Treatment

Treatment in the emergency department depends on the severity of the hemoptysis and the likelihood of a malignant cause. All patients with massive hemoptysis, and some patients with minor hemoptysis due to tuberculosis, mycetoma, or bronchiectasis, who are at significant risk of developing massive hemoptysis in the near future, require urgent management and hospitalization. All such patients require intravenous access, supplemental oxygen to ensure adequate arterial saturation, and typing and cross-matching of blood.

Patients with ongoing massive hemoptysis from one lung should be positioned with the bleeding lung dependent to minimize soiling of the contralateral lung. Tracheal intubation with a large-diameter endotracheal tube (8 French or larger to allow for bronchoscopy) is indicated if there is respiratory failure or if the patient is unable to clear the blood from the airways. Double-lumen endotracheal tubes have smaller lumina, which limit suctioning and ventilation. 2 If bleeding persists despite initial measures, the endotracheal tube may be advanced to the main-stem bronchus of the nonbleeding lung to minimize further aspiration of blood. The right main-stem bronchus is easily entered by advancing a standard orotracheal tube. This procedure will occlude the right upper lobe tertiary bronchus and ventilate the right middle and right lower lobes only.2 The left main-stem bronchus is more sharply angled from the trachea, and selective intubation usually requires special equipment and technique. Mechanical ventilation should be instituted as necessary to support ventilation.

Fresh-frozen plasma should be administered to correct coagulopathy, and platelet transfusions are indicated for thrombocytopenia. Cough suppression with codeine or opioids might be helpful to prevent dislodging of hemostatic clots but carries the risk of suppressing ventilation and increases the risk of aspiration.

Emergency consultation is indicated with a pulmonologist or thoracic surgeon who may arrange for bronchoscopy, high-resolution chest CT scan, or bronchial artery angiography to localize the specific bleeding site.10 Patients with massive hemoptysis that has subsided are at high risk of recurrence and require similar intensive management and hospital admission, usually to an intensive care unit. Massive hemoptysis is less common in children, but similar evaluation and management are appropriate.

Patients with minor hemoptysis due to bronchitis should be treated for the underlying disease as appropriate. Smoking cessation, oral antibiotics, and inhaled b-agonist bronchodilators have a role in the treatment in acute bronchitis. Patients at high risk for neoplasm should have a follow-up consultation with their primary care physician or a pulmonary subspecialist.

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