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Massive Haemoptysis

Minor haemoptysis is often of infective cause (bronchitis, pneumonia, bronchiectasis). After a CXR screening for pneumonia and lung lesions and consideration of patient risk factors for malignancy most patents can be discussed with the respiratory team and discharge with follow up (GP or Respiratory physician).

Massive haemoptysis was previous defined by volume (approximately > 100 ml or > 600 ml in 24 hours). More recent definitions consider massive haemoptysis to be life threatening airway haemorrhage related to briskness of bleeding, ability of a patient to maintain a patent airway and expectorate blood, the swiftness of available therapeutic options, and the patient’s underlying physiological reserve. This definition takes into account the multifactorial components of severe haemoptysis. Patients usually asphyxiate due to aspiration of blood to the contralateral lung, airway obstruction, and hypoxemia, rather than bleed to death.

General Considerations

  • PPE – infection control precautions, especially if suspicion of bleeding from an infective lesion e..g TB. Need to don appropriate PPE in light of potential massive blood loss – including eye protection
  • Blood loss quantification – ‘Massive Haemoptysis’ definition varies
    • Generally accepted 100mLs/hr OR 500mLs over 24 hours
    • Quantification of loss can be difficult
  • Always consider mimics – ENT source, haematemesis
  • Origin of bleeding: Most commonly Bronchial arteries (90%) rather than pulmonary arteries
  • The aetiology, haemodynamic stability, patient factors and volume of blood loss determine the therapeutic treatment
  • Most common cause of death is asphyxiation
  • Stabilisation of patient and diagnostic planning and disposition should occur concurrently and will require a multi-disciplinary team

ED Approach to Massive Haemoptysis

  1. Call for help, early involvement of anaesthetics, ICU, respiratory physicians, interventional radiology (surgeons)

  2. 100% oxygen via NRB, large bore IV access and urgent group and hold to blood bank, mobile CXR

  3. Assign assistant to suctioning and seat patient upright, if possible, until definitive airway established

  4. If able to identify affected lung position this downwards

  5. Early intubation and double lung ventilation with largest ETT possible

  6. Transition to unilateral lung ventilation if expertise present

  7. Concurrent resuscitation with blood products once available (crystalloid initially) – anticipate need for massive transfusion protocol activation

  8. Correct coagulopathy

  9. Urgent definitive management – bronchoscopy, angiography, surgery

  10. ICU admission/retrieval.

Further References and Resources

  • Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care. Illustrative case 7: Assessment and management of massive haemoptysis. Thorax. 2003;58:814-819
  • Davidson K (2020): Managing Massive Hemoptysis: Chest 2020 Jan;157(1):77-88. doi: 10.1016/j.chest.2019.07.012. Epub
  • Ong ZY (2016): A simplified approach to haemoptysis. Singapore Med J. 2016 Aug;57(8):415-8. doi: 10.11622/smedj.2016130.
  • ECI Anticoagulation Clinical Tool

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