Definition

• Severe is defined as ≥100-600 ml/day, massive >600 ml/day but clinical impact may be more important than absolute quantity (e.g., poor lung reserve might not be able to tolerate lower volumes of hemoptysis). 
• Massive hemoptysis most commonly originates from the bronchial arterial circulation.
• Bronchiectasis and cancer are the most common cause of massive hemoptysis, and bronchitis for trivial bleeding.
• Hemoptysis due to bronchiectasis in patients with cystic fibrosis or invasive aspergillus in neutropenic patients is increasingly common in the U.S.  

Evaluation

Differential diagnosis:

• Remember “BATTLE CAMP”: Bronchitis, bronchiectasis, Aspergilloma, Tumor, TB, Trauma, LV failure, Embolism (PE), Connective tissue disease (Goodpasture syndrome, granulomatosis with polyangiitis), CHF, coagulopathy, Abscess, AVM, alveolar hemorrhage, Mitral stenosis, PNA.
• Initial labs: CBC (platelets), PT/PTT/INR, type & screen/cross.
• Additional labs if clinical suspicion present: ANCA, anti-GBM, sputum cytology, AFB sputum cultures. 
• Imaging: CXR, CT, bronchoscopy, arteriography.
• Must rule out GI or ENT source.

Management

For severe hemoptysis:

• 2 large bore IVs.
• Transfer to ICU.
• Patient should lie with bleeding side down (if known).
• Airway is of key importance - consider intubation with double lumen endotracheal tube, or single lumen intubation to contralateral side (e.g. if bleeding localized to left, can insert ETT into right mainstem bronchus).
• Correct coagulopathy (goal platelets >50,000, INR <1.5).
• CT angiography is used to assess the site of bleeding.
• Call interventional radiology (IR) and pulmonary consult immediately.
• Less common, but if bleeding cannot be controlled, may need to call surgery for lobectomy.

Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000;28:1642-1647.

Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management.  Am Fam Physician 2005;72:1253-1260.

Piccini & Nilsson. Osler Medicine Handbook, 2nd Ed. Ch 84-Adla Sukhar, Sarah Noonberg, Edward Haponi