Managing Massive Hemoptysis

Written by Alex Chen

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Massive hemoptysis is a life-threatening emergency. Here are the top ten tips to give our patients the best shot at survival.

Why does this matter?
I am sure that everyone who reads this already knows the feeling you get when you see a patient with massive hemoptysis. It’s one of the leading causes of provider Code Browns in the world. Therefore, here are some tips from a couple of pulmonologists to guide you after you change scrubs.

Top Ten Ways to Help Massive Hemoptysis Patients

1. Always consider epistaxis and hematemesis as other sources of bleeding.

2. Up to 80% of malignancy-related massive hemoptysis have an episode of sentinel bleeding.

3. The lungs have a dual blood supply (pulmonary arteries and bronchial arteries) with ~90% of cases of massive hemoptysis stemming from the bronchial vasculature.

4. CT is very effective in localizing bleeding from the bronchial arteries; CXR is about 46%.

5. Put the bad lung down toward the bed.

6. Avoid nasotracheal intubation (tube doesn’t go as far and the size is usually smaller).

7. Use a single-lumen ETT ≥ 8.5mm (allows for some larger bronchoscopes); dual-channel may sound better but it is too small.

8. You should mainstem the good lung if you are able to lateralize it; however, be aware that the take off of the RUL is at high-risk of occlusion.

9. Management options include flexible bronchoscopy, rigid bronchoscopy, IR guided bronchial artery embolization (BAE), or surgery.

10. BAE has an initial success rate of 70-99%; however, risk of re-bleed is high: 58% at 30 days.

Source
Managing Massive Hemoptysis. Chest. 2019 Jul 30. pii: S0012-3692(19)31386-8. doi:10.1016/j.chest.2019.07.012. [Epub ahead of print]

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Reviewed by Clay Smith