Haemoptysis presentation
Adult coughing up blood. Confirm the blood is from the lower airway, not the nose, mouth or gut.
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Pulmonary MedicineEmergency
Haemoptysis: Major (Massive) Haemoptysis Management
Haemoptysis: Major (Massive) Haemoptysis Management: Haemoptysis presentation → Tracheostomy bleed, alveolar haemorrhage or child? Not this pathway → Ma...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Warning Tracheostomy bleed, alveolar haemorrhage or child? Not this pathway
These need a different plan. Check before you continue.
- Bleeding from or around a tracheostomy: suspect tracheo-innominate fistula. Overinflate the cuff, apply pressure and call surgery now
- Bilateral infiltrates, falling Hb, vasculitis, SLE or anti-GBM disease: suspect diffuse alveolar haemorrhage. Needs immunosuppression, not embolisation
- Children: use a paediatric pathway and paediatric teams
03Decision Major (life-threatening) haemoptysis?
Yes if there is risk of asphyxia, poor gas exchange or haemodynamic instability, at any volume. Guide only: more than 100 mL/h or 500 mL/24 h. With poor lung reserve, 50 mL can be life-threatening.
- If Yes
04Warning Major: airway first
Death is usually from asphyxia, not blood loss. A small volume of blood can flood the airways. Possible TB: staff wear P2/N95 masks (airborne precautions) for intubation and bronchoscopy.
- Bleeding side down (lateral decubitus) if the side is known
- Call anaesthesia/ICU, respiratory, interventional radiology and thoracic surgery now. None on site: arrange early transfer once the airway is safe
- Prepare for intubation: ETT 8.0 mm or larger, suction, bronchoscope
05Action Major: resuscitate and correct bleeding risk
Manage in ICU or resuscitation area.
- High-flow oxygen; 2 large-bore IV lines; crossmatch, FBC, coagulation, blood gas. Shock or heavy ongoing bleeding: activate the major haemorrhage protocol
- Stop anticoagulants and antiplatelets. Reverse: warfarin - vitamin K + PCC; dabigatran - idarucizumab; factor Xa inhibitor - haematology advice
- Mechanical heart valve, coronary stent in the last 12 months or recent VTE: high clot risk. Still hold the drug; decide reversal, bridging and restart with haematology and cardiology
- Consider tranexamic acid (adult) as a bridge: 500 mg IV slowly or nebulised, 8-hourly. Not studied in major haemoptysis. Not in active thrombosis; reduce dose in renal impairment
06Decision Needs intubation?
Yes if hypoxic despite oxygen, cannot clear blood, exhausted, reduced consciousness, or major bleeding continues.
- If Yes
07Action Needs intubation: secure the airway
Most experienced operator. Single-lumen ETT 8.0 mm ID or larger (8.5 mm or larger is ideal) to pass a therapeutic bronchoscope.
- Check tube position and clear blood with a flexible bronchoscope
- Bleeding continues: isolate the lung. Advance the ETT into the non-bleeding main bronchus, or place a bronchial blocker
- Right main bronchus intubation can block the right upper lobe
- Double-lumen tube only by an experienced operator: small lumens block with clot
08Action Localise the bleeding source
Stable enough for CT: CT angiography chest first. Too unstable for CT: bedside bronchoscopy.
- CTA (bronchial and pulmonary arterial phases): shows side, cause and target arteries; guides embolisation
- Bronchoscopy: shows the side, clears the airway, allows temporising treatment
- CXR can show the side but misses the site in about half
09Action If bleeding continues at bronchoscopy: temporise
These are a bridge to embolisation or surgery. Bleeding often recurs with these alone. Laser, APC or electrocautery: FiO2 0.4 or less (airway fire).
- Cold (4 °C) saline lavage in 50 mL aliquots
- Topical adrenaline, dilute (for example 1:100,000 = 10 microgram/mL) in 2 mL aliquots; max 0.6 mg total. Cardiac monitor; caution in coronary disease or arrhythmia
- Balloon tamponade or bronchial blocker to isolate the bleeding segment
- Oxidised regenerated cellulose or fibrinogen-thrombin if other measures fail
- Visible lesion: laser, APC or electrocautery (FiO2 0.4 or less)
- Rigid bronchoscopy, if available, clears large clots better
10Decision Source on CTA or angiography?
Most major haemoptysis (about 90%) is from bronchial arteries; about 5% from pulmonary arteries; about 5% from the aorta or non-bronchial systemic arteries.
- Bronchial or systemic artery
11Action Bronchial or systemic artery source: embolise (BAE)
First-line definitive treatment. Experienced interventional radiologist only. Not for pulmonary artery or aortic sources. Pregnancy, contrast allergy, severe coagulopathy or organ failure: relative contraindications; decide with IR.
- Superselective microcatheter. Do not embolise a vessel that supplies the spinal cord, heart or brain (paraplegia risk 0.6-4.4%)
- Embolise all abnormal bronchial and non-bronchial systemic arteries
- Agents: PVA particles 150-710 µm or microspheres 300-900 µm; no particles smaller than 150 µm; gelatin sponge only as an adjunct. NBCA glue for massive or refractory bleeding, highly experienced operators only
- Avoid routine coils in bronchial arteries: they block repeat access
- Recurrence 10-57%; repeat BAE is possible
12Decision Bleeding controlled?
After embolisation or other treatment.
- If Yes
13Action Bleeding controlled: ICU care and follow-up
Monitor for rebleeding. Early rebleeding usually means a missed or incompletely treated artery.
- ICU monitoring; after BAE check leg power and sensation (spinal cord ischaemia)
- Treat the cause: TB treatment, antibiotics, antifungals
- Aspergilloma: usually rebleeds unless resected; consider elective resection. Cystic fibrosis (rebleeding 30-40%) or TB: high rebleeding risk; plan with the specialist team; repeat BAE if needed
- Follow-up after BAE at 1, 3, 6 and 12 months
- Restart of antithrombotics: team decision
14Action Treat the underlying cause
Every patient needs a cause and a follow-up plan.
- Bronchiectasis: airway clearance; treat infection
- TB: treat with the TB service; notify public health
- Suspected cancer: lung cancer MDT referral
- Aspergilloma: consider resection
- No cause found: follow up; some patients develop lung cancer later
15Outcome Follow-up arranged
Respiratory follow-up. Return at once if bleeding recurs.
If No16Action Not controlled: repeat angiography or surgery
Thoracic surgery review. Emergency lung resection has high mortality (about 35-40%).
- Repeat angiography: look for missed bronchial, non-bronchial systemic or pulmonary artery sources
- Surgery (lobectomy or pneumonectomy) if disease is localised and lung reserve is adequate
- Resection after bleeding is controlled has lower mortality (0-4% vs 35% emergency)
- Surgery is preferred for iatrogenic PA rupture, chest trauma, and aspergilloma not controlled by other treatment
- Path rejoins step 13Shared downstream outcome
- Pulmonary artery
17Action Pulmonary artery source: PA embolisation
Rasmussen aneurysm, PA pseudoaneurysm or PA catheter injury. BAE does not treat these.
- Pulmonary angiography; occlude with coils, plugs or glue; stent graft in selected cases
- Iatrogenic PA rupture or chest trauma: call thoracic surgery now; surgery is often needed
- Path rejoins step 12Shared downstream outcome
- Aortic
18Action Aortic source: emergency vascular or cardiothoracic surgery
Aortobronchial fistula or ruptured thoracic aortic aneurysm (often after aortic graft or stent). Not for BAE.
- Call vascular and cardiothoracic surgery now
- Open repair or endovascular stent graft
- Path rejoins step 13Shared downstream outcome
- No clear source
19Action No clear source: angiography
Search all systemic arteries before you give up.
- Bronchial and non-bronchial systemic angiography; embolise abnormal arteries
- Negative: pulmonary angiography
- Bronchoscopy if not yet done
- Path rejoins step 12Shared downstream outcome
- Diffuse alveolar haemorrhage
20Outcome Diffuse alveolar haemorrhage: not for BAE
Diffuse bilateral bleeding (vasculitis, anti-GBM disease, SLE). Urgent ICU, renal and rheumatology care. Immunosuppression; plasma exchange in anti-GBM disease.
If No- Path rejoins step 08Shared downstream outcome
If No21Action Not major: find the cause
Admit if bleeding continues, oxygen falls or risk is high. If signs of major haemoptysis appear, go to the major pathway.
- CXR first
- Persistent or unexplained haemoptysis: urgent contrast CT chest and referral to a lung cancer MDT specialist within 2 weeks, even if CXR is normal
- Possible TB: airborne isolation and sputum TB tests
- Review anticoagulants and antiplatelets
- Admitted with ongoing bleeding (adult): consider tranexamic acid 500 mg nebulised or IV, 8-hourly. Not in active thrombosis; reduce dose in renal impairment
- CT not diagnostic and cancer risk high: bronchoscopy
- Path rejoins step 14Shared downstream outcome
Guideline Source
Management of life-threatening hemoptysis (Kathuria et al., J Intensive Care 2020); no formal society guideline exists
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. No formal society guideline: based on reviews (Kathuria 2020, Radchenko 2017, Charya 2021) and the CCI 2025 BAE consensus
- Tranexamic acid trials are in non-major haemoptysis; use in major haemoptysis is a bridge only
- Needs rapid access to interventional radiology, bronchoscopy and thoracic surgery; transfer early if not available
- Does not cover diffuse alveolar haemorrhage or tracheostomy bleeding in detail
Contraindicated Populations
ChildrenBleeding from a tracheostomy (possible tracheo-innominate fistula)Diffuse alveolar haemorrhage (not for BAE)
Applicable Regions
GlobalAU
AU: Persistent or unexplained haemoptysis: urgent CT chest and lung cancer MDT referral within 2 weeks (Optimal care pathway for lung cancer, 2nd ed). Warfarin reversal: 4-factor PCC (Beriplex) is replacing Prothrombinex-VF, with vitamin K. Andexanet is not on the ARTG. TB is notifiable; involve the state TB service.
Global: Interventional radiology and thoracic surgery availability varies; transfer early.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Haemoptysis: Major (Massive) Haemoptysis Management?
The Haemoptysis: Major (Massive) Haemoptysis Management is a emergency clinical algorithm for Pulmonary Medicine. It provides a structured decision tree to guide clinical decision-making, based on Management of life-threatening hemoptysis (Kathuria et al., J Intensive Care 2020); no formal society guideline exists.
What guideline is the Haemoptysis: Major (Massive) Haemoptysis Management based on?
This algorithm is based on Management of life-threatening hemoptysis (Kathuria et al., J Intensive Care 2020); no formal society guideline exists (DOI: 10.1186/s40560-020-00441-8).
What are the limitations of the Haemoptysis: Major (Massive) Haemoptysis Management?
Known limitations include: Adults only. No formal society guideline: based on reviews (Kathuria 2020, Radchenko 2017, Charya 2021) and the CCI 2025 BAE consensus; Tranexamic acid trials are in non-major haemoptysis; use in major haemoptysis is a bridge only; Needs rapid access to interventional radiology, bronchoscopy and thoracic surgery; transfer early if not available; Does not cover diffuse alveolar haemorrhage or tracheostomy bleeding in detail. Individual patient factors may require deviation from these recommendations.
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