Adequate suctioning of blood from the airway is necessary to provide clear visualization during endotracheal intubation. A single standard suction catheter such as a Yankhauer catheter can easily be overwhelmed, becoming ineffective in some patients with massive hemoptysis. Suggestions for adequate suctioning to ensure visualization during endotracheal intubation in this setting include employing a meconium aspirator attached to the endotracheal tube, or the suction assisted laryngoscopy and airway decontamination, or SALAD, technique with a DuCanto aspirator.^8,9 If blood overwhelms the ability of the catheter to clear the blood enough to allow visualization to facilitate endotracheal intubation, do not hesitate to move quickly to performing a cricothyrotomy.

If it is determined that the bleeding originates from one lung it is recommended to position the patient in lateral decubitus with the bleeding lung down to avoid contamination of the contralateral lung. Portable chest X-ray may help determine from which lung the bleeding originates.

3. Early consultation with ICU, interventional radiology, interventional pulmonology, thoracic surgery, and/or anesthesia (depending on local practice and underlying cause)

The definitive management of life-threatening hemoptysis involves source control, which usually requires a procedure, most commonly bronchial artery embolization performed by interventional radiology, bronchoscopy with local instillation of tranexamic acid (TXA), or epinephrine by interventional pulmonology or surgical resection by thoracics.^10–12

4. Administer nebulized tranexamic acid

Inhaled nebulized TXA has been shown in one small, randomized control trial (RCT) and one retrospective study to hasten resolution of non-massive hemoptysis.^13,14 The typical regimen is 500 mg three times daily. Larger doses of 1 to 2 g for massive hemoptysis have shown promise based on several case reports.^15–17 One RCT compared nebulized TXA with intravenous TXA and showed that resolution occurred in 30 minutes in 72 percent of patients in the nebulized group compared to 51 percent in the intravenous group, with a lower admission rate and lower volume of hemoptysis in the nebulized group.¹⁸ Larger RCTs are required before recommending TXA for patients with massive hemoptysis, however this author recommends its use in this setting, as the potential benefit likely outweighs the rare harms of nebulized tranexamic acid.

5. Reverse coagulopathies, if present

If patients with massive hemoptysis have recently taken an oral anticoagulant, they should receive specific reversal agents or prothrombin complex concentrates with or without Vitamin K, depending on the specific agent.¹⁹ If the patient has severe thrombocytopenia, consideration should be given to platelet transfusions, to target a platelet count greater than 50 x 109/L.²⁰ (If the fibrinogen is less than 150 mg/dL, consider giving fibrinogen concentrate.⁵