High risk and low incidence diseases: Massive hemoptysis

Massive hemoptysis (MH) is a serious condition that carries with it a high rate of morbidity and mortality.

This review highlights the pearls and pitfalls of massive hemoptysis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

MH is a rare but deadly condition. It is defined clinically as any bleeding from the tracheobronchial tree that compromises respiratory or circulatory function. The bronchial artery system is the primary source in the majority of cases of MH. The most common cause is tuberculosis worldwide, but bronchiectasis, bronchogenic carcinoma, and mycetoma are more common causes in the U.S. Patients with MH require rapid assessment and management, as decompensation can be rapid. Patients with altered mental status, inability to clear their sections, respiratory distress, or hemodynamic compromise require emergent airway intervention. The imaging modality of choice is computed tomography angiography with pulmonary arterial phase contrast. A reasonable order or sequence of management includes initial stabilization; assessment for the need for airway intervention; reversal of any coagulopathy; advanced imaging; and emergent consultation of pulmonary, cardiothoracic surgery, and interventional radiology. Ongoing resuscitation including blood products may be required in some patients with MH until definitive hemostasis is achieved.

An understanding of MH can assist emergency clinicians in diagnosing and managing this dangerous disease. Providing a prompt evaluation, obtaining intravenous access, pursuing advanced imaging, providing reversal of coagulopathy, supporting hemodynamics, and appropriate consultation are key interventions in MH.