Practical Management of Acute Hemoptysis

Disclaimer: there is little high-quality evidence on the ED management of hemoptysis, particularly non-massive hemoptysis. The recommendations made below are heavily influenced by published case reports and expert opinion, as well as discussions with local specialty services.

Hemoptysis refers to the expectoration of blood originating from the lower respiratory tract. Patients presenting to the emergency department (ED) with hemoptysis can range from those with a benign, self-limited cough to those with life-threatening airway compromise.

Classification of Hemoptysis Severity

The severity of hemoptysis is critical to guide management:

• Scant/Mild Hemoptysis: <1 tablespoon (<15 mL) of blood in 24 hours.

• Non-Massive Hemoptysis: >1 tablespoon of blood in 24 hours without risk of airway compromise or hemodynamic instability.

• Massive Hemoptysis: Any volume that risks airway compromise or hemodynamic instability.

Note: Definitions vary by source, but these are commonly used in practice by Respirology at our centre.

Common Causes of Hemoptysis:

The differential diagnosis for hemoptysis is broad, but key etiologies include:

• Infectious: Bronchitis, bronchiectasis, tuberculosis, fungal infections (e.g., aspergillosis), necrotizing pneumonia

• Malignancy

• Autoimmune: Goodpasture’s syndrome, lupus, granulomatosis with polyangiitis, Behcet’s disease

• Structural: Pulmonary embolism, trauma, foreign body, AVMs, fistulas

• Cardiovascular: Mitral stenosis, severe left heart failure, pulmonary hypertension

• Coagulopathy

Bottom Line: Definitive management depends on addressing the underlying cause of hemoptysis.

Approach to Non-Massive Hemoptysis

Case 1: Scant Hemoptysis

A healthy 31-year-old female with a respiratory infection develops mild hemoptysis. She is well-appearing with minimal or resolved bleeding.

Key Points:

• Tailor investigations for hemoptysis to the suspected underlying cause.

• All patients with hemoptysis should have a chest X-ray (CXR).

• Low-risk patients with a likely cause and a normal CXR can be safely discharged without specialist referral.

• If there is significant comorbidity (e.g., COPD, ILD, cystic fibrosis) or no identifiable cause, consider Respirology follow-up—these patients may benefit from outpatient bronchoscopy.

Case 2: Ongoing Non-Massive Hemoptysis

56-year-old male with COPD presents with ongoing hemoptysis and normal vitals.

Key Points:

• Further investigations (CT chest) should be considered if CXR is non-diagnostic or symptoms persist.

• High-resolution CT with contrast is preferred. If pulmonary embolism (PE) is a concern, consider CTPA.

• Disposition is individualized; consult Respirology for patients with ongoing symptoms to consider admission or expedited outpatient follow-up.

Red Flags Requiring ED Respirology Consult & Admission

• Cavitary lesions (e.g., TB, non-tuberculous mycobacteria, fungal)

• Necrotizing pneumonia

• Diffuse alveolar hemorrhage

• Known autoimmune or vasculitis with new findings on imaging

Massive Hemoptysis

Case 3: Massive Hemoptysis in the Alert Patient

65yo M, hx lung cancer on active therapy, with acute onset large volume hemoptysis. Bleeding copiously on assessment with hemodynamic instability, but is alert, responsive, and coughing up blood.

Airway Management: the most critical aspect of ED management of massive hemoptysis as these patients will asphyxiate long before they exsanguinate.

• Key point: in patients with massive hemoptysis who are alert and have an intact cough, do NOT intubate.
  • Bleeding is coming from the airways itself, so standard intubation will NOT protect the airway like it will from other sources of bleeding.
  • The cough reflex is far superior at clearing the airway than any other intervention that we have.
  • Intubation is only indicated in a forced-to-act situation (more on this below).
• Keep the patient upright, apply supplemental O2, provide patient with large bore suction for them to use, and closely monitor.

TXA

• Evidence for TXA particularly in massive hemoptysis is sparse – massive hemoptysis is often an exclusion criterion for most studies examining the benefit of TXA in hemoptysis.
• In non-massive hemoptysis:
  • TXA (nebulized or IV) has shown benefit compared to placebo.
  • Nebulized TXA has shown a small increased benefit compared to IV TXA.
• Based on conversation with local experts, I recommend administering both TXA 2g IV AND 500mg nebulized in massive hemoptysis.

Definitive Management

• Definitive management will depend on the source of bleeding. Potential options include
  • Rigid bronchoscopy for proximal airway bleeds
  • Interventional Radiology for ablation of specific vessels
  • Open surgical resection of large bleeding pulmonary lesion
  • Local radiation therapy for malignancy-related bleeding
• Consulting pathways will differ by centre, but call relevant consultants early. CT imaging is typically NOT required in massive hemoptysis prior to consultation.
  • At The Ottawa Hospital, all acute life-threatening hemoptysis goes through Thoracic Surgery first for initial stabilization by rigid bronchoscopy in the OR. The patient can then be referred to another service if other definitive care is needed.

Case 4: Massive Hemoptysis in the Altered Patient

65yo M, hx lung cancer on active therapy, with acute onset large volume hemoptysis. Bleeding copiously on assessment with hemodynamic instability, and is altered, somnolent, and has a weak cough.

• Role of TXA and definitive management principles apply the same as in the previous case.

Airway Management

• Features necessitating intubation and lung isolation in massive hemoptysis include:
  • Decreased LOC
  • Weak or absent cough
  • Difficulty managing secretions
  • Persistent hypoxia
• Try to determine laterality of bleeding prior to intubation: can be achieved by auscultation, portable CXR for unilateral opacification, or POCUS for unilateral B-lines.

• Recognize the soiled and physiologically challenging airway:
  • Keep patient upright for as long as possible
  • Maximize pre-oxygenation
  • Consider double setup with surgical airway kit ready, and neck prepped and landmarked
  • Consider STAT call to Anesthesiology
  • SALAD technique should be considered first-line approach. May convert to SAACI technique as second-line.

• Isolate the non-bleeding side with a mainstem intubation: isolates the “good” lung to minimize contamination from the bleeding side.
  • Recommended technique:
    • Pass bougie through the vocal cords with tip pointed anteriorly.
    • Once past the cords with the bougie:
      • For R mainstem intubation, rotate bougie 90d CLOCKWISE (tip pointing to the R) and advance until you feel hang up.
      • For L mainstem intubation, rotate bougie 90d COUNTERCLOCKWISE (tip pointing to the L) and advance until you feel hang up.
    • Thread ETT over bougie and advance deep into the airway.
    • Inflate cuff and confirm position with xray
  • Double-lumen ETTs may be considered for lung isolation if the.re is a provider with significant experience in placing them present at the bedside.
    • Evidence is lacking regarding the use of double-lumen ETT in the ED.
    • Correct placement of double-lumen ETTs is challenging even in the hands of experienced providers.
  • Wedge patient with non-bleeding side elevated slightly after intubation: reduces contamination of the “good” lung.

Summary: Hemoptysis in the ED

• Hemoptysis requires a systematic approach—focus on identifying and treating the underlying cause.

• Always assess the potential for airway compromise or hemodynamic instability.

• Massive hemoptysis is an airway emergency—prioritize airway protection and early specialist consultation.

• For ongoing non-massive hemoptysis or red flag findings, involve Respirology early.

• TXA may be helpful as adjunct therapy in both massive and non-massive hemoptysis.

• Ensure appropriate follow-up or admission as indicated.