Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Call for help; high‑flow O2; position bleeding lung down; suction with large ETT ≥8.5.
- Localize source via bronchoscopy; consider endobronchial blocker/iced saline/epinephrine topically.
- Obtain CTA chest arterial phase when stable; correct coagulopathy; prepare for IR.
- Proceed to bronchial artery embolization; manage underlying disease (TB, bronchiectasis, tumor).
- Post‑control: ICU monitoring; recurrence plan; smoking cessation and pulmonary follow‑up.
Clinical Synopsis & Reasoning
Life‑threatening bleeding (>100–200 mL/h or any bleed causing instability/respiratory failure). Prioritize airway and bleeding‑lung isolation, position bleeding side down, localize with bronchoscopy/CTA, and arrange bronchial artery embolization; treat the underlying cause.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Flexible bronchoscopy (early) | Localization/temporizing | Identify side/segment; suction; topical measures | Balloon blockers if needed |
| CTA chest with arterial phase | Etiology/roadmap | Hypertrophied bronchial arteries; aspergilloma, TB, malignancy | Guides IR embolization |
| Labs (CBC/coags), type & cross | Resuscitation | Anemia/coagulopathy | Reverse anticoagulation; TXM for MTP |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Large ETT (≥8.5) with possible lung isolation | Airway control | Immediate | Facilitates suction/bronchial blocker | Avoid small ETT |
| Tranexamic acid 500–1000 mg nebulized/topical (adjunct) | Antifibrinolytic | Minutes | Adjunct hemostasis | Evidence mixed; avoid systemic thrombosis risks |
| Bronchial artery embolization (procedure) | Definitive hemostasis | Hours | High initial success; recurrence possible | Requires IR expertise |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- CHEST/BTS reviews on massive hemoptysis management — Link