Massive Hemoptysis
>100-200 mL/24h OR any amount causing hemodynamic/respiratory compromise
All Pathways
Cardiothoracic SurgeryEmergency
Massive Hemoptysis Management (CCI/EMCrit 2025)
Massive Hemoptysis Management (CCI/EMCrit 2025): Massive Hemoptysis → ⚠️ AIRWAY IS PRIORITY #1 → Immediate Actions → Intubation Needed? → Airway Managem...
Pathway Overview
12 steps
Algorithm Steps
12 total
01Start 02Warning ⚠️ 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
03Action 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
04Decision Intubation Needed?
Respiratory failure, hemodynamic instability, or massive ongoing bleeding
05Action 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
06Action 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
07Action 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
08Decision Definitive Therapy Selection
Based on stability and anatomy
09Action 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
10Action 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
11Outcome Bleeding Controlled
Continue disease-specific therapy
12Action 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%)
- Path rejoins step 10Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 06Shared downstream outcome
Guideline Source
CCI 2025 Consensus on Bronchial Artery Embolization for Hemoptysis
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Definition of 'massive' varies (100-600+ mL/24h in literature)
- BAE success rates vary by etiology and center experience
- Requires interventional radiology and thoracic surgery availability
- Spinal cord ischemia risk with BAE (1-6%)
- Recurrence rates 10-30% after BAE
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Massive Hemoptysis Management (CCI/EMCrit 2025)?
The Massive Hemoptysis Management (CCI/EMCrit 2025) is a emergency clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on CCI 2025 Consensus on Bronchial Artery Embolization for Hemoptysis.
What guideline is the Massive Hemoptysis Management (CCI/EMCrit 2025) based on?
This algorithm is based on CCI 2025 Consensus on Bronchial Artery Embolization for Hemoptysis (DOI: CCI-2025-BAE-Consensus).
What are the limitations of the Massive Hemoptysis Management (CCI/EMCrit 2025)?
Known limitations include: Definition of 'massive' varies (100-600+ mL/24h in literature); BAE success rates vary by etiology and center experience; Requires interventional radiology and thoracic surgery availability; Spinal cord ischemia risk with BAE (1-6%); Recurrence rates 10-30% after BAE. Individual patient factors may require deviation from these recommendations.
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