Massive Hemoptysis Management

Algorithm Steps

1. ▶

   Start

   Hemoptysis Presentation

   Patient coughing up blood

   1. ◆

      Decision

      Massive Hemoptysis?

      Quantify and assess severity

      • Massive: >100-200mL/24h OR
      • Hemodynamic instability
      • Respiratory compromise
      • Risk of asphyxiation
      • Life-threatening: >500mL/24h
      1. ●

         Action

         Non-Massive Hemoptysis

         Outpatient workup if stable

         • CXR as initial imaging
         • CT chest if CXR abnormal
         • Bronchoscopy if recurrent
         • Treat underlying cause
         • Follow-up arranged
         1. ✓

            Outcome

            Treat Underlying Cause

            Address etiology

            • Bronchiectasis: Optimize treatment
            • TB: Anti-TB therapy
            • Malignancy: Oncology referral
            • Aspergilloma: Consider resection
            • Pulmonary HTN: Specific therapy
      2. ⚠

         Warning

         ⚠️ Immediate Stabilization

         Protect airway, ensure oxygenation

         • Large bore IV access x2
         • Type and crossmatch
         • High-flow oxygen
         • Position bleeding side down (if known)
         • Reverse anticoagulation if applicable
         1. ◆

            Decision

            Airway Secure?

            Can patient protect airway?

            • Alert and protecting airway
            • Maintaining oxygenation
            • Not drowning in blood
            1. ●

               Action

               Intubation Required

               Secure definitive airway

               • Large ETT (≥8.0) for bronchoscopy access
               • Consider mainstem intubation to non-bleeding lung
               • Consider double-lumen tube if skilled
               • Bronchial blocker alternative
               • Video laryngoscopy preferred
               1. ●

                  Action

                  Localize Bleeding Source

                  Imaging and bronchoscopy

                  • CTA chest: Identify source and etiology
                  • Bronchoscopy: Direct visualization, therapeutic
                  • 90% of massive hemoptysis from bronchial arteries
                  • 10% from pulmonary arteries
                  1. ●

                     Action

                     Bronchoscopic Interventions

                     Temporizing measures

                     • Cold saline lavage
                     • Topical vasoconstrictors (epinephrine 1:20,000)
                     • Endobronchial tamponade (balloon, Fogarty catheter)
                     • Oxidized cellulose or fibrin glue
                     • Electrocautery/laser if available
                     1. ●

                        Action

                        Bronchial Artery Embolization (BAE)

                        First-line definitive treatment

                        • Success rate 70-90% immediate control
                        • Recurrence 10-30% at 1 year
                        • Identify ALL abnormal bronchial arteries
                        • Avoid spinal artery embolization (paralysis risk)
                        • May need repeat procedures
                        1. ◆

                           Decision

                           BAE Successful?

                           Bleeding controlled?

                           1. ●

                              Action

                              Post-Procedure Management

                              ICU monitoring

                              • ICU admission for monitoring
                              • Treat underlying condition
                              • Antibiotics if infection
                              • Antifungal if aspergilloma
                              • Plan for recurrence
                           2. ●

                              Action

                              Surgical Intervention

                              When embolization fails or not possible

                              • Lobectomy or pneumonectomy
                              • High mortality in emergency (20-40%)
                              • Better outcomes in elective/semi-elective
                              • Consider if: Localized disease, good pulmonary reserve
                              • Avoid if: Bilateral disease, poor lung function
                  2. ◆

                     Decision

                     CTA Findings?

                     Identify vascular source

                     • Bronchial artery hypertrophy
                     • Pulmonary artery pseudoaneurysm
                     • Aortobronchial fistula
                     • No clear source
                     1. ●

                        Action

                        Pulmonary Artery Source

                        Different approach needed

                        • PA pseudoaneurysm (Rasmussen)
                        • PAA embolization
                        • May need coils, plugs
                        • Higher complexity procedure