of the bleeding. Angiography is capable of localizing the bleed in the event, whereas CT and bronchoscopy were unable to do so. The ability of IR to localize the bleed in a timely manner is significantly aided by information gained via CT and bronchoscopy; therefore, if the patient is stable, CT should be obtained. Treatment options include early bronchoscopy as described earlier and angiography followed by BAE. In the appropriate patient, this minimally invasive, nonsurgical option for hemorrhage control is superior to emergent surgery. However, for the patient in extremis, who is too unstable for IR, surgery is the best option. Table 2 summarizes the capabilities and limitations of these interventions.