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 The definition of massive hemoptysis varies from 100 to 1000 mL over a 24-hour period; the intent of this quantification being the identification of patients needing immediate intervention. 

 However, the urgency of intervention depends on several factors, including the overall functional status of patients, rapidity of bleeding over shorter intervals of time, cause of the disease, and available treatment options.

Therefore, investigators have proposed alternative definitions of life-threatening hemoptysis based on the magnitude of the functional effects of the hemoptysis rather than just the measurement of the same. 

Some criteria suggested for such definitions include the need for hospitalization, transfusion, intubation, hypoxemia, and hypotension. 

These criteria have been at least partly motivated by the practical problem of unreliable patient measurements of hemoptysis.

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[Delayed surgery after stabilization leads to the best surgical results.]

• 2
  • Need for endotracheal intubation
    • decision should be based on clinical judgment
    • generally considered for
      • inability to protect airway
      • inability to maintain adequate oxygenation (defined as arterial oxygen saturation ≥ 90%) despite use of supplemental oxygen
      • inadequate spontaneous ventilation despite maximal noninvasive support
  • see also Hemorrhagic shock
  • place patient in lateral decubitus with bleeding site down if source of bleeding known
    2
• admit to intensive care unit for continued assessment and management, including
  2
  • if hemodynamic or respiratory compromise
    2
    • rapid intubation with rigid bronchoscope for airway clearance, bleeding tamponade, and contralateral lung isolation
    • if no rigid bronchoscope treatment available
      • intubate with large-caliber endotracheal tube (≥ size 8) and use fiberoptic bronchoscope for airway clearance
      • consider tracheal unilateral intubation with balloon catheter insertion to protect nonbleeding lung from aspiration
    • correction of coagulopathy if present
    • bedside chest x-ray to possibly identify bleeding site
  • if no acute respiratory failure
    2
    • immediate measures
      • history and physical if possible to help rule out nonpulmonary causes of bleeding, such as epistaxis and hematemesis
      • initial chest x-ray to attempt to localize bleeding side or site
      • rigid bronchoscopy for rapid tamponade of bleeding lobar bronchus (flexible bronchoscopy is alternative)
    • if possible bleeding site identified on chest x-ray
      • for endobronchial lesion
        • for control of bleeding, consider
          • cold saline
          • epinephrine
          • antidiuretic hormone analogues
          • endobronchial stent tamponade
          • laser, electrocautery, or argon plasma coagulation for visible lesions
        • if not successful, perform emergency bronchial arterial embolization (BAE)
      • if no endoluminal lesion
        • for control of bleeding, consider
          • balloon tamponade
          • endobronchial spigot
          • oxidized regenerated cellulose mesh
          • biocompatible glue
          • fibrinogen-thrombin
          • tranexamic acid
        • if successful, most often bridge to BAE or surgery
    • if no possible bleeding site identified on chest x-ray, perform computed tomography (CT) and/or multidetector CT angiography to identify site and cause of bleeding
    • if bleeding localized on CT, perform BAE to control bleeding
      • if successful but multiple recurrences occur, perform surgery
      • if unsuccessful, perform surgery
    • if bleeding not localized on CT, manage conservatively and monitor closely
• order of investigations and interventions, for example flexible fiber-optic bronchoscope and BAE, may vary by healthcare center and available options

• chest x-ray
  1
  ,
  2
  • initial imaging modality in most cases, but may have limited utility for massive hemoptysis (opacities may represent preexisting lesions, aspirated gastrointestinal, or upper airway blood and may not represent blood originating in lung)
  • reportedly may identify site of bleeding in 33%-82% and identify underlying cause in 35%
  • helps lateralize bleeding and detects focal vs. diffuse involvement
  • may help identify underlying parenchymal and pleural abnormalities, such as
    • masses
    • pneumonia
    • chronic lung disease
    • atelectasis
    • cavitary lesion
    • alveolar opacities due to alveolar hemorrhage
  • may be useful to help guide approach to bronchial artery embolization and avoid unnecessary bronchoscopy
• normal findings on chest x-ray
  • should prompt additional diagnostic studies, such as bronchoscopy and/or multidetector computed tomography angiography (MDCTA)
    1
  • may suggest bronchiectasis as cause of bleeding
    2
    • among 10 patients with normal chest x-ray, 7 had bronchiectasis in retrospective cohort study of 80 patients with large or massive hemoptysis (AJR Am J Roentgenol 2002 Nov;179(5):1217)
• American College of Radiology (ACR) considers chest x-ray usually appropriate as initial evaluation for patients with massive hemoptysis without cardiopulmonary compromise (J Thorac Imaging 2014 May;29(3):W19)
• STUDY SUMMARY

  chest x-ray may help identify site but may have limited utility for identifying both site and cause of bleeding compared to CT in patients with massive hemoptysis
  COHORT STUDY: AJR Am J Roentgenol 2002 Nov;179(5):1217

  Details

• CT may be useful for identifying site of bleeding and underlying etiologies
  2
  • for site of bleeding
    • reported accuracy 70%-88.5%
    • reported to be superior to chest x-ray and comparable to bronchoscopy
  • for underlying etiologies
    • reported accuracy 66%-77%
    • reported to be superior to chest x-ray and bronchoscopy
  • may also detect extrapulmonary causes of hemoptysis, such as false aortic aneurysms
  • can replace or complement bronchoscopy
  • may be useful to help guide approach to bronchial artery embolization and avoid unnecessary bronchoscopy
• multidetector CT (MDCT)
  2
  • may help delineate bronchial and nonbronchial systemic arteries
  • findings suggestive of bleeding from nonbronchial systemic artery
    • pleural thickness ≥ 3 mm near parenchymal opacity
    • enhancing vessels within extrapleural fat layer
  • reported to identify 63%-100% of bleeding sites
  • reported to be superior to bronchoscope at identifying underlying cause of bleeding and capable of identifying abnormalities beyond level of bronchoscope
  • IV contrast may be used for optimal enhancement
  • may be limited in identifying
    • endobronchial blood clots, which may mimic appearance of tumors
    • endobronchial processes obscured by acute bleeding filling bronchial lumen
  • combined use of MDCT and bronchoscopy may be preferable
• American College of Radiology (ACR) appropriateness criteria for patients with massive hemoptysis without cardiopulmonary compromise
  • CT without IV contrast may be appropriate and should be considered for patients
    • with chest x-ray findings suggestive of malignancy and with high risk of malignancy
    • with negative or unremarkable chest x-ray and risk factors, such as age > 40 years or with > 30-pack-year smoking history
  • Reference - J Thorac Imaging 2014 May;29(3):W19
• STUDY SUMMARY

  CT may have higher rate of identifying cause of bleeding, but similar rate of identifying site of bleeding, compared to bronchoscopy in patients with massive hemoptysis
  COHORT STUDY: AJR Am J Roentgenol 2002 Nov;179(5):1217

  Details
• STUDY SUMMARY

  CT has moderate performance for detecting nonbronchial systemic arterial source of bleeding in patients with massive hemoptysis 

  DynaMed Level1
  DIAGNOSTIC COHORT STUDY: Radiology 2003 Apr;227(1):232

  Details

• multidetector CT angiography (MDCTA)
  1
  ,
  2
  • may help
    • provide comprehensive evaluation of lung parenchyma, airways, and thoracic vessels
    • guide approach to angiography by obtaining detailed image of thoracic vasculature
  • alternative approaches (such as bronchoscopy) should be considered for
    • unstable patients
    • patients with active bleeding requiring endobronchial management
    • patients with bilateral lung abnormalities that may obscure imaging
  • vessel assessment should include
    • bronchial and nonbronchial arteries
    • pulmonary circulation
  • findings suggestive of specific bleeding sites
    • pulmonary hemorrhage
      • focal or diffuse hazy consolidation or ground-glass opacity
      • thickened interlobular septa superimposed on background of ground-glass attenuation ("crazy paving" pattern)
    • bleeding from bronchial arteries
      • orthotopic on axial images
        • clusters of enhancing nodules or lines in mediastinum
        • at level of or below aortic arch
        • often connected to descending aorta
      • abnormal diameter (> 2 mm)
      • traceable (visible from origins to hilum)
    • bleeding from nonbronchial systemic artery
      • enlarged vascular structures within extrapleural fat plus pleural thickening (≥ 3 mm) and abnormal lung parenchyma
      • unparalleled route to bronchi
    • bleeding from pulmonary artery
      • pulmonary artery pseudoaneurysm
      • aneurysm or presence of pulmonary artery in inner wall of cavitary lesion
    • pseudoaneurysm, brightly enhanced nodule within a lesion
• American College of Radiology (ACR) appropriateness criteria for patients with massive hemoptysis without cardiopulmonary compromise
  • CT angiography with contrast usually appropriate
  • Reference - J Thorac Imaging 2014 May;29(3):W19
• STUDY SUMMARY

  MDCT angiography prior to endovascular treatment may reduce failure of endovascular treatment in elderly patients and reduce emergent surgical resection and number of diagnostic procedures compared to single-detector CT in patients with hemoptysis 

  DynaMed Level2
  COHORT STUDY: AJR Am J Roentgenol 2010 Sep;195(3):772

  Details

• digital subtraction angiography (DSA)
  1
  • reported to have limited role in evaluation of hemoptysis
  • commonly reserved for patients who have already had endovascular treatment and other diagnostic evaluation
• American College of Radiology (ACR) appropriateness criteria for patients with massive hemoptysis without cardiopulmonary compromise
  • bronchial arteriography with or without embolization usually appropriate
  • pulmonary arteriography may be appropriate
  • Reference - J Thorac Imaging 2014 May;29(3):W19

• bronchoscopy considered primary method for identifying site of bleeding, examining airways, and for definitive or initial bleeding control
  1
  ,
  2
  • may be preferred approach for initial evaluation and bleeding control over computed tomography (CT) prior to definitive treatment for
    • unstable patients
    • patients with active bleeding requiring endobronchial management
    • patients with bilateral lung abnormalities where radiography may be challenging
  • for identifying site (or side) and/or cause of bleeding
    • reported to identify site of bleeding in 73%-93% of episodes, depending on rate and severity of bleeding
    • reported to have lower sensitivity for identifying cause compared to multidetector computed tomography
  • performed with rigid or flexible endoscope
    • rigid endoscope (size 8 or larger) preferable
      • to maintain airway patency
      • to preserve ventilation and preventing asphyxia
      • for better visualization of airways
      • for effective tamponade of accessible bleeding sites
      • to allow isolation of nonaffected lung
      • for suctioning blood clots and secretions
    • flexible bronchoscopy
      • preferable for convenience (bedside evaluation)
      • has limited use in massive, life-threatening hemoptysis
      • may be used to suction blood clots and secretions
  • useful for obtaining additional information on endobronchial lesions and sampling tissue for diagnosis or microbial cultures
  • adverse effects include bronchial mucosa irritation and recurrent bleeding
  • therapeutic adjuncts to bronchoscopy to assist with bleeding control include
    • lavage with cold saline (4 degrees Celsius [39.2 degrees Fahrenheit]) solution at level of bleeding source
    • balloon inflation or laser/plasma coagulation
    • tranexamic acid (oral, IV, or topical application), fibrinogen/thrombin
    • endobronchial stent tamponade
    • endobronchial airway blockade using silicone spigot, oxidized regenerated cellulose mesh, or biocompatible glue
    • electrocautery, cryotherapy, or brachytherapy
• see also endobronchial ablative therapies for efficacy on bleeding control
• STUDY SUMMARY

  bronchoscopy may be useful for identifying site of bleeding, but not cause of bleeding, in patients with massive hemoptysis
  COHORT STUDY: AJR Am J Roentgenol 2002 Nov;179(5):1217

  Details
• STUDY SUMMARY

  bronchoscopy may not be necessary for identifying bleeding site if previously identified on CT or chest x-ray and bronchoscopic treatment not needed in patients with massive hemoptysis
  COHORT STUDY: AJR Am J Roentgenol 2001 Oct;177(4):861

  Details

• endovascular embolization may be performed as definitive treatment or as bridge to surgery and may be used to treat recurrent hemoptysis
  1
• bronchial artery embolization (BAE) is most common endovascular procedure performed for patients with massive hemoptysis
  1
  ,
  2
  • bleeding reported to originate from bronchial arteries in > 90% of patients
  • BAE reported to promptly stop bleeding in 57%-100% of patients
  • recurrence within 1 month reported in 10%-29% of patients
  • recurrence may be due to
    • incomplete embolization of bronchial vessels
    • recanalization of embolized arteries
    • presence of nonbronchial systemic arteries
    • development of collateral circulation in response to continuing pulmonary inflammation
    • bleeding of pulmonary artery origin
• nonbronchial systemic arteries and pulmonary arteries may also be targeted for embolization
  1
• procedural-related complications rare (< 5%) but may include
  2
  • transient fever and chest pain
  • transient dysphagia
  • transient or permanent neurological deficits
  • groin hematoma
  • subintimal dissection or perforation of arteries by guidewire
  • spinal artery embolization (Pol J Radiol 2016;81:382)
• emergency transcatheter arterial embolization reported to be successful after first procedure for hemostasis in 86% of 148 patients with massive hemoptysis due to pulmonary tuberculosis in case series (Cell Biochem Biophys 2015 Jan;71(1):179)
• STUDY SUMMARY

  conservative approach including bronchial artery embolization as first-line therapy may reduce in-hospital mortality and postoperative complications compared to early surgery in patients with massive hemoptysis 

  DynaMed Level2
  BEFORE AND AFTER STUDY: Ann Thorac Surg 2009 Mar;87(3):849

  Details
• STUDY SUMMARY

  bronchial artery embolization reported to immediately control bleeding in patients with massive hemoptysis 

  DynaMed Level3
  CASE SERIES: Int Angiol 2008 Aug;27(4):319

  Details
• STUDY SUMMARY

  immediate hemoptysis control reported in 86% of patients following embolization, but patients with aspergilloma reported to have 100% recurrent bleeding and 50% mortality 

  DynaMed Level3
  CASE SERIES: Eur Radiol 2010 Mar;20(3):558

  Details

• minimally invasive procedures, such as endovascular embolization, preferred for most patients as surgery has reported 20%-30% morbidity and mortality rate
  1
• surgery may be treatment of choice in select patients, such as those with
  1
  ,
  2
  • chest trauma
  • iatrogenic pulmonary artery rupture
  • aspergilloma, following urgent bronchial artery embolization
  • diffuse and complex arteriovenous malformations
  • mycetoma not responding to other therapies
  • recurrent life-threatening hemoptysis
  • bronchovascular fistula
• surgery should be avoided in patients with
  2
  • poor functional status
  • moderate-to-severe lung function impairment
  • bilateral pulmonary disease
  • other comorbidities
• STUDY SUMMARY

  delaying surgery and using bronchial artery embolization as first-line treatment may reduce in-hospital mortality and postoperative complications in patients with massive hemoptysis 

  DynaMed Level2
  BEFORE AND AFTER STUDY: Ann Thorac Surg 2009 Mar;87(3):849

  Details