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Approach to Life-Threatening Hemoptysis

ARTICLE in CLINICAL PULMONARY MEDICINE OCTOBER 2003
DOI: 10.1097/01.cpm.0000087525.38267.23

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CRITICAL CARE/RESPIRATORY CARE

Approach to Life-Threatening Hemoptysis

Jorge Roig, MD, PhD, FCCP,* Laureano Molins, MD, Ramon Orriols, MD,
Josep Gomez, MD, PhD, and Manuel Gonzalez, MD

Abstract: The classic concept of massive hemoptysis has been replaced

by the newer one of life-threatening hemoptysis (LTH), which means
any bleeding from the lower respiratory tract that may cause the death
of the patient. Although asphyxia is the usual mechanism of death,
hypovolemic shock also plays a role in certain cases. The amount of
expectorated blood does not always correlate with the actual volume of
bleeding. The underlying state of health, especially basal respiratory
function, plays a crucial role when the real consequences of bleeding
are considered. The following factors have to be evaluated when a
temporary or definitive treatment is chosen: setting of the hemoptysis,
presumptive etiology, degree of clinical instability, equipment resources, and personal expertise in different techniques. The most
important role of bronchoscopy is its rapid availability when hemoptysis is severe and the patient is not sufficiently stable to be immediately
taken to the angiography department. In that situation, orotracheal
intubation and bronchoscopy may be lifesaving. Rigid bronchoscopy, in
skilled hands, has proven to be superior to flexible bronchoscopy in
massive hemoptysis. Fiberoptic bronchoscopy (FOB) is also helpful as
an extreme emergency measure to properly place an orotracheal tube
contralateral to the bleeding side. Endoscopic local measures may
sometimes help to transitorily stop bleeding. If the cause of hemoptysis
is itself susceptible to primary surgical treatment and the condition of
the patient is sufficiently good in terms of pulmonary reserve, life
expectancy, and hemodynamic stability, then surgery is indicated. If the
condition of the patient is not good enough, a temporary method to stop
hemorrhage and stabilize the patient is then warranted. Although
bronchoscopy and bronchial artery embolization (BAE) should be
ideally complementary, recent data suggest that BAE may be a more
effective temporary measure to stop bleeding.
Key words: hemoptysis, massive, life-threatening
(Clin Pulm Med 2003;10: 327335)

From the *Department of Pulmonary Medicine, Emergency, and Anesthesiology, Hospital Nostra Senyora de Meritxell, Escaldes-Engordany,
Principality of Andorra; Department of Pulmonary Medicine, Hospital
Universitari Vall Hebro, Barcelona, Spain, and Department of Thoracic
Surgery, Hospital Sagrat Cor, Barcelona, Spain.
Address correspondence to: Jorge Roig, MD, PhD, FCCP, Hospital Nostra
Senyora de Meritxell Department of Pulmonary Medicine Fiter Rosell 113.
Escaldes-Engordany, Principality of Andorra. Email:averoig@mypic.ad.
Copyright 2003 by Lippincott Williams & Wilkins
1068-0640/03/1006-0327
DOI: 10.1097/01.cpm.0000087525.38267.23

GENERAL CONSIDERATIONS

emoptysis refers to the expectoration of blood that originates from the lower respiratory tract. From a general
point of view, it is a common symptom that may result from
a wide range of causes. Occasionally, blood from the upper
gastrointestinal tract or upper respiratory tract may closely
mimic hemoptysis.1,2 The prognosis is good in most cases of
mild hemoptysis, even if the underlying cause remains unidentified. In the case of LTH, a consistent negative predictive factor is massive bleeding itself and the presence of some
specific causes, such as lung malignancy or bleeding diathesis.3 In spite of the difficulties inherent in a case of LTH,
clinicians have to attempt an etiologic diagnosis because
some of the etiologies, as we will see later, require a therapy
that is not included in other general therapeutic recommendations.
Three factors are probably more decisive than the
volume of expectorated blood: the basal state of health of the
patient, especially cardiovascular status and pulmonary reserve; the speed of bleeding; and the amount of blood that
may be retained within the lungs without being brought up.4
This last and sometimes-neglected phenomenon is a frequent
problem in hemoptysis caused by diffuse alveolar hemorrhage (DAH), whatever the etiology,57 and also may be
sometimes expected in elderly people with low respiratory
muscle strength and chronic difficulties in expectorating.
Bronchoalveolar lavage revealing an increasingly bloody
lavage fluid return is the key to diagnosing alveolar hemorrhage. A list of causes of DAH is shown in Table 1.
The term massive hemoptysis is variably applied in the
literature. The volume of expectorated blood has ranged from
200 mL to as much as 1,000 mL during 24 to 48 hours in
different series.8,9 When a patient is bleeding actively on
clinical presentation, there is a clear risk of death through
asphyxia or hemodynamic collapse. Then, a more aggressive
therapeutic approach is mandatory. In this situation, we
believe it should be called massive hemoptysis, whatever the
amount of expectorated blood; clinical anamnesis is not
feasible because patient, relatives, and even health providers
usually panic. Sometimes, clinical information may be obtained from patient records, but the first rule is to prevent the
patient from dying from respiratory failure or hypovolemic

Clinical Pulmonary Medicine Volume 10, Number 6, NovDec 2003

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Clinical Pulmonary Medicine Volume 10, Number 6, NovDec 2003

TABLE 1. Causes of Diffuse Alveolar Hemorrhage (DAH)

Bone marrow transplantation, especially autologous
Drug-induced pulmonary hemorrhage*
Isolated pulmonary capillaritis with negative antineutrophil
cytoplasmic antibodies
Isolated pulmonary capillaritis with positive antineutrophil
cytoplasmic antibodies
Pulmonary arterial fibromuscular dysplasia
DAH associated with high altitude pulmonary yedema
DAH with positive antiglomerular basement membrane antibodies
without renal involvement
Collagen vascular diseases
Idiopathic pulmonary hemosiderosis
Systemic vasculitides
Negative pressure alveolar hemorrhage (acute upper airway
obstruction)
Serious group A streptococcal infections
Ehlers-Danlos syndrome
Crack-cocaine inhalation
Severe bleeding diathesis, such as disseminated intravascular
coagulation
Trimellitic anhydride inhalation
Primary antiphospholipid syndrome
Lung transplant rejection
Pulmonary-renal syndrome
Pulmonary infection in the immunocompromised host
Pulmonary veno-occlusive disease
*Anticoagulant therapy, thrombolytic therapy, dextran solutions in hysteroscopic procedures, and many drugs such as valproato, propylthiouracil,
phenytoin, retinoic acid syndrome, penicillamine, nitrofurantoin, mytomicin,
and other types of chemotherapy.

Only 2 reports, 1 associated with hemothorax.

Pulmonary capillaritis complicating collagen vascular diseases, mixed

connective disease, rheumatoid arthritis, polymiositis, systemic lupus erythematosus, scleroderma.

Wegener granulomatosis, microscopic polyangiitis (polyarteritis nodosa), cryoglobulinemia, Behcet syndrome, Heno ch-Schoenlein purpura.

Goodpastures syndrome, immunoglobulin A glomerulonephritis,

paucine-immune crescentic glomerulonephritis.

ity. However, its role in LTH and massive bleeding is not so

clear.4,8,9 The top priority is to avoid asphyxia and to ensure
proper ventilation and hemodynamic stability, goals not
within the scope of benefits derived from CT. Some CT
findings may be extremely helpful in clinical differential
diagnosis. CT can detect occult lung abnormalities unobserved in the radiograph. CT is frequently invaluable in the
early detection of cavitation and the halo-sign within an
infiltrate, when a chest radiograph fails to show this information. These findings are helpful in increasing the index of
suspicion of certain aggressive, necrotic lung infections with
a high risk of unexpected massive bleeding, such as aspergillosis or mucormycosis.10 13 An early diagnosis of these
causes could favor a more effective surgical therapeutic
approach, as discussed later. High-resolution CT is most
useful in the diagnosis of bronchiectasis, to the point that
bronchography has been abandoned. Helical CT has provided
significant insight into the diagnosis of pulmonary embolism
and aortic dissection, 2 specific causes of potential LTH that
require distinctive therapeutic approaches. The diagnostic
yield is not so high in other etiologies, such as pulmonary
arteriovenous vascular malformations. In this case, diagnosis
by contrast-enhanced magnetic resonance angiography also
has been recently reported, but the effectiveness of this
method may be inhibited by severe active bleeding. Pulmonary arteriography seems superior in this particular setting
because it permits a combined diagnostic and therapeutic
procedure. CT scanning has some pitfalls, the most common
being that accumulated blood in dependent areas or clots in
the bronchial lumen may be misleading and suggest tumor.
Moreover, except in those cases stated above, in which
CT-based diagnosis may indicate the need of urgent surgery,
scanning does not usually lead to any immediately effective
treatment. Finally, in cases of massive hemoptysis, removal
of an unstable patient from the intensive care unit (ICU) is
injudicious unless a therapeutic procedure is planned.

ETIOLOGY
shock. Here, the frontier between LTH and massive hemoptysis is subtle and depends on clinical judgment. A difficulty
is that LTH and even massive hemoptysis often are not
heralded by any progressive increase in the volume of hemoptysis. Consequently, there must be awareness of the large
list of potential causes of LTH. Moreover, all medical centers
should have a customized protocol to effectively treat this
frightening condition, according to local expertise and technical equipment availability.

THORACIC COMPUTED TOMOGRAPHY (CT)

Thoracic scan is a reputable complementary test in the
search for a cause of hemoptysis, especially when a chest
radiograph is not sensitive enough to identify any abnormal-

328

The likely decreasing frequency of massive hemoptysis, at least in developed countries, is reflected in the scarcity
of large series in the last decade.14,15 In general, it seems clear
that the etiology of LTH and massive hemoptysis in advanced
countries has shifted from infection-derived causes to other
etiologies. Chronic inflammatory bronchial and lung diseases
are probably the leading causes of LTH in the United States
and part of Europe. The incidence of specific diagnoses varies
depending on geographic areas with a higher prevalence of
causes related to active infection, such as tuberculosis, hydatidic cyst, or paragonimiasis in Third World countries. Improvement in diagnostic methodology and the trend to more
invasive diagnostic procedures have undoubtedly contributed
to the decrease in the percentage of cases of LTH of unknown
cause and the increase of other etiologies that previously have
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Clinical Pulmonary Medicine Volume 10, Number 6, NovDec 2003

been underestimated. For example, the widespread availability of bronchial arteriography has taught us that some, until
now, presumptive causes of hemoptysis, such as chronic
bronchitis, may in fact result from impressive, occult vascular
lesions that perfectly explain even a life-threatening bleeding.16 In tertiary centers, the impact of underlying anticoagulant therapy seems to have prognostic implications. In a
recent retrospective series reported by Alobeidy et al,17 as
many as 26% of patients who presented hemoptysis were
receiving anticoagulation therapy, and mortality among them
was 30%. The most frequently identified causes in this study,
which was not exclusively focused on LTH, were pneumonia
and inflammatory abnormalities.
An exhaustive MEDLINE search on less-known causes
of LTH has enabled us to elaborate a list of uncommon
potential etiologies (Table 2). Some of them have been

Approach to Life-Threatening Hemoptysis

neglected, basically because of their rarity.18 25 However, it

is advisable to keep them in mind because many require a
specific diagnostic and therapeutic approach. In some cases, a
delay in diagnosis may worsen the outcome. The progressive
increase in incidence of iatrogenic causes in LTH has encouraged us to elaborate in Table 3 a summary of medical and
surgical procedures associated with LTH. A list of those
drugs that have been reported to be effective in medical
treatment of LTH is shown in Table 4.26 33

FOB
FOB is a valuable diagnostic technique in mild to
moderate hemoptysis, but its principal role in LTH is to
identify the site of bleeding and to offer immediate temporary
measures to stop bleeding in severe cases.34 It is well known
that when FOB is performed during active bleeding, there is

TABLE 2. Uncommon, Sometimes Neglected, Potential Causes of Life-Threatening Hemoptysis

Infections
Viral lung or bronchial infection*
Necrotizing bronchial fungal infection
Bacterial endocarditis
Mycotic intrathoracic aneurisms
Hirudo medicinalis (common leech)
Cardiovascular
Eisenmenger syndrome
Mitral stenosis
Left ventricle pseudoanerysm
Aortobronchial fistulas
Vascular pulmonary abnormalities associated with liver disease
Vasculitis
Tracheobronchial form of Wegener Behcet vasculitis
Hughes-Stovin syndrome
Takayasu arteritis
Miscellaneous
Lymphangioleiomyomatosis
Uremia
Exogenous lipid pneumonia
Intrathoracic Recklinghausen disease
Extreme breath-hold diving
Bullous emphysema
Broncholitis obliterans organizing pneumonia
Sarcoidosis
Respiratory bronchiolitis associated interstitial lung disease
Subphrenic abscess penetrating the diaphragm

Tumors
Some pulmonary metastasis
Some endobronchial metastasis
Cystic mediastinal mass
Inflammatory pseudotumor
Pulmonary cavernous hemangiomatosis
Bronchial Circulation
Bronchial Dieulafoy disease
Racemose hemangioma of bronchial artery
Spontaneous rupture of a bronchial artery
Trauma
Lung erosion of a rib fragment
Posttraumatic coronary-pulmonary artery fistula
Late postraumatic pulmonary hematoma
Congenital Abnormalities
Agenesis of pulmonary artery
Congenital anomalies of large mediastinal vessels, such as hemitruncus
Cystic disease with/without laryngeal papylomatosis
Pulmonary sequestration
Accessory cardiac bronchus
Other Bronchial Abnormalities
Broncholithiasis
Tracheopatia osteochondroplastica
Aspiration of foreign body#
Iatrogenic causes
See Table 3

*Usually associated with disseminated intravascular coagulation and bleeding diathesis.

Occasionally reported in tropical Third World countries.

Sometimes caused even by only a localized pulmonary bulla.

Angiosarcoma and hepatocellular carcinoma.

Thyroid papillar carcinoma.

Teratoma, schwanomma.
#
Sometimes after a long asymptomatic period and occasionally with pulmonary botryomycosis.

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Clinical Pulmonary Medicine Volume 10, Number 6, NovDec 2003

TABLE 3. Iatrogenic Causes of Potentially Life-Threatening

Hemoptysis

TABLE 4. Drugs Reported to be Potentially Effective in

Some Causes of Hemoptysis

Surgical corrections of congenital heart disease*

Endobronchial brachytherapy (EBB)
Self-expanding, indwelling airway and esophageal stent-related
fistulas
Bronchoscopy-related bleeding complications
Migration to lung of vascular and heart (cardioverter defibrillator)
patches
Aortobronchial fistula after vascular aortic thoracic graft
Coronary angiography with abciximab infusion
Late bleeding after anticoagulation therapy in pulmonary
embolism
Bronchial arterial infusion of cytostatic therapy to treat pulmonary
metastasis
Pulmonary irradiation*
Lymphoma and other mediastinal tumors irradiation
Catheter-induced pulmonary artery lesion*
Transtracheal aspiration
Percutaneous lung aspiration
Long-standing tracheostomy with tracheoinnominate artery fistula
Thrombolytic therapy, especially with unsuspected cavitary lung
disease
Retained intrathoracic old gauze (gauzeoma) or sponge
Bronchovascular fistula after lung transplantation
Drug-induced bleeding diathesis and other causes of DAH
(Table 1)
Intravascular migration of fractured sternal wire after median
sternotomy
Positive pressure ventilation in patients with cavitary tuberculosis
Bronchovascular fistula after lung transplantation
Bronchial stump aspergillosis in old endobronchial silk thread
sutures
Hemoptysis secondary to veno-occlusive pulmonary disease
(VOPD) after Glen operation
Pulmonary venous stenosis after catheter radiofrequency ablation

Tranexamic acid, especially in children with pulmonary cystic

fibrosis*
Vasopressin*
Immunosuppresive drugs and steroids in some cases of DAH
Immunosuppresive drugs and steroids in vasculitis
Recombinant activated factor VII (rFVIIa)
Percutanoeus intracavitary treatment in lung fungal infection
Cidofovir in juvenile laryngeal papillomatosis-related multicystic
lung disease
Other specific antiviral therapies in respiratory viral infections
Antibacterial therapy in respiratory bacterial infections
Antifungal therapy in fungal respiratory infections
Antituberculous medication in pulmonary mycobacterial disease
Antiparasite medication in lung infections caused by parasites
Anticoagulant therapy in pulmonary thromboembolic disease
Hormonal treatment in lymphangioleiomyomatosis and thoracic
endometriosis
Corrective therapy of coagulopathies, including those of
iatrogenic cause

*Occasional long latency period.

Increased risk if close contact between the endobronchial brachytherapy

(EBB) applicator and the tracheobronchal walls at the vicinity of great
vessels, initial dose 2000 cGy, previous laser treatment, and second
administration of intraluminal therapy.

Endoscopic foreign body removal, biopsy of highly vascular endobronchial lesions, such as carcinoid tumor, transbronchial biopsy, or brushing of
unsuspected inflammatory, hypervascularized, areas, endobronchial clot removal immediately after massive hemoptysis, endobronchial biopsy of
benign tissue with unexpected submucosal bronchial artery, needle aspiration
of unsuspected pulmonary artery aneurism.

a decreased diagnostic yield but an increased potential to

identify the bleeding site. Once considered the first step when
LTH was encountered, the role of FOB has been progressively supplanted by the better results obtained with BAE,
provided that this technique is available and is performed by
skilled angiographers.35 In fact, both techniques, FOB and

330

*Concern about their real effectiveness because they have been anecdotally reported in uncontrolled studies.

Vasculitis-related hemoptysis without DAH, such as may occur in

Behcet disease, Hughes-Stovin syndrome, or Takayasu arteritis.

Reported in massive hemoptysis associated with Aspergillus infection in

patients with leukemia.

Instillation of amphotericin B, sodium iodide, potassium iodide, paste of

glycerin, and amphotericin B, epsilon-amino-caproic acid.

Recent reports suggest that triazoles offer a safer and effective alternative to amphotericin B.

BAE, should be complementary and rapidly sequential whenever possible. We think that the most important role of FOB
is its rapid availability when hemoptysis is severe and the
patient is not sufficiently stable to be immediately taken to the
angiography department. If the patient needs to be stabilized
by intubation, it often takes little time for bedside FOB in the
ICU. This may give a suggested location for bleeding that can
help angiographers know where to start. In that situation,
large channel FOB performed with intubation may be lifesaving if endoscopic local measures to stop bleeding are
properly applied.
In LTH, it is strongly recommended that a rigid bronchoscope be at hand in case the flexible bronchoscope is
insufficient to control the hemorrhage. If the bleeding is
massive, that is, the patient is asphyxiating or collapsing in
spite of intubation and frequent suctioning, initial rigid bronchoscopy is mandatory if available.34,36
A variety of local methods to stop endobronchial moderate bleeding has been described. In severe hemorrhage,
blocking of the lumen from the region of bleeding is an
effective temporary method of stopping the hemoptysis.34
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Clinical Pulmonary Medicine Volume 10, Number 6, NovDec 2003

Some types of tamponade balloons are commercially available, the Fogarty catheter being the most popular. Familiarity
with a specific type is crucial to ensure appropriate placement
and good results. Placement of double-lumen tubes again
requires an experienced operator. They are designed to permit
adequate suctioning of blood, but the capacity for suction is
inferior to the large channel of other tubes or rigid bronchoscopy. An excellent in-depth review of the advantages and
pitfalls of double-lumen tubes has been recently published.37
Recent surveys among pulmonologists show that the
majority do not rely on endoscopic measures. A report by
Haponik et al38 showed that as many as 77% of practitioners
attending the 1998 American College of Chest Physicians
annual scientific assembly had experience of endobronchial
measures to control bleeding; however, only 14% of them
found these really effective. This lack of confidence in endobronchial techniques runs parallel to a progressive confidence
in the efficacy of interventional angiography. In the same
survey, 50% of clinicians were in favor of angiographic
procedures, a substantial increase compared with the 23%
who favored this approach 10 years before. These data
coincide with a recent study supporting the performance of
rapid arteriography with embolization, if feasible, instead of
an initial endoscopic procedure.35 The usual techniques consist of the instillation of cold saline or dilute epinephrine
through the bronchoscope. A potentially more appealing
approach is the intralesional injection of epinephrine solution
through a transbronchial cytology needle, although it has only
been reported in a recent case of a bleeding endobronchial
tumor.39 There has been a report of a massive hemoptysis
caused by advanced lung cancer being successfully stemmed
by injecting cyanoacrylate glue as a filling material in conjunction with a dynamic stent.40 To the best of our knowledge, preliminary studies suggesting that some benefit could
be obtained from endobronchial infusion therapy with thrombin have not been validated by later studies until now.
FOB is helpful as an emergency measure to properly
place an orotracheal tube contralateral to the bleeding side
and protect ventilation on that side. The success of this method
depends on the previous identification of the bleeding side,
either by endoscopic visualization or by means of presumptive
location according to clinical and radiologic features.

RIGID BRONCHOSCOPY
Rigid bronchoscopy is believed to be superior to flexible bronchoscopy in massive hemoptysis, a situation in
which the speed and volume of bleeding may often overtake
the suctioning capacity of the relatively narrow channel of all
flexible bronchoscopes.34,36 The advantages of effectively
cleaning the airways and ensuring permeability must be
balanced against reality: Many pulmonologists are not sufficiently trained in the art of rigid bronchoscopy; consequently,
this technique has become progressively underused. A recent
2003 Lippincott Williams & Wilkins

Approach to Life-Threatening Hemoptysis

survey of the American College of Chest Physicians has

shown that as many as 70% of pulmonologists are not in the
habit of performing rigid bronchoscopy.38 In many instances,
this unfamiliarity precludes its indication for massive hemoptysis because the frightening situation produced by massive
bleeding makes the method inadvisable in unskilled hands.
Rigid bronchoscopy also may require movement to the operating room, with potential hazards of transport. Cryotherapy, which requires rigid bronchoscopy, has been found to be
useful in the treatment of bleeding endobronchial mucormycosis and tracheobronchial amyloidosis. Laser resection also
may be useful to remove exophytic, bleeding, proximal airway lesions.

BAE
Bronchial and other collateral systemic arteries are now
considered the source of bleeding in the majority of cases of
LTH.41 Pulmonary arteries are probably responsible for less
than 10% of cases. Pulmonary arteriography instead of initial
bronchial angiography now usually is restricted to clinical
suspicion of pulmonary aneurysms, arteriovenous malformations, and sometimes pulmonary embolism. Actual visualization of bleeding through extravasation of contrast is uncommon. However, with bronchiectasis there is enough evidence
supporting confident inference of the bleeding site from the
finding of hypervascularized, tortuous areas on angiography.
Anatomic variability is a characteristic feature of the bronchial circulation, which has to be taken into account because
it may hamper the effectiveness of BAE.
The contribution of nonbronchial systemic collateral
vessels seems to be particularly relevant when pleural disease
is observed on the chest radiograph. The most significant
factor affecting long-term results is whether the inflammation
caused by the underlying disease can be medically controlled.
The degree of severity of the angiographic findings does not
seem to be a predictive factor of long-term results. A variety
of nonbronchial systemic arteries, especially intercostal arteries, may be involved in hemoptysis. Branches from

TABLE 5. Complications of BAE

Spinal complication (paraplegia)
Chest pain
Dysphagia
Main-stem bronchus infarction
Bronchial stenosis
Splenic or other systemic infarct
Bronchial-esophageal fistula
Paradoxic embolization or migration of coil
Pulmonary hypertension (if coexistent left-to-right shunt)
Referred pain to the ipsilateral forehead and orbit

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TABLE 6. Algorithmic Approach to Life-Threatening Hemoptysis

*Try to exclude those causes that would be unresponsive to these general measures, such as DAH, severe left-sided heart failure, and others.

Preferably with intubation if presence of respiratory compromise or the patient is hemodynamically unstable; rigid bronchoscopy preferred if enough local
expertise and active massive bleeding.

Once the patient is properly ventilated, if necessary, it seems to be the most effective measure for rapid control of bleeding in most instances.

If continued bleeding.

Processes in which an allegedlly radical surgical approach is superior to any other medical alternatives, such as usually happens with most tumors, localized
mycetoma, or bronchiectasis.

Once the patient is stabilized. Meanwhile, consider continuing transitory measures.

#
If poor pulmonary reserve or extensive abnormalilties causing bleeding, consider nonresection surgery (physiologic lung exclusion), particularly if
unsuccessful previous BAE.

phrenic, subclavian, axillary, left gastric arteries and thyrocervical trunk are among the less common possible sources of
bleeding. A list of complications relating to BAE is shown in
Table 5.

332

SURGERY
If the primary process that causes bleeding intrinsically
requires a surgical therapeutic approach and the condition of
the patient is good enough in terms of pulmonary reserve, life
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expectancy, and hemodynamic stability, then surgery is indicated urgently. It must be kept in mind that, at least in older
series, urgent surgical procedures, most likely in unstable
patients, were associated with a higher morbidity that elective
surgery. In consequence, if the condition of the patient is not
good enough, a temporary method to stop hemorrhage and
stabilize the patient is then warranted.9,15 Usually, angiography with embolization is the preferred method, although its
success in certain etiologies, such as mycetoma or malignant
tumors, has been relatively low compared with surgery, in
some series.42 48
An innovative surgical approach to massive hemoptysis, as an alternative to conventional surgery, has been recently reported. It is called physiological lung exclusion and
has been found to be extremely helpful in cases of LTH that
occur in high-risk surgical patients in whom bronchial angiography embolization has failed.49,50 By means of extrapleural thoracotomy, surgical interruption of the bronchus
and pulmonary artery of the involved lobe or lung is performed without ligating the pulmonary veins. The method,
sometimes performed bilaterally, was previously found efficacious in cystic fibrosis-related LTH.51 This procedure has
now been expanded into other similar clinical situations.
Postoperative recovery is accelerated if muscle-sparing thoracotomy and postoperative epidural analgesy are used.

THERAPEUTIC APPROACH TO LTH

Although a worldwide consensus has not been
achieved, some general recommendations are usually accepted in most review articles.4,9,14,15 Application of the
conclusions suggested by classic studies is hampered by the
following: Those studies usually considered a selection of
patients who could benefit from surgery. For patients with a
poor pulmonary reserve, there was a dramatic lack of the
nonsurgical therapeutic options commonly available today.
The progressive increase of invasive diagnostic and therapeutic procedures goes hand in hand with an increased risk of
iatrogenic LTH, a condition almost negligible in the old
series. Our point of view is that clinicians should avoid any
dogmatic approach to dynamically adapt to the situation of
each patient and to the real diagnostic and therapeutic options
of any specific setting.
Table 6 shows our proposal for an algorithmic approach
to LTH. General measures are listed in Table 7. It must be
emphasized that some causes are not included in this general
approach, in particular DAH; mitral stenosis; and aneurysms
associated with some vasculitides, such as Behcet disease,
Hughes-Stovin syndrome, or Takayasus arteritis. These
causes can dramatically respond to corticosteroids and immunosuppressive treatment. LTH associated with aortobronchial fistulas may be successfully treated with endoluminal
stent graft repair.52,53
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Approach to Life-Threatening Hemoptysis

TABLE 7. General Measures in Life-Threatening Hemoptysis

Immediate intubation and mechanical ventilation if
a. asphyxia
b. hypovolemic shock
Evaluate admission to the respiratory and critical care unit*
Nothing by mouth
Ipsilateral decubitus lying on the alleged bleeding side
Intravenous line
Evaluate local applicability of the general algorithmic approach:
Table 6
Provision to allow rapid blood replacement (typed and crossmatched blood)
Control of bleeding speed and volume of expectorated blood
Chest radiograph
Complete blood cell count with white cell differential and platelet
count
Coagulation profile with correction of clotting abnormalities
Arterial blood gases
Liver function tests, creatinine, electrolytes, urinalysis
Consider specialized laboratory tests, if indicated from clinical
evaluation
Consider specialized diagnostic procedures, according to clinical
suspicion
*Admission to pulmonary division ward is acceptable if good hemodynamic stability and no respiratory compromise.

Preferably central catheter for central venous pressure control in case of

hemodynamic instability.

A differential diagnosis of the cause of LTH should always be attempted. Pulmonary and thoracic surgery specialists consultation is warranted.

Consider obtaining a bleeding time if suspected qualitative platelet

dysfunction, either drug-related or underlying disease-related, such as happens in uremia.

Such as antineutrophil cytoplasm antibodies (ANCA), anti-GBM antibodies, antinuclear antibodies, microbiologic testing.

In stable patients not requiring intubation, some diagnostic procedures

may be indicated according to clinical suspicion, such as echocardiogram,
perfusion and ventilation lung scan, and thoracic CT.

In summary; when there is an identified entity causing

the bleeding and underlying condition is sufficiently good,
and the treatment of choice of the primary process is usually
surgical resection (localized bronchiectasis, tumor, mycetoma, etc.), surgery is indicated once clinical stability has
been obtained. If the patient is not fit for surgery because of
hemodynamic instability or poor pulmonary reserve, angiography with embolization is usually the best therapeutic option
because urgent surgery in unstable patients is associated with
a high risk of morbidity and mortality. However, in certain
circumstances, BAE may be not successful. Failure to stop
bleeding may be due to technical drawbacks or to the relatively low success sometimes observed in determined specific
causes, such as necrotic tumors or cavitary infections (mycetoma, cavitary invasive fungal infection, abscess).10 13,42 48
On the other hand, in the case of patients for whom medical

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Roig et al

treatment is usually effective, temporary measures to stop

bleeding are recommended as the first step.

ACKNOWLEDGMENTS
We are indebted to Judith Wood for her editorial
assistance.
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