Resident Grand Rounds

Series Editor: Mark A. Perazella, MD, FACP

Massive Hemoptysis
Renee J. Flores, MD
Sunder Sandur, MD, FACP

A 77-year-old man with underlying bronchogenic cancer of the right lung presented to the emergency department with
complaints of coughing up blood-streaked sputum for 3 days, followed by expectoration of a large volume of bright red blood
just prior to presentation. His past medical history was pertinent for advanced chronic obstructive pulmonary disease, type 2 di-
abetes mellitus, hypertension, peripheral vascular disease, and hyperlipidemia. He was noticeably dyspneic and in extremis.
Blood pressure was consistent with circulatory shock (mean arterial pressure, 50 mm Hg), and oxygen saturation was dimin-
ished at 85% despite 100% facemask oxygen therapy. The patient was intubated with a size 8 endotracheal tube and placed on
mechanical ventilation. He received 1 L of 0.9% saline and intravenous dopamine for blood pressure support. Physical examina-
tion revealed diminished breath sounds in the right lung. Laboratory studies revealed the following: hemoglobin, 9.3 mg/dL;
platelets, 245 x 103/L; prothrombin time, 10.6 seconds; partial thromboplastin time, 38 seconds; and normal renal function pa-
rameters. A chest radiograph noted the lung mass and associated alveolar hemorrhage. The patient was admitted to the inten-
sive care unit with a diagnosis of massive hemoptysis and evaluated by the pulmonologist. Due to the patients advanced lung dis-
ease and lung cancer, aggressive surgical therapy was not an option. The family decided to pursue comfort measures, and
intravenous morphine was administered. The patient died within the next 6 hours.

emoptysis is a potentially life-threatening man- ing the previous year, and 28% reported death from

H ifestation of underlying lung disease. It is es-

sential to recognize the severity of bleeding
(massive versus nonmassive) in patients who
present with hemoptysis and determine the potential
causes so that appropriate interventions can be initiat-
pulmonary hemorrhage.3 Asphyxia rather than exsan-
guination is usually the cause of death,4 and it is com-
monly accompanied by cardiovascular collapse. The
death rate from untreated massive hemoptysis ranges
from 30% to 85% in multiple studies.1,5 8 Among pa-
ed. This article reviews the diagnosis and management tients who survive the initial hemorrhagic episode,
of massive hemoptysis. bleeding ceases in 75% of cases within 24 hours, and in
all cases by day 5.9
DEFINITION AND NATURAL HISTORY
Hemoptysis is the expectoration of gross blood or DIFFERENTIAL DIAGNOSIS
blood-streaked sputum. Hemoptysis is classified as mas- Acute bronchitis is the most common cause of non-
sive or nonmassive based on the rate of bleeding. Ex- massive hemoptysis (Table 1). Other frequent underly-
pectoration of less than 100 mL of blood in a 24-hour ing causes of nonmassive hemoptysis include bronch-
period is considered nonmassive hemoptysis. The defin- iectasis, pulmonary tuberculosis, and lung cancer.
ition of massive hemoptysis varies widely in the litera- Although there is overlap, massive hemoptysis is more
ture, ranging between 100 and 600 mL of blood in a often due to advanced bronchiectasis, lung cancer, pul-
24-hour period; however, the most commonly used def- monary tuberculosis (that erodes into a large vessel),
inition is 600 mL in 24 hours.1 It is estimated that more and lung abscess. The etiology largely depends on the
than 400 mL of blood in the alveolar space is sufficient
to cause impairment of oxygenation.2
Most cases of hemoptysis, both massive and nonmas-
Dr. Flores is an internal medicine resident, Department of Medicine, St.
sive, are self-limited and resolve spontaneously. In a sur- Marys Hospital, Waterbury, CT. Dr. Sandur is a clinical assistant professor
vey study of 230 chest physicians, 86% indicated that of medicine, Yale University School of Medicine, New Haven, CT, and a staff
they had treated patients with massive hemoptysis dur- physician, Department of Medicine, St. Marys Hospital.

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 Flores & Sandur : Massive Hemoptysis : pp. 37 43

Table 1. Etiology of Hemoptysis

TAKE HOME POINTS Infection: chronic inflammatory lung disease (ie, acute/chronic
bronchitis), bronchiectasis (including cystic fibrosis), lung abscess,
Massive hemoptysis, defined as expectoration of aspergilloma, tuberculosis
more than 100 mL of blood from the lung in a Neoplasm: bronchogenic carcinoma, pulmonary metastases,
24-hour period, requires admission to the intensive bronchial adenoma, sarcoma
care unit. Foreign body/trauma: broncholith, aspirated foreign body,
A first step in diagnosing hemoptysis is to deter- tracheovascular fistula, chest trauma
mine the bleeding source: respiratory tract versus a Cardiac/pulmonary vascular: left ventricular failure, mitral valve
nasopharyngeal or gastrointestinal tract source. stenosis, pulmonary embolism/infarction, pulmonary artery
perforation (complication of pulmonary artery catheter)
Querying the patient identifies the correct source
in 50% of cases. Alveolar hemorrhage: Goodpastures syndrome, systemic
vasculitides/collagen vascular disease, drugs (nitrofurantoin,
Massive hemoptysis is managed in a stepwise fash-
isocyanate, trimellitic anhydride, D-penicillamine, cocaine),
ion: protect the airway and stabilize the patient, lo- coagulopathy
calize the bleeding site, and administer specific Iatrogenic causes: postlung biopsy, ruptured pulmonary artery
therapy. from Swan-Ganz catheter
A chest radiograph localizes bleeding in 60% of Other: pulmonary arteriovenous malformation, bronchial telangiec-
cases and is equivocal in 15%. tasia, pneumoconiosis
Flexible bronchoscopy facilitates localization of the
bleeding site, suctioning of the airway, and admin-
istration of site-specific therapy.
Surgical management of massive hemoptysis is de- cough with frothy sputum that is alkaline when tested
finitive in selected candidates if the lesion can be by litmus paper. In contrast, hematemesis originates
localized. from the gastrointestinal tract, is accompanied by nau-
sea and vomiting, and is frequently acidic. Epistaxis is
usually traumatic and may be localized by anterior rhi-
noscopy and examination of the oropharynx. Aspirat-
demography of the population sample. Bronchogenic ed blood or swallowed blood from any of the sites can
carcinoma and chronic inflammatory lung disease are make it difficult to initially identify the origin of bleed-
the most common causes of massive hemoptysis in the ing. Upon clinical presentation, only 30% of patients
United States. Tuberculosis remains the leading cause of spontaneously report the site of bleeding. However,
massive hemoptysis worldwide.10 Less common causes in- when queried, patients are highly accurate in predict-
clude aspergillomas, bronchial adenomas, chest trauma, ing the bleeding site (50% of the time), while physical
pulmonary arteriovenous malformations, cocaine- examination by a physician identifies the origin of
induced lung injury, pulmonary embolism, cardiac mi- bleeding only 43% of the time and is equivocal 25% of
tral valve stenosis, pulmonary alveolar hemorrhage syn- the time.1 Therefore, all patients with hemoptysis
dromes, and cystic fibrosis. As patients with cystic fibrosis should be asked about the site of the bleeding.5
live longer, complications such as massive hemoptysis are The clinical history and physical examination help to
becoming increasingly common. In a retrospective co- narrow the differential diagnosis. In a patient with known
hort of 28,853 patients with cystic fibrosis observed over pulmonary tuberculosis, the source of the bleeding may
10 years, the incidence of massive hemoptysis was 0.87%, be a pulmonary artery aneurysm (Rasmussens an-
and the overall prevalence was 4.1%.11 More recently, ia- eurysm) in an old cavitary lesion. In smokers older than
trogenic causes of massive hemoptysis have increased in 40 years, bronchogenic carcinoma is more prevalent and
frequency; these include bleeding following a trans- should be considered. A history of deep vein thrombosis
bronchial biopsy or transthoracic needle biopsy or bleed- suggests pulmonary infarction and/or embolism. Travel-
ing from a ruptured pulmonary artery caused by Swan- ers or immigrants from Asia, the Middle East, and South
Ganz catheter placement. America may develop hemoptysis as an initial manifesta-
tion of paragonimiasis and hydatiform cysts. Cyclical he-
DIAGNOSIS moptysis occurring during a menstrual cycle suggests the
History and Physical Examination diagnosis of catamenial hemoptysis. On physical exami-
Hemoptysis must first be differentiated from hema- nation, saddle nose with rhinitis and septal perforation
temesis and epistaxis. Hemoptysis is characterized by are signs of Wegeners granulomatosis. Stridor raises the

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 Flores & Sandur : Massive Hemoptysis : pp. 37 43

possibility of tracheal tumors or a foreign body. Oral and

aphthous ulcers, genital ulcers, and uveitis are suggestive
of Behets disease, in which pulmonary arteriovenous
malformations are responsible for hemoptysis. Digital
clubbing may be seen in bronchiectasis, tuberculosis, and
lung carcinoma.10

Laboratory and Imaging Studies

Studies that should be obtained in patients with signif-
icant bleeding or recurring hemoptysis include mea-
surement of hemoglobin and hematocrit (to assess the
magnitude and chronicity of bleeding), coagulation stud-
ies (including international normalized ratio, partial
thromboplastin time), and platelet count (to exclude
thrombocytopenia or another coagulopathy), urinalysis,
and renal function tests (to exclude pulmonary-renal
syndromes such as vasculitis, Goodpastures syndrome, or
Wegeners granulomatosis). Routine laboratory data, Figure 1. Bronchial arteriogram. Left bronchial arteriogram in
however, are usually not helpful in the diagnosis or man- a patient with massive hemoptysis revealing bronchial artery
agement of hemoptysis, except in the presence of a coag- enlargement and hypervascularity.
ulopathy or thrombocytopenia. In these circumstances,
bleeding can be more severe and laboratory data are cru-
cial when initiating appropriate therapy. only employed when other diagnostic techniques have
A chest radiograph is useful in localizing the bleed- failed.18
ing source if there is a lung mass, cavitary lesion, or alve- There are no specific independent risk factors that
olar hemorrhage.12,13 In general, a chest radiograph lo- predict the onset or the extent of hemoptysis. Howev-
calizes bleeding in 60% of cases and is equivocal in er, the presence of cavitation on radiologic examina-
15%.14 Chest computed tomography (CT) scanning in tion and perihilar location of a pulmonary infiltrate
conjunction with other diagnostic tests localizes the le- may predict recurrence after a sentinel event of he-
sion in 63% of cases.8 Thoracic CT scans with contrast moptysis. Pulmonary artery aneurysm within such cavi-
may detect aneurysms and arteriovenous malforma- tary lesions (Rasmussens aneurysm) may occur as a re-
tions or bronchiectasis not visible on routine chest ra- sult of erosion of the blood vessel, predisposing the
diograph. Therefore, except for life-threatening situa- patient to massive bleeding.19
tions, thoracic CT scans should be performed prior to
bronchoscopy. MANAGEMENT
Bronchial artery angiography (standard or selective) All patients with massive hemoptysis should be ad-
is highly effective in localizing the source of bleeding and mitted to the intensive care unit (ICU) to allow closer
identifying a vessel for embolization15 (Figure 1). The monitoring of hemodynamic status and assessment of
bronchial arteries supply the proximal airways, such as the magnitude of blood loss. Patient management
the trachea and mainstem bronchi, whereas the pul- should be undertaken in a stepwise fashion: (1) airway
monary circulation supplies the intrapulmonary airways protection and patient stabilization, (2) localization of
and alveoli. The bronchial circulation (a high pressure the bleeding source, and (3) administration of specific
circuit with systolic pressure of 120 mm Hg) is the most therapy (Table 2). Initial management is undertaken
common source of massive hemoptysis, accounting for by the medical team in most cases, with surgical inter-
95% of all cases. Less than 5% of bleeding arises from the vention warranted in certain circumstances.
pulmonary circulation (a low pressure circuit with a sys- Step 1 includes admission to the ICU, maintenance
tolic pressure of 1520 mm Hg).16,17 If bronchial artery of an adequate airway, administration of supplemental
angiography does not reveal a bleeding vessel, a pul- oxygen, correction of coagulopathy, fluid resuscitation,
monary angiogram is required to investigate the pul- and attempts to localize the bleeding source. If the
monary circulation.16 Bronchial arteriography is highly airway is compromised or if bleeding continues, the pa-
sensitive in identifying a source of bleeding, but this tient should be intubated by an experienced physician.
imaging modality is invasive and time consuming and A size 8 or larger caliber endotracheal tube (ETT)

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 Flores & Sandur : Massive Hemoptysis : pp. 37 43

Table 2. Management of Massive Hemoptysis

Steps Recommendations Options Comments

Protect airway and Admit to intensive care unit and Allows monitoring of hemodynamics
stabilize patient monitor and magnitude of blood loss
Maintain adequate airway Consider double-lumen tube Facilitates suctioning and FB
Consider unilateral intubation FB can verify placement of double-
Supplemental oxygen lumen ETT
Fluid resuscitation IV vasopressin
Lateralize bleeding site (bleeding side
down)

Localize the History and physical examination

bleeding site Radiology Chest radiograph and CT
Bronchoscopy Flexible or rigid bronchoscopy Early bronchoscopy to identify, lo-
cate, and guide therapy

Administer specific Bronchoscopic therapy Iced saline lavage Size 47 Foley catheter
therapy Topical agents: epinephrine, throm-
bin, fibrinogen
Endobronchial tamponade for endo-
bronchial lesions
Laser photocoagulation for alveolar
hemorrhage
Pharmacologic therapy Vasopressin, steroids
Angiography and embolization Semi-definitive therapy or bridge to
surgery
Surgical resection Segmentectomy, lobectomy, pneumo- Embolization unfeasible, failed embo-
nectomy lization, unstable patient, pulmo-
nary artery hemoptysis, mycetoma
Radiation therapy Aspergilloma, vascular tumors
CT = computed tomography; ETT = endotracheal tube; FB = flexible bronchoscopy; IV = intravenous.

should be used to permit subsequent bronchoscopic lo- troversial. The consensus is to perform immediate
calization of bleeding, adequate suctioning of the air- bronchoscopy in patients with rapid clinical deteriora-
way, and specific endobronchial therapy. A Carlins tion and delay bronchoscopy for up to 48 hours in sta-
double-lumen ETT facilitates lung separation, suction- ble patients. Most pulmonologists use a flexible bron-
ing of blood, and localization of the bleeding site with choscope in patients with massive hemoptysis because
concurrent flexible bronchoscopy (Figure 2). The it is easy to use at the bedside and can reach distal le-
double-lumen tube also can be left in place for 24 hours sions. Others prefer rigid bronchoscopy because of its
without the bronchoscope, allowing time for the bleed- greater ability to suction blood and secretions and
ing to stop. Some authors discourage the use of the maintain airway patency; however, its inability to visual-
double-lumen ETT due to difficulty in placement, in- ize the upper lobes or peripheral lesions remains a
creased rates of tube dislodgement, and increased rates of major limitation.17,21 Once the bleeding is localized, the
postoperative pneumonia and ischemic mucosal injury.20 patient should be placed in a dependent position with
Step 2 includes bronchoscopy to localize the bleed- the bleeding side down to prevent aspiration.23
ing site and suction the airway.21 Bronchoscopy has Step 3 involves administration of specific therapy.
been reported to successfully localize bleeding in 49% Flexible bronchoscopy permits directed therapy using
to 92.9% of cases of massive hemoptysis.21,22 The yield iced saline to lavage the involved lung21,24,25 and admin-
of bronchoscopy is greater if the procedure is per- istration of topical hemostatic agents, such as epineph-
formed in the first 24 hours after the onset of bleed- rine or thrombin-fibrinogen.26 Ice-saline lavage of up
ing. However, the ideal timing of bronchoscopy is con- to 1000 mL in 50-mL aliquots at the bleeding site has

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 Flores & Sandur : Massive Hemoptysis : pp. 37 43

Tracheal
Bronchial

Figure 2. Double-lumen endotracheal tube for endobronchial

tamponade. It has a bronchial lumen, which is placed in the left
main bronchus to ventilate the left lung, and a tracheal lumen,
which remains supracarinal and ventilates the right lung while
preventing occlusion of the right upper lobe orifice. The exter-
nal lumina are connected to the ventilator using a Y connector
device. Left- and right-sided double-lumen tubes are available.
(Adapted with permission from Dellinger RP. Fiberoptic bron-
choscopy in adult airway management. Crit Care Med 1990;
18[8]:884.)

been shown to be up to 90% effective in stopping

bleeding in some studies.17,21,23 There are no specific
recommendations based on the literature on the
choice of agent for site-specific therapy, as most case re-
ports are uncontrolled observational studies. Other al-
ternative site-specific therapies using the flexible bron- B
choscope include endobronchial tamponade using a
balloon tamponade catheter to prevent aspiration to Figure 3. (A) Fogarty balloon embolectomy catheter with
the unaffected contralateral lung and preserve gas ex- balloon inflated and (B) Fogarty balloon embolectomy cath-
change (Figure 3).20,21 A bronchus-blocking balloon eter inserted through the channel of the fiberoptic broncho-
catheter has been designed to be used through the scope with balloon inflated after insertion (Adapted with per-
working channel of the flexible bronchoscope20,27 and mission from Patel SR, Stoller JK. The role of bronchoscopy in
has a second channel that is used to instill vasoactive- hemoptysis. In: Wang KP, Mehta AC, editors. Flexible bronch-
hemostatic agents such as ice saline, epinephrine, oscopy. Cambridge: Blackwell Scientific; 1995:315. Copyright
vasopressin, or thrombin-fibrinogen to control bleed- 1995, Blackwell Publishing Ltd.)
ing.17,20,26,28 Once bleeding has ceased, the balloon may
be deflated, the catheter removed, and the patient re-
ferred for subsequent therapy. Surgical Management
Nonbronchoscopic medical management is used to Surgery is indicated if bronchial artery embolization
treat massive hemoptysis if endobronchial therapy fails; is unavailable or technically unfeasible or if bleeding or
this includes bronchial artery embolization with or aspiration of blood continues despite embolization. Sur-
without adjunctive pharmacologic therapy with intra- gical resection of the bleeding site is possible if the le-
venous vasopressin. Bronchial artery embolization sion can be localized and the patient is a surgical candi-
achieves immediate control of bleeding in 75% to 90% date. Surgery is also preferable when the acuity (rate
of cases.15,18 Postembolization recurrence of hemopty- and amount of bleeding) of hemoptysis precludes safe
sis has been observed in 20% of cases.29 bronchial artery embolization. More specific indications

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 Flores & Sandur : Massive Hemoptysis : pp. 37 43

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