One of the most hair-raising presentations to the emergency department (ED) can be  massive hemoptysis with respiratory failure. While life-threatening hemoptysis represents a minority of hemoptysis cases seen in the ED, it is imperative we have an efficient and organized approach to management, as respiratory failure and death can occur rapidly. The definition of massive hemoptysis is variable across publications with expectorated blood volumes ranging from 100 to 1,000 mL per 24 hours, as these volumes are difficult to estimate for any given patient. A more practical definition of massive or life-threatening hemoptysis is that which causes signs of worsening respiratory distress, hemodynamic instability, abnormal gas exchange, or airway obstruction.¹ However, it is important to understand that death from hemoptysis is almost always due to hypoxia or asphyxiation (blood impedes gas exchange in the lungs, typically because of bleeding from high-pressure bronchial arteries into the lungs) as opposed to hemodynamic instability.² Death from hemoptysis is akin to drowning, so airway considerations usually take precedence over hemodynamic considerations. A common clinical pitfall is assuming that a patient who is coughing up a small amount of blood is not at risk for respiratory failure. Some patients accumulate blood in the lungs without voluminous expectoration, as reflected by hypoxemia and respiratory distress. These patients are at imminent risk of respiratory failure.

1. Differentiate hemoptysis from upper respiratory tract and GI sources

Hemoptysis has a different management algorithm from upper respiratory tract bleeding and gastrointestinal bleeding, underlying the importance of this first step. Patients with a chief complaint of hemoptysis are often incorrect with regards to the source of bleeding, so relying on the patient’s history of hemoptysis alone is a pitfall. Coffee-ground appearance, nausea, vomiting, melena, abdominal pain and known gastric and/or liver disease suggest a gastrointestinal source. Concomitant epistaxis, blood in the nares, or sensation of blood dripping in the posterior pharynx suggests an upper respiratory tract source. A thorough nasopharyngeal and oral exam is recommended; nasopharyngoscopy may be necessary to rule out an upper respiratory source of bleeding. True hemoptysis is usually bright red and/or foamy blood, and is associated with respiratory symptoms as well as a sensation of warmth in the chest.³ Individuals at risk for massive hemoptysis include those with a history of lung cancer, bronchiectasis, and tuberculosis.⁴

2. Maintain adequate oxygenation and ventilation

The decision to intubate is often a difficult one, as securing the airway removes the cough reflex and may increase the rate of blood pooling in the lungs leading to even worse gas exchange. The majority of patients with massive hemoptysis can effectively clear the blood out of the lungs with vigorous coughing. In fact, patients’ ability to clear the airway is often more effective than endotracheal intubation and suctioning.⁵ If a patient with massive hemoptysis is able to maintain adequate oxygenation with coughing, intubation is not recommended. Indications for endotracheal intubation in patients with massive hemoptysis include impending or worsening respiratory failure with hypoxemia and dyspnea, hemodynamic instability, low Glasgow coma score with poor airway protection, ineffective cough with inability to clear adequate volume of blood from the lungs, and expected worsening clinical course if patient needs to be sent outside of the ED for a CT scan or definitive procedure.6 Position the patient with the head of the bed at 30 to 45 degrees during intubation whenever possible, and use an 8.5 or 9 size endotracheal tube to allow for bronchoscopy and/or endobronchial blocker placement whenever necessary.⁷ Rapid sequence intubation with video laryngoscopy or ketamine-assisted awake intubation are this author’s recommended first-attempt airway strategies in patients with massive hemoptysis who require airway control.