Massive Hemoptysis Management (CCI/EMCrit 2025)

Algorithm Steps

1. ▶

   Start

   Massive Hemoptysis

   >100-200 mL/24h OR any amount causing hemodynamic/respiratory compromise

   1. ⚠

      Warning

      ⚠️ AIRWAY IS PRIORITY #1

      Death is from asphyxiation, not exsanguination

      • Mortality >50% without intervention
      • 150 mL fills anatomic dead space
      • Patient drowns in their own blood
      1. ●

         Action

         Immediate Actions

         Stabilize and protect airway

         • BLEEDING LUNG DOWN (lateral decubitus)
         • High-flow O2, prepare for intubation
         • Large bore IV access, type & crossmatch
         • Hold anticoagulants/antiplatelets
         • Tranexamic acid 1g IV (consider)
         • Call: Pulmonology, IR, Thoracic Surgery
         1. ◆

            Decision

            Intubation Needed?

            Respiratory failure, hemodynamic instability, or massive ongoing bleeding

            1. ●

               Action

               Airway Management

               Intubate with largest ETT possible

               • ≥8.0 ETT to allow bronchoscopy
               • Consider mainstem intubation of non-bleeding lung
               • Double-lumen tube if experienced (lung isolation)
               • Bronchial blocker alternative
               • Suction frequently
               1. ●

                  Action

                  Localize Bleeding Source

                  Identify side and cause

                  • CXR: may show infiltrate on bleeding side
                  • CT Angiography (if stable): identifies source, anatomy
                  • Bronchoscopy: localizes to lobe/segment
                  • Common causes:
                  • • Bronchiectasis, TB, aspergilloma
                  • • Lung cancer, pulmonary artery erosion
                  • • AVM, trauma, iatrogenic
                  1. ●

                     Action

                     Bronchoscopy

                     Diagnostic and potentially therapeutic

                     • Flexible or rigid (rigid better for massive)
                     • Localize bleeding segment
                     • Therapeutic options:
                     • • Cold saline lavage
                     • • Topical epinephrine (1:20,000)
                     • • Endobronchial tamponade (balloon, blocker)
                     • • Laser/electrocautery if visible lesion
                     1. ◆

                        Decision

                        Definitive Therapy Selection

                        Based on stability and anatomy

                        1. ●

                           Action

                           Bronchial Artery Embolization (BAE)

                           First-line definitive therapy (Class I)

                           • ~90% of massive hemoptysis from bronchial arteries
                           • Initial success rate ~80%
                           • Super-selective catheterization recommended
                           • Embolic agents (CCI 2025):
                           • • PVA particles (most common)
                           • • Gelfoam (temporary)
                           • • NBCA/glue (massive/refractory cases)
                           • • Coils (larger vessels)
                           • ⚠️ Identify spinal artery before embolizing
                           1. ●

                              Action

                              Post-Procedure Management

                              Monitor and treat underlying cause

                              • ICU monitoring 24-48h
                              • Treat underlying disease (TB, infection)
                              • Recurrence rate 10-30% after BAE
                              • Repeat BAE possible if anatomy favorable
                              • Surgical consultation if recurrent
                              1. ✓

                                 Outcome

                                 Bleeding Controlled

                                 Continue disease-specific therapy

                           2. ●

                              Action

                              Surgical Resection

                              When BAE fails or not feasible

                              • INDICATIONS:
                              • • BAE failure or recurrence
                              • • Rasmussen aneurysm (PA erosion)
                              • • Lung cancer with hemorrhage
                              • • Aspergilloma (definitive cure)
                              • • Trauma with vascular injury
                              • Lobectomy or pneumonectomy
                              • High mortality in emergency setting (20-40%)