Investigation and Management of Massive Hemoptysis

Michal M. Reid, Chris J. Reisenauer, Dennis A. Wigle, Janani S. Reisenauer

Key Points

  • Death is usually due to hypoxia, not exsanguination.
  • The most common causes of hemoptysis remain chronic inflammatory lung diseases and bronchogenic carcinoma.
  • A multidisciplinary team including the intensive care physician, endoscopic pulmonologist, interventional radiologist, and thoracic surgeon is necessary.
  • Endobronchial and/or angiographic control is usually possible.
  • Surgical treatment has high mortality and morbidity and is reserved for failures of endoscopic and angiographic therapy

Hemoptysis is the coughing of blood that originates from the tracheobronchial tree or pulmonary parenchyma.[1] The term comes from the Greek words haima meaning blood, and ptysis meaning spitting.[2] Although there is no universally accepted volume that defines massive hemoptysis, the term is typically reserved for any volume of blood in the airway that represents an imminent threat to life. The literature varies when defining massive hemoptysis. The range of 200–1000 mL/ 24 hr has been noted because the anatomic dead space of the tracheobronchial tree approximates 200 mL.[2] However, most clinicians cite an expectorated blood of 600 mL/24 hr as being massive, because of the observance of impaired oxygen transfer when approximately 400 mL of blood is in the alveolar space.[2]

Massive bleeding in the airway is potentially a lethal problem due to asphyxiation by flooding of the tracheobronchial tree. Exsanguination itself is rarely the cause of death.[3],[4] The coughing up of blood prompts most people to seek medical attention. Although fewer than 5% of patients with hemoptysis expectorate large volumes, the incidence of acute mortality in this group ranges from 7% to 32%., If improperly managed, mortality can increase up to 50%. In one study of 59 patients with hemoptysis, the mortality rate was 59% in patients with malignancy and 58% in patients with bleeding >1000 mL/24 hrs, but it was only 9% if the bleeding was < 1000 mL/24 hrs.[5] Very rapid bleeding, such as from a fistula to a major vessel, is usually fatal. Assessment of the patient with a moderate amount of hemoptysis can represent a clinical dilemma because many patients expectorate only small amounts of blood but aspirate into unaffected airways. Expectorated blood is often swallowed and cannot be accurately quantified. Many patients with hemoptysis have compromised lung function, and even small quantities of blood in the bronchial tree can lead to significant respiratory distress.

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Last updated: October 18, 2022