A 36-year-old chronic alcoholic male patient presented to the emergency department with history of a large amount of blood being coughed out for the past 24 h. He had had three such episodes, the last one just about 1 h ago. There was no history of such previous episodes in the past. Although there was no history of fever, he had been feeling weak for the past 2 weeks.

Hemoptysis is defined as coughing of blood from the respiratory system. Hemoptysis is one of the important symptoms of cardiopulmonary disease. It can be mild or severe requiring admission to the intensive care unit (ICU). If massive hemoptysis is not treated aggressively, it is associated with significant mortality.

Step 1: Initiate resuscitation

Take history of the patient and find out the approximate amount of hemoptysis. Severe hemoptysis is defined as hemoptysis of more than 400–600 mL/24 h. After a quick physical examination of the patient, initiate resuscitation.

Airway:

•Maintaining an open airway should be the first priority in the management. The main objective is to prevent asphyxiation.

•Intubate with single-lumen endotracheal tube in cases of severe and diffuse endobronchial bleeding. It may achieve immediate control of the airways to allow

A. Bansal, M.D., F.R.C.P. (*)

Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India

e-mail: avdeshb@hotmail.com

V. Kantroo, D.N.B.

Department of Respiratory Medicine & Critical Care, Indraprastha Apollo Hospitals, New Delhi, India

adequate suctioning and diagnostic and therapeutic fiber-optic bronchoscopy. It may also be helpful in cases of nonavailability of the double-lumen tube or expertise.

•Double-lumen endotracheal tube can be helpful to isolate and ventilate the lungs separately if the bleeding is lateralized. The double-lumen tubes are, however, easily obstructed by clots and do not permit passage of bronchoscopes of adequate size to allow bronchial toilet under unobstructed vision. It may still, however, be possible to confirm the tube position. Be careful as it can result in tube displacement.

Breathing:

•Large amount of blood in the tracheobronchial tree may be a major impediment to gas exchange. Maintain oxygen saturation above 94% by administering oxygen. Position the patient in lateral decubitus toward the site of bleeding as it spares the contralateral lung from aspiration.

Circulation:

•All patients should be admitted to the intensive care unit. Vital signs should be monitored continuously.

•The intra-arterial line should be inserted for continuous blood pressure monitoring.

•Two large-bore intravenous lines or a central venous catheter should be inserted and intravenous fluids should be started.

•If the condition is rapidly deteriorating, O-positive blood (O-negative in case of women of childbearing age) should be transfused while waiting for blood grouping and crossmatching. Meanwhile, determine the blood type, crossmatch, and request for red cell units, depending on the requirement. Assess the severity of volume loss (see Chap. 64).

Step 2: Clinical assessment and localization of bleeding site

•The first step in diagnosing hemoptysis is to determine the bleeding source: respiratory tract versus a nasopharyngeal or gastrointestinal source. Querying the patient identifies the correct source in 50% of cases.

•Hemoptysis is characterized by cough with frothy sputum, which is alkaline when tested with litmus paper. In contrast, hematemesis is accompanied by nausea and vomiting, and is frequently acidic. Epistaxis is usually traumatic and may be localized by anterior rhinoscopy and examination of the oropharynx. Aspirated blood or swallowed blood from any of the sites can make it difficult to initially identify the origin of bleeding.

Step 3: Find out the etiology

Take a detailed history and perform physical examination, keeping in mind the various causes of severe hemoptysis (Table 8.1).

Physical examination: The amount, color, and character of bleeding should be noted. On examination, look for specific signs that can point to a specific diagnosis as mentioned in Table 8.2.

Oral and aphthous ulcers, genital ulcers, and uveitis—Behcet’s disease in which pulmonary arteriovenous malformations (AVM) are responsible for hemoptysis

Cutaneous purpura or ecchymosis—coagulation disorders

Diastolic murmur—mitral stenosis

Saddle nose with rhinitis and septal perforation—Wegener’s granulomatosis

Step 4: Plan investigations

The following investigations should be ordered in all patients:

•Hemoglobin, hematocrit, platelets count, coagulation studies (prothrombin time including international normalized ratio, partial thromboplastin time).

•Renal function tests.

•Liver function tests.

•Arterial blood gas analysis.

•D-dimer, urinalysis.

•Chest skiagram: Chest radiography helps in localizing the bleeding source in 60% of cases and identifying possible etiology such as a lung mass, cavitary lesion, or alveolar hemorrhage.

•Further investigations will depend on the possible diagnosis.

•Sputum/bronchoalveolar lavage should be tested for bacteria including mycobacteria, fungi, and malignant cells.

•Multidetector computed tomography (MDCT) has proved to be of considerable diagnostic value in localizing the site of bleeding. Contrast-enhanced MDCT produces high-resolution angiographic studies with a combination of multiplanar reformatted images. Therefore, MDCT angiography is able to identify the source of bleeding and underlying pathology with high sensitivity. This is of particular importance to the interventional radiologist planning for arterial embolization.

•If MDCT is not available, contrast-enhanced single-detector spiral CT can be performed to detect bronchial and nonbronchial systemic arterial vascular lesions such as thoracic aneurysm and AV malformation. Except for life-threatening situations, thoracic CT scans should be performed prior to bronchoscopy.

Step 5: Bronchoscopy

•Diagnostic bronchoscopy is the primary method for diagnosis and localization of hemoptysis. Rigid bronchoscopy is ideally recommended in cases of massive hemoptysis because of its ability to maintain airway patency.

•Flexible bronchoscopy (FOB) is used more widely, considering the ease of performance at the patient’s bedside without the use of general anesthetic and operating theatre suite. Vasoactive drugs can be instilled directly into the bleeding source. The overall diagnostic accuracy of bronchoscopy in localizing the site of bleeding is 50%, but it is less useful in identifying the underlying cause. Further disadvantages include nonvisualization during active hemoptysis, and ineffectiveness of endobronchial therapies in most cases. The ideal time for bronchoscopy is controversial, but the consensus is to perform urgent bronchoscopy in patients with massive hemoptysis.

•In case plug of blood clot is seen in a segment, it is recommended not to remove it as it may restart massive hemoptysis.

•Administer local therapy: The following therapeutic measures can be tried through the fiber bronchoscope to control bleeding.

–Iced saline bronchial lavage in the involved lung

–Iced saline lavage of up to 1,000 mL in 50 mL aliquots at the bleeding site

–Administration of topical hemostatic agents, such as epinephrine (1:20,000) or thrombin-fibrinogen

–Tamponade therapy, using oxidized regenerated cellulose mesh

•Another alternative site-specific therapy that can be tried using the flexible bronchoscope includes endobronchial tamponade using a balloon tamponade catheter to prevent aspiration to the unaffected contralateral lung and preserve gas exchange.

•A bronchus-blocking balloon catheter has been designed to be used through the working channel of the flexible bronchoscope which has a second channel that is used to instill vasoactive hemostatic agents, such as iced saline, epinephrine, vasopressin, or thrombin-fibrinogen, to control bleeding.

Step 6: Start pharmacotherapy

•Antibiotics and steroids, depending on the underlying condition, are necessary to control the precipitating cause.

•Intravenous vasopressin has not been shown to improve the outcome, and therapies such as vitamin K supplements and tranexamic acid have a doubtful role.

•Correct coagulation abnormalities with appropriate platelet, fresh frozen plasma, and cryoprecipitate.

•Recombinant activated factor VII (rFVIIa) can be tried as it has been reported as an effective temporizing measure in unstable patients with hemoptysis due to community-acquired pneumonia, when conventional treatment is not immediately available in the setting of a regional hospital.

Step 7: Bronchial artery embolization (BAE)

•Bronchial artery angiography is highly effective in localizing the source of bleeding and identifying a vessel for embolization. The bronchial circulation (a high-pressure circuit with systolic pressure of 120 mmHg) is the most common source of massive hemoptysis, accounting for 95% of all cases. Less than 5% of