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Rapid overview: Initial evaluation and management of life-threatening hemoptysis

Rapid overview: Initial evaluation and management of life-threatening hemoptysis
Clinical features
"Life-threatening hemoptysis" refers to hemoptysis that results in significant airway obstruction, abnormal gas exchange, or hemodynamic instability. Approximate volumes of blood associated with life-threatening hemoptysis: 150 mL (about half a cup) in 24 hours or a bleeding rate of 100 mL/hour.
Common causes: Bronchiectasis (includes cystic fibrosis), bronchogenic neoplasms, tuberculosis, fungal infections (eg, aspergilloma)*.
Initial evaluation and management – will often need to occur concurrently:
All patients with life-threatening hemoptysis should be admitted to the ICU
Directed history: Timing and amount of hemoptysis, fever, chills, purulent sputum, risk factors for tuberculosis and cancer, weight loss, use of anticoagulant or antiplatelet medications, bleeding from other sites, vaping, travel history regarding parasite exposure, family history of blood clots or bleeding (eg, hereditary hemorrhagic telangiectasia). Secure airway, breathing, and circulation:
  • Intubate if clinically indicated (refer below)
  • Monitor of oxygen saturation, blood pressure, heart rate, ECG, respiratory rate
  • Quantitate hemoptysis
  • Administer crystalloid intravenous fluids for hypotension
Directed physical exam: Assess degree of respiratory distress, look for telangiectasias, bruising. Provide supplemental oxygen: Target a pulse oxygen saturation of 88 to 96% or PaO2 of 60 to 70 mmHg (7.98 to 9.31 kPa).
Laboratory: Complete blood count, differential, INR, PTT, routine chemistries, type and cross match, D-dimer, sputum bacterial and mycobacterial stains and culture. Positioning: If the side of bleeding is known, position patient with bleeding side down (eg, right lateral decubitus for right lung bleeding).
Imaging: Obtain chest radiograph; while less sensitive than CT (with or without contrast) or bronchoscopy it can sometimes determine side/cause of bleeding.

If patient stabilizes, obtain chest computed tomography without contrast. 		Reverse bleeding disorders, if possible:
  • Fresh frozen plasma to reverse warfarin
  • Specific reversal agent for DOACs
  • Platelet transfusion for <50 × 103 platelets/microL or for platelet defects due to uremia or antiplatelet agents (eg, aspirin, clopidogrel)
  • Desmopressin for platelet dysfunction for uremia or aspirin use
Flexible bronchoscopy: Expertise required. Can be performed bedside in an unstable patient. Bronchoscopy is helpful diagnostically and can be combined with local therapies to temporize the bleeding (eg, iced saline, local vasoconstrictors, bronchial blocker/balloon).
Surgical consultation: Assess possible need for urgent surgery (eg, hemoptysis that is due to trauma, iatrogenic rupture of the pulmonary artery, tracheoinnominate artery fistula).
Interventional radiology consultation: Consider possible pulmonary angiogram and embolization in patients with ongoing active bleeding (eg, hemoptysis due to AVMs, bronchiectasis, cavitary lesions).
Tracheal intubation and mechanical ventilation: Indicated for patients with impending or actual acute respiratory failure, hemodynamic instability, depressed mental status, or need for airway protection
Rapid sequence induction (eg, etomidate, ketamine, or PropofolΔ).
Intubate with #8 endotracheal tube (8 mm internal diameter) or larger, if possible.
  • In general, position endotracheal tube in the trachea. For patients with rapid bleeding from one side, the endotracheal tube may be positioned to isolate the bleeding lung. For left sided bleeding, the tip of the endotracheal tube can be inserted into the right mainstem bronchus, being careful not to obstruct the right upper lobe; for right sided bleeding, the tip of the endotracheal tube can be positioned in the left mainstem bronchus.
  • Placement of a double-lumen tube requires specialized training and is usually not necessary.
Initial ventilator settings: CMV or AC, tidal volume 6 to 8 mL/kg predicted body weight, respiratory rate 10 to 12/minute, inspiratory flow rate 60 L/min (increase if needed to enable longer expiratory phase), PEEP 5 cm H2O. Titrate O2 to target SpO2 ≥88 to 92% or PaO2 60 to 70 mmHg. Adjust per ABGs.
Single lung ventilation: If using single lung ventilation to isolate bleeding lung, use tidal volume 4 to 6 mL/kg and adjust per ABGs.
Supportive therapies
Antibiotics: Antibiotic therapy for patients with acute bronchitis, pneumonia, or exacerbations of bronchiectasis.
Bronchodilators: Inhaled bronchodilator therapy for patients with COPD or asthma.
Vasopressors: Vasopressors for hypotension that is refractory to volume resuscitation.
Experimental therapy: Inhaled recombinant factor VIIa (off-label tranexamic acid is generally, only used if other initial therapies have failed).
Transfusion of packed red cells: Rarely required.

ICU: intensive care unit; ECG: electrocardiogram; PaO2: arterial oxygen tension; INR: international normalized ratio; PTT: partial thromboplastin time; CT: computed tomography; DOAC: direct oral anticoagulant; AVM: arteriovenous malformation; CMV: continuous mandatory ventilation; AC: assist-control ventilation; PEEP: positive end-expiratory pressure; SpO2: oxygen saturation; ABG: arterial blood gas; COPD: chronic obstructive pulmonary disease.
* Refer to UpToDate content for more complete listing of causes of hemoptysis.
¶ Refer to UpToDate content for information about specific reversal agents for DOACs.
Δ Propofol may not be suitable for patients with hemodynamic instability due to further worsening of hypotension.

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