Clinical assessment and management of massive hemoptysis

OBJECTIVE: Massive hemoptysis is a potentially lethal condition that deserves to be investigated thoroughly and brought under control promptly. The mortality rate depends mainly on the underlying etiology and the magnitude of bleeding. Although the diagnosis of hemoptysis may be established by chest radiograph, many pathologies may be missed. Because bronchoscopy and computed tomography are complementary, they may indicate pathologies not detectable by chest radiograph. Finding the etiology and site of the hemoptysis is imperative. INVESTIGATIONS: Urgent bronchoscopy should be performed in unstable patients because it exacts a paramount role in the diagnostic search and therapy. It can be used to facilitate the introduction of balloon-tip catheters into the bleeding bronchus for tamponade of the hemorrhagic artery, protecting de facto the contralateral lung or nonbleeding bronchi from blood aspiration. Endobronchial tamponade should only be used as a temporary measure until a more specific treatment is instituted. In stable patients, computed tomography should be ordered before any bronchoscopic exploration. INTERVENTIONS: Surgery was once regarded as the treatment of choice in operable patients with massive hemoptysis. Bronchial artery embolization (BAE) is an excellent nonsurgical alternative; it is proven to be very effective and lacks the mortality and morbidity encountered in surgical interventions. Nevertheless, surgery is recommended in patients with massive hemoptysis caused by thoracic vascular injury, arteriovenous malformation, leaking thoracic aneurysm with bronchial communication, hydatid cyst, and other conditions in which BAE would be inadequate. MEDICAL MANAGEMENT: Conservative medical therapy may suffice in certain conditions, like bronchiectasis, coagulopathies, Goodpasture's syndrome, and acute bronchopulmonary infections. Preparation for other interventions (endobronchial tamponade, BAE, or surgery in eligible candidates) should be undertaken if the bleeding fails to respond to conservative measures. Supportive therapy should be applied vigorously to all patients with massive hemoptysis.