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
- Position bleeding side down; secure airway; call bronchoscopy and IR.
- Bronchoscopic localization and temporization; obtain CTA when stable.
- Definitive therapy with embolization or surgery if needed; manage underlying cause.
Clinical Synopsis & Reasoning
Life-threatening bleed from the lower respiratory tract. Prioritize airway protection and isolate bleeding lung (lateral decubitus with bleeding side down). Use bronchoscopy for localization and temporary control; definitive management often with bronchial artery embolization.
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 |
|---|
| Clinical estimation of volume and hemodynamics | Severity | Define massive/unstable | — |
| CT angiography of chest (once stabilized) | Localization | Bleeding source and vessels | IR planning |
| Flexible bronchoscopy | Diagnosis/therapy | Localize and tamponade with balloon/ice saline | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| >150 mL in 24 h or any causing instability/hypoxemia | Life-threatening | Airway protection; isolate bleeding lung (lateral decubitus) |
| Bronchiectasis/cavitary TB/aspergilloma | Recurrent bleed risk | Bronchial artery embolization |
| Anticoagulation/antiplatelet use | Bleeding risk | Reverse/hold agents |
| Malignancy or post-procedure bleed | Ongoing source | Urgent bronchoscopy and IR |
| Uncontrolled bleeding despite measures | Failure | Surgical consult |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Airway protection with large ETT or double-lumen tube | Airway | Immediate | Prevent asphyxiation | Requires expertise |
| Topical vasoconstrictors/iced saline via bronchoscope | Temporizing | Minutes | Reduce bleeding locally | — |
| Bronchial artery embolization by IR | Definitive (common) | Hours | Control bleeding source | Recurrence possible |
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
- Pulmonary/IR guidance on massive hemoptysis — Link