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Severe hemoptysis

December 21, 2016 by Josh Farkas

CONTENTS

BasicsGeneral principles of hemoptysis management (#General_principles_of_hemoptysis)

Ddx vs pseudohemoptysis (#Ddx_versus_pseudohemoptysis)

Triage:  Who needs ICU? (#Triage:_who_needs_ICU?)

Common causes of severe hemoptysis (#Common_causes_of_severe_hemoptysis)

Roadmap for management of severe hemoptysis (#Roadmap)

0)  Initial evaluation (#(0)_Initial_evaluation)

1)  Reverse coagulopathy (#(1)_Coagulopathy_management)

2)  Indications for intubation (#(2)_Is_intubation_bene�cial?)

3)  CT scan (#(3)_CT_is_front-line_investigation_(not_bronchoscopy))

4)  IR embolization (#(4)_Bronchial_artery_embolization_is_often_front-line_treatment)

5)  Intubation (#(5)_Intubation_procedure_itself)

6)  Bronchoscopy (#(6)_Bronchoscopy)

7)  Interventional pulmonology (#(7)_Interventional_pulmonology)

8)  Surgery (#(8)_Surgical_resection)

9)  Diffuse alveolar hemorrhage (DAH) (#(9)_Diffuse_alveolar_hemorrhage)

Checklist (#Checklist)

Podcast (#Podcast)

Questions & discussion (#Questions_&_discussion)

Pitfalls (#pitfalls)

TOC ABOUT THE IBCC TWEET US IBCC PODCAST

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Approach to severe hemoptysis

YesNo

Indications for intubation?- unable to clear blood from airway- significant hypoxemia / dyspnea- too unstable for CT scan / IR

Yes

CT scan Intubate

Yes

No

Focal source ofbleeding defined?

No

Focal source ofbleedingdefined?

Bronch (avoidintubation ifable)

Consider whether patient mayhave diffuse alveolar

hemorrhage

Yes

No

Focal source of bleedingdefined? CT scan

Reversecoagulopathy

1

2

35

InterventionalPulmonology

Fail

Interventional radiologyembolization

4

Bronchoscopy

6b

6a

7Surgery

Fail

8

9

0

3

-Internet Book of Critical Care, by @PulmCrit

General principles of hemoptysis(back to contents) (#top)

patients usually die from hypoxemia (not exsanguination)

The primary concern is how the patient is doing from a respiratory standpoint (e.g. respiratory rate, saturation), not the patient's hemoglobinlevel.If the patient is coughing up lots of blood but keeping blood out of their lungs (normal oxygen saturation, no respiratory distress) – thenthey're doing OK.  This looks scary, but in fact these patients are defending their lungs.If the patient is coughing up some blood but most of the blood is accumulating in the lungs (as revealed by hypoxemia & respiratorydistress) – this is more immediately dangerous.  Despite a lower volume of expectorated blood, these patients are at a higher risk ofrespiratory failure.

goals of therapy

(1) Keep blood out of the lungs & preserve respiratory function.  This may be achieved using the patient's own cough re�ex (if they arekeeping up with the bleeding).  Alternatively, interventions such as an endobronchial blocker can be used (more on this below).(2) Stop the source of bleeding.  This may involve manipulation of coagulation and direct intervention.

Ddx versus pseudohemoptysis(back to contents) (#top)

pseudo-hemoptysis

De�ned as expectoration of blood originating from the nasopharynx, oropharynx, larynx, or gastrointestinal tract.Important to recognize because it requires an entirely different diagnostic algorithm.

factors suggesting ENT source

Subjective sensation of blood dripping downward in the posterior pharynx.Blood visualized in the nares.When in doubt consult ENT for nasolaryngoscopy – this test can be done rapidly and safely at the bedside.  Occasional patients may behaving severe posterior epistaxis masquerading as hemoptysis; this is essential to recognize rapidly.

factors suggesting GI source

Coffee-ground appearanceHistory of vomiting or regurgitation

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Triage: who needs ICU?(back to contents) (#top)

de�nition of “massive hemoptysis”

This is very vague, because in reality it's often impossible to precisely quantify the volume of hemoptysis.Numerous de�nitions exist, all of which are equally arbitrary and relatively unhelpful.A reasonable de�nition might be coughing up >200-600 ml fresh blood over several hours.  This indicates the need for emergent therapy(26141487 (https://www.ncbi.nlm.nih.gov/pubmed/26141487) ).

factors to consider in triage

(1) Larger volumes of fresh red blood are more worrisome.(2) An acute-onset or an accelerating pattern is more worrisome.(3) CT may help:  structural abnormalities (i.e. malignancy, bronchiectasis) & lots of blood in the lung tissue are worrisome.(4) Worsening respiratory failure is a worrisome sign (even if the patient isn't coughing up lots of blood).

This implies accumulation of blood within the lung.(5) Underlying lung disease and degree of physiologic reserve.

Common causes of severe hemoptysis(back to contents) (#top)

malignancy

Lung cancerMetastatic cancer (e.g. renal cell CA metastatic to bronchi)

infection

BronchiectasisCystic Fibrosis

Lung abscessNecrotizing pneumonia (bacterial or fungal)

David Feller-Kopman@dfellerk

Definition of massive hemoptysis varies in the literature. Some say 150mL/24h, others say 600mL/24h I’ve always erred on the low end and prefer the term “life threatening hemoptysis”. Others say, “I know it when I see it”. This counts

406 7:46 PM - Aug 22, 2019

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Aspergilloma (“fungus ball”)TuberculosisSeptic pulmonary embolism due to right-sided endocarditis

vasculitis

Mostly diffuse alveolar hemorrhage due to Granulomatosis with polyangiitis (previously known as Wegener's)

iatrogenic

tracheoinominate �stulaPA catheter perforationtransbronchial biopsy

Roadmap(back to contents) (#top)

Approach to severe hemoptysis

YesNo

Indications for intubation?- unable to clear blood from airway- significant hypoxemia / dyspnea- too unstable for CT scan / IR

Yes

CT scan Intubate

Yes

No

Focal source ofbleeding defined?

No

Focal source ofbleedingdefined?

Bronch (avoidintubation ifable)

Consider whether patient mayhave diffuse alveolar

hemorrhage

Yes

No

Focal source of bleedingdefined? CT scan

Reversecoagulopathy

1

2

35

InterventionalPulmonology

Fail

Interventional radiologyembolization

4

Bronchoscopy

6b

6a

7Surgery

Fail

8

9

0

3

-Internet Book of Critical Care, by @PulmCrit

(https://emcrit.org/wp-content/uploads/2016/12/hemomap.svg)

There are numerous approaches to hemoptysis.  This may depend to a certain extent on local resources and practice patterns.  This roadmap isintended to provide a general schema for approaching this, but it certainly won't be applicable to every patient.  For example, if the bleeding isclearly coming from a known central airway mass, then early involvement of interventional pulmonology would be warranted (and depending onthe location of the mass, intubation might be impossible).

(0) Initial evaluation(back to contents) (#top)

history, focus on: 

? Prior history of structural lung disease? Tobacco history, history of malignancy? Medications impairing coagulation? Other infectious/in�ammatory symptoms? Recent procedures

exam

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1) Unilateral wheeze may reveal a focal endobronchial lesion.2) Thoracic ultrasonography

Focal B-lines may represent intra-parenchymal blood.Diffuse B-lines could raise a question of diffuse alveolar hemorrhage.

labs

ElectrolytesCBC with differentialCoags (INR, PTT, �brinogen; thromboelastography in patients with cirrhosis)Urinalysis, ESR, and CRP if diffuse alveolar hemorrhage is possible.

stat portable chest X-ray

Over time, blood may move around.  This may eventually obscure what is going in.Even if a CT chest is ordered, consider getting a STAT chest x-ray.  A �lm at an early time-point can be helpful.Chest X-ray may lateralize the bleed in ~46% of cases and identify a speci�c cause of bleeding in ~35%(31374211 (https://www.ncbi.nlm.nih.gov/pubmed/31374211) ).

nebulized tranexamic acid (TXA)

Shown to be bene�cial in one RCT which excluded patients with massive hemoptysis (30321510 (https://www.ncbi.nlm.nih.gov/pubmed/30321510) ).Appears to be safe and well tolerated.This is a reasonable treatment to provide while awaiting other interventions or tests.

Should not be viewed as de�nitive therapy.Should not delay or interfere with other interventions.More appropriate for patients on the more stable end of the hemoptysis spectrum.

A reasonable dose might be 500 mg nebulized q8 hours (possibly with an initial dose of 1000 mg).

(1) Coagulopathy management(back to contents) (#top)

optimization of systemic coagulation

Check coagulation tests and review medication list for any anticoagulants.Optimize coagulation as able (discussed further in chapter on anticoagulation reversal).Nebulized tranexamic acid may be considered (more on this below)

Might helpShouldn't delay other interventionsShouldn't be considered de�nitive treatment for massive hemoptysis

(2) Is intubation bene�cial?(back to contents) (#top)

intubation can cause harm

Most patients are very good at coughing blood out of their airways.  Intubation & suctioning is generally less effective than the patient'snatural ability to clear their airway.If the patient is protecting their airway (e.g. blood is not accumulating in the lungs, there is no respiratory distress) – then intubation won'timprove upon this.  Intubation will likely impair clearance of blood from the airways.When able, it may be safest to avoid intubation (e.g. perform bronchoscopy and/or bronchial embolization under light sedation).

indications for intubation:

(1) Ineffective cough (e.g. gurgling, inability to clear blood from airway).(2) Worsening respiratory failure (hypoxemia, dyspnea).

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(3) Intubation may be logistically necessary to facilitate CT scan and/or interventional radiology.

timing of intubation

If intubation is required for respiratory failure (#1-2 above), then proceed without delay.If intubation is needed to expedite a procedure (#3 above) and patient is clearing blood effectively, then delay intubation as long as possible. For example, if the patient is effectively clearing blood from the airway and requires transport to another hospital, it might be safest totransport the patient without intubation �rst.   In this scenario, intubation may actually destabilize the patient by impairing the natural coughre�ex.

(3) CT is front-line investigation (not bronchoscopy)(back to contents) (#top)

CT has diagnostic yield superior to that of bronchoscopy in de�ning the bleeding lesion

Similar e�cacy vs. bronchoscopy with regards to localization.Superior e�cacy in de�ning speci�c pathologic diagnosis (23932395 (https://www.ncbi.nlm.nih.gov/pubmed/23932395) ).  May identify site andcause of bleeding in ~75% of patients (31374211 (https://www.ncbi.nlm.nih.gov/pubmed/31374211) ).  This is far greater than bronchoscopy, whichmay identify a speci�c etiology of hemorrhage in closer to 50% of patients.

yield of CT scan may decrease over time 

Over time, lungs �ll up with blood, which obscures the source of bleeding.

Otis B Rickman, DO@OtisBRickman

Replying to @PulmCrit @iBookCC1/x I can't amen this first point enough!! If a person is coughing up blood and is holding their own physiologically, please don't take away the cough reflex with induction and intubation. Think about from physiologic perspective. What is deadspace of lung? ~150ml.

15 12:36 PM - Jul 25, 2019

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Otis B Rickman, DO@OtisBRickman

Replying to @OtisBRickman and 2 others2/x How much deadspace is cleared with 1 cough? Almost all of it! How much can you clear with a 160cm bronchoscope with a 2.8mm working channel? Not that much!! Not to mention the amount of blood that will accumulate during apnea and cough suppression to facilitate intubation.

10 12:38 PM - Jul 25, 2019

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Otis B Rickman, DO@OtisBRickman

Replying to @OtisBRickman and 2 others3/x Seen too many patients harmed by well-intentioned physicians who wanted to "secure" the airway during hemoptysis.

11 12:40 PM - Jul 25, 2019

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Fluid instilled into the lungs during bronchoscopy (e.g. epinephrine or tranexamic acid) may mimic blood on CT scan.

immediate CT scan should be done if possible

Contrast helps show vascular causes of bleeding (e.g. arteriovenous malformations).Detailed understanding of vascular anatomy may facilitate planning for IR embolization.A special CT protocol may help visualize both bronchial and pulmonary arteries.  Discussion with radiology may ensureoptimal CT technique.

(https://i0.wp.com/emcrit.org/wp-content/uploads/2016/12/hemoptysis.png)

(4) Bronchial artery embolization is often front-line treatment(back to contents) (#top)

Early & ongoing communication with interventional radiology is essential.

IR embolization is often the �rst-line therapy for severe hemoptysis (Khalil 2015 (https://www.ncbi.nlm.nih.gov/pubmed/26141487) ).

~90% of massive hemoptysis originates from the bronchial arteries (under systemic pressure), rather than from the pulmonary arteries (alower-pressure system).  Overall, bronchial artery embolization has an initial success rate of ~80% (31374211(https://www.ncbi.nlm.nih.gov/pubmed/31374211) ).Usually embolization is directed at bronchial arteries, but it can also target pulmonary arteries.One potential exception is large central airway masses, which may be supplied by several vascular territories and thus be di�cult toembolize.

Interventional pulmonology may be more useful for these lesions.

some details

Success is improved by pre-procedure localization of bleeding (via bronchoscopy or CT).If the �rst embolization fails, repeat embolization may still be successful.

Risk factors for recurrent bleeding after initial embolization include aspergillomas, tuberculosis, bronchiectasis, and non-bronchialsystemic collateral circulation (31374211 (https://www.ncbi.nlm.nih.gov/pubmed/31374211) ).

(5) Intubation procedure itself(back to contents) (#top)

anticipate di�culty

Blood may camou�age anatomic landmarks, making intubation di�cult.Be prepared to suction, ideally with a large-bore suction catheter (LINK).Be prepared to proceed to cricothyrotomy if the airway �lls with blood and all landmarks are obscured.

use a large ETT

Ideally #9 ETT for patients who are average size or taller.  Davidson et al. suggest using an 8.5 mm ETT or larger (31374211(https://www.ncbi.nlm.nih.gov/pubmed/31374211) ).Using a large-bore ETT will facilitate bronchoscopy and placement of an endobronchial blocker (if needed).

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do not place a double-lumen ETT!

A double-lumen ETT (with one lumen in each bronchus) sounds neat, but in practice works poorly for the following reasons.(a) Placement is tricky.(b) The tube is easily malpositioned (not a very stable airway).(c) It's di�cult to perform bronchoscopy through the small lumens.(d) To control massive hemoptysis, a double-lumen ETT requires shutting down an entire lung.  In contrast, an endobronchial blockercan be placed within a lobar or segmental bronchus (thereby shutting down less lung tissue).

(6) Bronchoscopy(back to contents) (#top)

potential goals of bronchoscopy

1. May de�ne a focal source of bleeding (e.g. endobronchial tumor or blood coming from a single airway).

Matt Siuba@msiuba

Listened to the awesome @iBookCC podcast this morning.

One point to re-emphasize: if you need to intubate someone with hemoptysis, choose a LARGE tube!#FOAMcc twitter.com/PulmCrit/statu…

josh farkas @PulmCritPulmCrit Minute - 5 pearls on massive hemoptysis.(fresh @ibookCC chapter here: emcrit.org/ibcc/hemoptysi…)

21 8:13 AM - Jul 25, 2019

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Note, however, that it is often di�cult to tell where the blood is coming from.  There is real potential for operator error/misdiagnosis.  CTis replacing bronchoscopy as the �rst-line test to localize bleeding (26141487 (https://www.ncbi.nlm.nih.gov/pubmed/26141487) ).

2. May diagnose diffuse alveolar hemorrhage (blood coming from all airways, doesn't clear with sequential lavage).3. Occasionally used to deploy an endobronchial blocker to contain the bleeding.

who needs bronchoscopy?

Not every patient with hemoptysis.  If CT scan shows a culprit lesion, bronchoscopy may not be needed.Potential indications

Generally done in anyone intubated due to hemoptysis (to assess the severity of bleeding and perform tamponade if necessary)If source of bleeding remains unclear despite CT scan.

instillation of tranexamic acid through the bronchoscope

Traditional approach was to instill cold saline, epinephrine, or activated factor VIIa.  None of these are particularly attractive (activated factorVIIa may work, but it is profoundly expensive).The best option may be endobronchial tranexamic acid.  There isn't a lot of evidence supporting this, but it seems to work (23966576(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3829500/) ).  The largest reported study used a regimen of 500 mg diluted in 15 ml saline (23168726(https://www.ncbi.nlm.nih.gov/pubmed/23168726) ).

(6a) Non-intubated bronchoscopy (“awake bronch”)

Try not to sedate the patient too much (so that their cough re�ex remains preserved and they are able to clear blood from their lungs afterthe procedure).Main goal is to identify a focal source of bleeding (if present) or to determine whether the patient might have diffuse alveolar hemorrhage.

(6b) Intubated bronchoscopy

Deep sedation (e.g. high-dose propofol infusion) will make this easier, because the patient won't cough and shift blood around.  A static lungwill make it easier to determine where blood is coming from.If focal bleeding is found, an endobronchial blocker can be placed to tamponade bleeding (while preserving function of the remaining lung).

endobronchial blocker

If bleeding localized to speci�c lung/lobe/segment, this may be blocked off with balloon tamponade.The goal is to compartmentalize bleeding & protect the remaining lung tissue.Video below shows how this is done.Either paralysis or deep sedation (e.g. propofol infusion) is generally needed to prevent the patient from coughing this out or dislodging it.

(7) Interventional pulmonology

Endobronchial Blocker Placement -- BAVLSEndobronchial Blocker Placement -- BAVLS

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(back to contents) (#top)

There is increasing use of advanced bronchoscopic techniques to achieve hemostasis (e.g. argon plasma coagulation, rigid bronchoscopy).This is primarily useful for lesions in the proximal airways.  As such, the utility of interventional pulmonology may be gauged, based on CTscan and/or �exible bronchoscopy showing a large airway lesion.

(8) Surgical resection(back to contents) (#top)

a surgical approach requires the following:

(a) Localized bleed that is refractory to other therapies(b) Patient with su�cient pulmonary function to tolerate resection of the involved lung tissue (e.g. pneumonectomy or lobectomy).

Patients with hemoptysis cannot undergo pulmonary function tests, so their ability to tolerate resection must be estimated based ontheir pre-morbid functional capacity (e.g. how many �ights of stairs are they able to climb).

utility of surgery?

Not generally an option for patients with massive hemoptysis and underlying lung disease (e.g. COPD, bronchiectasis, lung cancer).Surgery works best for a previously healthy patient with a speci�c focus of bleeding (e.g. broncholith, aspergilloma, lung abscess, bronchialadenoma).

(9) Di�use alveolar hemorrhage(back to contents) (#top)

This requires an entire chapter – see diffuse alveolar hemorrhage chapter (sorry we will get there eventually).

Checklist(back to contents) (#top)

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Approach to severe hemoptysis

YesNo

Indications for intubation?- unable to clear blood from airway- significant hypoxemia / dyspnea- too unstable for CT scan / IR

Yes

CT scan Intubate

Yes

No

Focal source ofbleeding defined?

No

Focal source ofbleedingdefined?

Bronch (avoidintubation ifable)

Consider whether patient mayhave diffuse alveolar

hemorrhage

Yes

No

Focal source of bleedingdefined? CT scan

Reversecoagulopathy

1

2

35

InterventionalPulmonology

Fail

Interventional radiologyembolization

4

Bronchoscopy

6b

6a

7Surgery

Fail

8

9

0

3

-Internet Book of Critical Care, by @PulmCrit

Podcast(back to contents) (#top)

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88f8-a65fff2da477.jpg)

Follow us on iTunes (https://itunes.apple.com/ca/podcast/the-internet-book-of-critical-care-podcast/id1435679111)

The Podcast Episode

Want to Download the Episode?Right Click Here and Choose Save-As (http://tra�c.libsyn.com/ibccpodcast/IBCC_Episode_46_Massive_Hemoptysis.mp3)

Questions & discussion(back to contents) (#top)

To keep this page small and fast, questions & discussion about this post can be found on another page here (https://emcrit.org/pulmcrit/hemoptysis/) .

(https://i1.wp.com/emcrit.org/wp-content/uploads/2016/11/pitfalls2.gif)

Rushing every patient to bronchoscopy (since bronchoscopy has a lower yield than CT scan).  Whenever possible, early multi-detector CTangiography of the chest can be enormously helpful.Failure to correct coagulopathy.

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Intubation is often counterproductive:  it doesn't �x the problem, and may actually increase blood accumulation in the lung.  Intubationshould ideally be avoided or delayed if possible.Placement of an ETT that doesn't allow for bronchoscopy (small ETT, or double-lumen ETT).

Going further: 

Nebulized TXASalim Rezaie, RebelEM (https://rebelem.com/txa-for-everyone-inhaled-txa-for-hemoptysis/) .Justin Morgenstern, First10EM (https://�rst10em.com/nebulized-txa-for-hemoptysis-wand-2018/)

EMCrit podcast199:  Massive Hemoptysis with Oren Friedman (https://emcrit.org/emcrit/massive-hemoptysis/)

A wee bit more (https://emcrit.org/emcrit/wee-massive-hemoptysis/) on Massive Hemoptysis with George KovacsMassive Hemoptysis (https://�rst10em.com/massive-hemoptysis/) (Justen Morgenstern, First10EM)Massive Hemoptysis (https://lit�.com/massive-haemoptysis-ddx/) (Chris Nickson, LITFL)

The Internet Book of Critical Care is an online textbook written by Josh Farkas (@PulmCrit), an associate professor ofPulmonary and Critical Care Medicine at the University of Vermont.

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