Acute management of massive haemoptysis

Opening Vignette A 31-year-old man presented to the emergency department (ED) with two episodes of haemoptysis within 24 h. One cup of blood (~250 mL in volume) was expectorated before the patient arrived at the ED. Health records revealed that he had been recently evaluated for pulmonary tuberculosis, and his sputum acid-fast bacilli smear and molecular test were negative, while culture was pending. On physical examination, he was tachypnoeic with a temperature of 37.5°C, respiratory rate of 30/min, heart rate of 140/min, blood pressure of 100/60 mmHg and peripheral oxygen saturation of 99% in room air. Additionally, 200 mL of fresh blood from another bout of haemoptysis was found in a cup at the bedside. Heart sounds and lungs were normal on auscultation. The rest of the examination was unremarkable. Laboratory tests showed the following: total white cell count 17.7 × 109/L, haemoglobin 10.6 g/L, platelets 375 × 109/L, urea 3.5 mmol/L, creatinine 79 mmol/L, sodium 138 mmol/L, potassium 3.6 mmol/L, international normalised ratio 1.14, prothrombin time 11.7 s, activated partial thromboplastin time 32.2 s. Chest X-ray revealed a large, rounded mass (4.4 cm diameter) in the left lung apex.INTRODUCTION Massive haemoptysis—defined as coughing out of a large amount of blood (at least 100 mL in adults)—may lead to sudden and rapid deterioration of the patient. Anatomically, 150 mL of blood occluding tracheal dead space is sufficient to result in rapid death by asphyxiation,[1] though 100 mL of blood is the least amount of blood reported to cause life-threatening haemoptysis.[2] A practical frontline definition and approach would be to assess for anticipated loss of airway patency, desaturation due to abnormal gaseous exchange and haemodynamic instability indicative of life-threatening haemoptysis.[2] In more than 90% of massive haemoptysis cases, bleeding arises from high pressure systemic circulation such as the bronchial vascular tree, collaterals from the intercostal, subclavian or internal mammary artery, and the aorta. It is less likely to occur from the low pressure pulmonary artery system.[1] Common causes of haemoptysis in Asia are listed in Table 1, with the predominant causes being tuberculosis (TB), fungal infection/mycetoma, bronchiectasis, and lung cancer.[3,4]Table 1: Causes of massive haemoptysis.GENERAL APPROACH Rapid assessment to exclude an upper airway cause of bleeding (e.g. epistaxis) and haematemesis, and to uncover an underlying aetiology of massive haemoptysis, should be performed [Figure 1]. Clinical assessment can identify patients with strong protective cough reflex and good cardiopulmonary reserve.[1] Frontline doctors may elect not to intubate these patients, who must nonetheless be closely monitored. In the event of deterioration, they will require emergency intubation and stabilisation. For patients with weak protective cough reflex or poor cardiopulmonary reserve, intubation may be electively initiated. High-flow nasal oxygenation and non-invasive ventilation are not indicated, as these do not help protect the airway in massive haemoptysis. Mild or moderate bleed may progress to life-threatening haemoptysis. Treatment of underlying causes based on clinical evaluation will prevent progression. For cases with surgical indications—such as torrential bleed resulting in rapid instability, a high risk of bleeding recurrence and the need to obtain biopsy tissue for diagnosis—direct surgical assessment should be requested.Figure 1: Approach to massive haemostasis. aBronchial arteries, non-bronchial collaterals and pulmonary vessels can be targeted selectively for embolisation. bAs per Box 1. cTamponade, instillation of cold normal saline, adrenaline and/or tranexamic acid and thermal ablation. dVia suction or cryoextraction. CT: computed tomography, CXR: chest X-ray, HFNO: high flow nasal oxygen.Box 1: Bronchoscopy-based methods and agents.INITIAL STABILISATION General approach For patients who expectorate ≥100 mL of blood at any one time and who are at risk of airway loss, emergency stabilisation should be initiated. Other patients who need emergency stabilisation include those with tachypnoea, orthopnoea, inability to lie supine, ongoing hypoxaemia (inability to maintain peripheral oxygen saturation of 90% despite supplemental oxygen therapy), mean arterial pressure 7 g/dL, platelets >50 × 109/L, international normalised ratio 1.0 g/L—should be adhered to as much as possible through transfusion of blood products. Effects of anticoagulation therapy can be reversed with specific agents [Table 2]. In patients with platelet dysfunction (e.g. due to severe chronic kidney disease), IV desmopressin may be administered. In the management of coagulopathy, clotting function may be assessed with thromboelastography or rotational thromboelastometry to guide therapy,[6] although evidence of improved mortality outcomes in massive haemoptysis has not been demonstrated.Table 2: Management options for coagulopathy.FURTHER INVESTIGATIONS Chest X-ray has variable efficacy in identifying the side of bleeding and the underlying aetiology.[8] Due to its ease and rapid availability, CXR is routinely performed in patients with massive haemoptysis. Comparison with previous CXR films may reveal new changes and aid in localisation. Multidetector computed tomography (MDCT) is the imaging modality of choice in massive haemoptysis, if available and the patient is stable for transfer. Although MDCT is comparable to bronchoscopy for identifying bleeding sites, it is more efficient in elucidating the underlying cause of bleeding.[8] Furthermore, MDCT angiography precisely identifies culprit vessels and delineates the anatomy of bronchial, non-bronchial and pulmonary artery vasculature, thereby facilitating endovascular embolisation. In a cohort of patients with massive haemoptysis managed in intensive care, adding MDCT angiography to clinical evaluation—including bedside assessment, CXR and bronchoscopy—was observed to modify up to 21% of treatment decisions.[9] In another intensive care cohort with massive haemoptysis, preprocedural MDCT angiography was associated with higher technical success in a subgroup of patients above 70 years, leading to lower rates of emergent surgery.[10] Preprocedural MDCT angiography is highly recommended to facilitate endovascular embolisation procedures such as selective bronchial artery embolisation. MANAGEMENT Endovascular embolisation Endovascular embolisation comprises bronchial artery, collateral vessel bronchial artery embolisation (BAE) and pulmonary artery occlusion (PAO). Except in cases of diffuse bleeding, such as diffuse alveolar haemorrhage that requires medical therapy, endovascular embolisation is the mainstay management modality for massive haemoptysis localised to a specific bleeding source. Bronchial artery embolisation targets bleeding from bronchial arteries and non-bronchial collaterals. While BAE involves cannulation of the arterial vasculature, PAO requires venous cannulation—typically via the femoral vein—with a catheter passing through the right heart to access the pulmonary arterial vasculature. Compared to PAO, BAE is far more commonly performed, as bronchial arterial and collateral vessels account for 90% or more of bleeding. Evidence strongly supports the use of BAE in the management of massive haemoptysis.[11] Possible adverse effects, such as oesophageal ischaemia, pulmonary infarction, systemic embolisation, chest pain, paraplegia or tetraplegia from inadvertent spinal artery embolisation, groin haematoma, bleeding and infection, are rare, with a reported incidence of 0.6%–4.4%.[12] Recent complication rates have trended lower with the use of superselective catheters. Immediate success rates range from 87% to 100%.[12] Recurrence rates vary from 9.8% to 57.5%, with risk factors including mycetoma, sarcoidosis, cystic fibrosis, and the presence of angiographic features such as non-bronchial collaterals. In cases of recurrent haemoptysis, BAE remains an effective treatment modality before surgery. Bronchoscopic intervention In frontline management of massive haemoptysis, bronchoscopy is adjunctive. Flexible bronchoscopy may help identify the bleeding side and guide placement of large-bore ETT for isolation of the non-bleeding lung. However, blood visualised during bronchoscopy may have spilled from the contralateral lung, potentially leading to false localisation. Together with suctioning and removal of clots, bronchoscopy is an option for patients who require further stabilisation before transfer for CT or BAE. Bronchoscopy-directed suction or cryoextraction of clot can be used to relieve ETT obstruction caused by large clots. Less commonly, with the involvement of interventional pulmonologist in the frontline management of haemoptysis, bronchoscopy-based methods may be attempted to achieve temporary haemostasis by wedging the bronchoscope into the bleeding segment for tamponade, instillation of ice-cold saline, adrenaline or TXA, thermal ablation, and placement of bronchial blockers, spigots and stents[13] [Box 1]. Rigid bronchoscopy provides definitive airway control while allowing for insertion of large-bore instruments into the airway for suction clearance of clots, optimisation of thermal ablation and deployment of bronchial blockers, spigots and stents.[13] In patients requiring emergent surgery, rigid bronchoscopy offers the advantage of providing a definitive airway, allowing for effective management of airway bleeding and relief of airway obstruction caused by large clots. Surgery Emergency surgery is indicated for patients who have failed BAE and bronchoscopy, are unlikely to respond to embolisation, have high risk of recurrence or require concomitant surgical biopsy for diagnosis. Emergent surgery is associated with poorer outcomes compared to scheduled elective surgery performed after initial control of bleeding.[14] TAKE HOME MESSAGE Massive haemoptysis can cause rapid deterioration and death from asphyxiation, rather than exsanguination. For patients with life-threatening features, initial stabilisation with airway protection, large-bore Yankauer suction, IV access, fluid resuscitation, IV TXA, correction of coagulopathy and empirical treatment of the underlying condition should be prioritised. Imaging such as CXR, MDCT or MDCT angiography should be performed after initial stabilisation. Computed tomography is an effective imaging modality for localisation of bleed and elucidation of aetiology. Endovascular embolisation is the mainstay definitive management for massive haemoptysis where the source of bleed can be localised. As bronchial arteries and non-bronchial systemic arteries account for the majority of massive haemoptysis, BAE is the most commonly used treatment modality. In diffuse bleeding that cannot be localised, assessment to identify the underlying cause and therapy should be promptly initiated. Closing Vignette In anticipation of airway loss and asphyxiation from massive haemoptysis, the patient was intubated under rapid sequence induction with a size 8 ETT. Intravenous fluids and blood transfusion for resuscitation were initiated in view of the borderline blood pressure and ongoing bleed. After discussion with the interventional radiologist, MDCT angiography for delineation of vasculature, followed by selective BAE of the left upper lobe was performed. There was no abnormal extravasation of contrast seen. Haemostasis was achieved with embolisation of tortuous and aberrant branches of the bronchial artery in the left lung. After the procedure, the patient was transferred intubated to the intensive care unit for overnight observation. As there was no further bleeding, suctioning requirements were minimal and the patient was haemodynamically stable, he was extubated the next day. Based on clinical and radiological features and negative sputum test for acid-fast bacilli and tuberculosis molecular test, his left upper mass was diagnosed as mycetoma from post-tuberculosis sequelae. The patient was subsequently discharged. Sputum culture returned negative for tuberculosis. He remained on follow-up in the event of recurrence of haemoptysis requring surgical intervention. Over a six-month follow-up period, he developed episodes of mild to moderate haemoptysis, which were managed symptomatically with short courses of cough suppressants and oral TXA. Subsequently, he was referred to thoracic surgery and underwent an elective left upper lobectomy for definitive treatment.Financial support and sponsorship Nil. Conflicts of interest See KC is a member of the SMJ Editorial Board and was thus not involved in the peer review and publication decisions of this article. SMC CATEGORY 3B CME PROGRAMME Online Quiz: https://www.sma.org.sg/cme-programme Deadline for submission: 6 pm, 27 February 2026