First Things First (assess & treat for the following)

• FIRST: Protect the airway.
  • Any patient with massive hemoptysis should be admitted to a monitored setting.
  • Death from hemoptysis usually results from asphyxiation rather than exsanguination.
  • Intubation: clinical judgment based on volume & rate of bleeding as well as patient’s cardiopulmonary reserves
  • Remember, anatomic dead space only 100-200 ml.
  • Use largest ETT possible (8.0 ETT or larger) to facilitate therapeutic bronchoscopy.
  • Temporizing measures for specific iatrogenic hemorrhage
    • Tracheostomized pt? Apply anterior/downward pressure on tracheal cannula and over-inflate cuff (tracheo-arterial fistula).
    • PA catheter balloon recently inflated? (PA rupture): Withdraw catheter slightly and re-inflate balloon to compress bleeding vessel more proximally.
• SECOND: Localize/lateralize the site of bleeding with CXR or FOB.
  • Stable vs. unstable pt will alter algorithm.
  • CXR may mislead; fails to localize source in 20-50%.
  • Urgent bronchoscopy for massive hemoptysis
  • Protect non-bleeding lung by positioning patient with bleeding side dependent.
  • Unilateral lung intubation may protect non-bleeding lung.
  • If R-sided source can selectively intubate L lung over bronchoscope
  • If L-sided source can selectively intubate R lung, but risk obstruction of RUL orifice
  • If L-sided source can selectively ventilate R lung by intubating trachea and then occluding LUL bronchus with 14 Fr Fogarty balloon catheter
  • Use double-lumen ETT only if skilled & knowledgeable practitioner is available; serious consequences with poor positioning.
    • Double-lumen ETT will hamper therapeutic bronchoscopy and suctioning due to smaller-diameter lumen.

• THIRD: Resuscitate, supportive care
  • Supplemental oxygen
  • Volume resuscitation, evaluate need for transfusion
  • Correct coagulopathy
  • Sedation
  • Cough suppression: codeine sulfate
  • Immediate pulmonary & surgical evaluation
  • Rule out pseudohemoptysis.
    • Upper GI bleeding
    • Nasopharynx or oral cavity bleeding
    • Evaluate posterior pharynx & upper larynx.
    • Hematemesis usually dark, frequently acidic, may be mixed with food particles
    • Hemoptysis usually bright red, frothy, alkaline pH
• FOURTH: Provide definitive and specific treatment (see General Management Principles)
• FINALLY: Prevent recurrent bleeding.