Management of life-threatening hemoptysis in the ICU

Life-threatening hemoptysis is commonly encountered in the ICU and its management can be challenging even for experienced clinicians. Depending on the etiology and severity, one can tailor the treatment modality and therapeutic intervention(s). The grading of severity of hemoptysis varies greatly in the literature; however, unlike hemorrhage in other scenarios, small amounts of blood can significantly impair oxygenation and ventilation leading to cardiovascular collapse. Importantly, the initial evaluation and management should focus on airway and hemodynamic stabilization along with maintenance of oxygenation and ventilation. In this review, we discuss commonly encountered etiologies, vascular anatomy, diagnostic evaluation, and therapeutic interventions. We examine the evolving trends in etiologies of life-threating hemoptysis over the years. The role of flexible and rigid bronchoscopy as both a diagnostic and therapeutic modality is explored, as well as the use and indications of several bronchoscopic techniques, such as topical hemostatic agents, endobronchial tamponade, and tranexamic acid (TXA). In addition, we assess the use of multi-row detector computed tomography as the initial rapid diagnostic method of choice and its use in planning for definitive treatment. The efficacy and long-term results of bronchial artery embolization (BAE) are evaluated, as well as indications for surgical intervention. Furthermore, the importance of a multidisciplinary approach is emphasized. The necessary interplay between intensivists, consultative services, and radiologists is described in detail and an algorithmic management strategy incorporating the above is outlined. Given the complexity in management of life-threatening hemoptysis, this paper aims to summarize the available diagnostic and therapeutic methods and provide a standardized approach for the management of patients with this often difficult to treat condition.