Massive Hemoptysis

Risk factors

• Bronchiectasis (any cause, especially cystic fibrosis) — most common in developed world
• Tuberculosis with cavitary disease (Rasmussen aneurysm) — most common globally
• Lung cancer (bronchogenic carcinoma, especially squamous cell with central cavitation)
• Aspergilloma colonizing a pre-existing cavity
• Bronchitis (chronic and acute) — most common cause of non-massive hemoptysis
• Mitral stenosis, AV malformations, pulmonary embolism with infarction
• Vasculitis (granulomatosis with polyangiitis, microscopic polyangiitis, anti-GBM disease)
• Coagulopathy and anticoagulant use
• Trauma (penetrating or blunt)
• Iatrogenic — Swan-Ganz catheter rupture of pulmonary artery, recent bronchoscopy or biopsy

Pathophysiology

Approximately 90% of massive hemoptysis arises from the bronchial circulation (systemic pressure ~100 mmHg) rather than the pulmonary circulation (pressure ~15-25 mmHg). Chronic inflammation, infection, or malignancy stimulates bronchial artery hypertrophy and neovascularization. Erosion of a tortuous, high-pressure bronchial vessel into an airway produces brisk bleeding. Less commonly, pulmonary arterial sources include Rasmussen aneurysm in TB cavities, AV malformations, and iatrogenic PA rupture.

Clinical presentation

Differential diagnosis

• Upper airway / oral bleed (pseudohemoptysis) — Blood from gums, epistaxis swallowed and re-expectorated; ENT exam clarifies; absent cough-driven expectoration
• Hematemesis — Coffee-ground or red emesis, acidic, mixed with food; precedes nausea rather than cough
• Bronchitis — Most common cause of small-volume hemoptysis; viral URI, smoker, no constitutional symptoms
• Lung cancer — Smoker >40 y, weight loss, mass on imaging, may erode central airway
• Tuberculosis — Constitutional symptoms, exposure history, upper-lobe cavitation, AFB sputum
• Bronchiectasis / CF — Chronic productive cough, recurrent infections, tram-track on CT
• Pulmonary embolism with infarction — Pleuritic pain, hypoxia, risk factors; CTPA diagnostic
• Vasculitis / DAH — Anti-GBM, ANCA, glomerulonephritis, alveolar infiltrates, dropping Hgb without expectoration
• Mitral stenosis — Dyspnea, pulmonary venous hypertension, opening snap; pink frothy sputum

Diagnostic workup

Diagnostic algorithm

flowchart TD
  A[Massive hemoptysis] --> B[Position bleeding side DOWN<br/>O2, IV access x2, T&C]
  B --> C{Airway protection?}
  C -->|Compromised| D[Intubate w/ large ETT<br/>± mainstem to unaffected side]
  C -->|Stable| E[Urgent CT angio chest]
  D --> F[Bronchoscopy:<br/>tamponade, APC, topical]
  E --> G[Bronchial artery angio +<br/>embolization]
  F --> G
  G --> H{Bleeding controlled?}
  H -->|Yes| I[Treat underlying cause]
  H -->|No| J[Surgical resection<br/>or repeat embolization]

Treatment

Complications

• Asphyxiation (primary cause of death)
• Hemorrhagic shock
• Aspiration pneumonia and ARDS
• Spinal cord ischemia from bronchial artery embolization
• Rebleeding (within hours to months)

PANCE pearls

• Massive hemoptysis kills by asphyxiation, NOT exsanguination — protect the airway first.
• Position bleeding side DOWN if known; if unknown, supine with head down on the side most likely affected by imaging.
• Most bleeding (90%) is from BRONCHIAL arteries (systemic pressure) — bronchial artery embolization is first-line definitive therapy.
• Swan-Ganz catheter rupture of the pulmonary artery presents as sudden massive hemoptysis in an ICU patient — do NOT remove the catheter; deflate balloon, leave in place to mark the bleeding pulmonary artery for embolization.
• Always check anti-GBM and ANCA when diffuse alveolar hemorrhage is suspected — many vasculitic causes present without true frank hemoptysis.

References

• CHEST 2020 — Davidson K, Shojaee S. Managing Massive Hemoptysis. CHEST 2020;157:77-88
• ATS — Ittrich H et al. The Diagnosis and Treatment of Hemoptysis. Dtsch Arztebl Int 2017;114:371-381 (frequently referenced in ATS materials)
• SIR — Society of Interventional Radiology Position Statement on Bronchial Artery Embolization (2018)