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Level 2 of 6Must-remember

Haemoptysis: from blood-streaked sputum to massive haemorrhage

Assess, manage and stay safe — enough on its own

The card — assess, manage, caution

Assessment— look, ask, measure

  • Prove it is haemoptysis first: haemoptysis is expectoration of blood originating below the vocal folds, so inspect the nares, gums and oropharynx with a torch in the first minute — posterior epistaxis tracking down the pharyngeal wall is the commonest impostor, and haematemesis is the other.
  • Distinguish by story and appearance: haemoptysis is preceded by coughing with a chest tickle or gurgle and the blood is bright red, frothy, mixed with sputum or pus and alkaline; haematemesis follows nausea, retching and vomiting and is dark red or coffee-ground, may contain food and is acidic; epistaxis blood is bright red, non-frothy and clotted.
  • Ask which side it feels like: many patients describe a tickle, warmth or gurgling localised to one side of the chest immediately beforehand, and patients localise the bleeding side correctly more often than is generally appreciated — often the only lateralising information you will have before imaging.
  • Measure the three signs that define severity, not the volume the patient reports: elevated pulse, hypotension and decreased oxygen saturation suggest large-volume haemorrhage warranting emergent evaluation and stabilisation.
  • Use the functional definition: massive or life-threatening haemoptysis is any amount of blood that is haemodynamically significant or that threatens ventilation — a patient producing 60 mL from a destroyed left lung with a saturation of 84% has massive haemoptysis; one who has filled a bowl slowly over two days and is pink and comfortable does not.
  • Know the numerical conventions and use the lowest: more than 150 mL in 24 hours or a bleeding rate of 100 mL/hour or more (Harrison's); more than 200-600 mL in 24 hours (CMDT); more than 200 mL in 24 hours (Kumar and Clark); more than 8 mL/kg in 24 hours in a child.
  • Watch the trend, not the total: 300 mL then 50 mL is settling, while 100 mL then 400 mL will need an airway within minutes — re-measure the loss and its rate at defined intervals.
  • The danger signs in order of how fast they kill: inability to clear blood from the airway (gurgling at the mouth, weak cough, pooling in the pharynx); falling saturation despite high-flow oxygen or SpO2 below 90% on a reservoir mask; exhaustion, rising PaCO2, drowsiness or agitation; tachycardia, hypotension and cool peripheries; inability to speak in full sentences.
  • Never dismiss a sentinel or herald bleed: a moderate bleed from a cavity, mycetoma, central tumour or aortic graft carries the same weight as a large one and must never be read as reassurance because it stopped spontaneously.
  • Ask about anticoagulants and antiplatelets — they act less as a cause than as an amplifier converting a trivial bronchial bleed into a lethal one — and about age over 40, current or former smoking, known structural lung disease, weight loss, night sweats and immunosuppression.
  • Auscultate for the bleeding lung: unilateral coarse crackles, gurgling or bronchial breathing over one zone identifies the bleeding side, a sign lost once bleeding has contaminated both lungs.
  • Look for the cause on general examination: finger clubbing (lung cancer or bronchiectasis), cachexia, hepatomegaly and lymphadenopathy (malignancy), fever with a pleural rub and consolidation (pneumonia or infarction), a mid-diastolic murmur (mitral stenosis), raised venous pressure with bibasal crackles (heart failure), mucocutaneous telangiectasia (hereditary haemorrhagic telangiectasia).
  • Match the associated symptoms to the cause: fever, night sweats and weight loss suggest tuberculosis; chronic productive cough since childhood suggests bronchiectasis or cystic fibrosis; repeated small haemoptyses or blood-streaking in a smoker over 40 with hoarseness, weight loss or a changed cough suggest lung cancer; pleuritic pain with unilateral leg swelling suggests pulmonary infarction; orthopnoea with pink frothy sputum indicates pulmonary oedema; haematuria, rash or arthralgia point to a pulmonary-renal syndrome.
  • Take a chest radiograph in every case — its greatest immediate value is lateralisation — but remember a normal film does not exclude serious disease.
  • Send blood immediately: full blood count, clotting screen and INR, urea, electrolytes and creatinine, and cross-match early.Not available at your setup — Coagulation (PT/INR), Renal function (creatinine/urea).
  • Remember the two mimic-heavy groups: in children haemoptysis is rare and almost always serious, blood in an infant's mouth is usually swallowed maternal blood and in an older child swallowed epistaxis is far commoner than true haemoptysis; and pseudohaemoptysis — red-pigmented sputum without blood from Serratia marcescens, rifampicin or factitious illness — should be considered when the picture does not fit.

Management— do this, in order

  • Position first, because gravity is the most valuable free intervention available: place the patient in the decubitus position with the bleeding lung dependent if the side is known, and nurse them upright if it is not — never with the bleeding lung uppermost and never supine.
  • Give high-flow oxygen 15 L/min via a non-rebreathe reservoir mask targeting SpO2 94-98%; in known COPD the usual target is 88-92%, but during active large-volume bleeding high-flow oxygen comes first and the target is corrected once bleeding is controlled, because hypoxaemia kills far sooner than hypercapnia.
  • Set up continuous wide-bore suction with a second unit available, because clot blocks suckers.
  • Give tranexamic acid early and before imaging: 1 g IV over 10 minutes, then 1 g by infusion over 8 hours (or 1 g IV slowly 8-hourly); child 15 mg/kg IV over 10 minutes to a maximum of 1 g, then 15 mg/kg IV 8-hourly to a maximum of 1 g per dose.Doctor / Nurse
  • Add nebulised tranexamic acid as an adjunct, never a substitute: 500 mg, that is 5 mL of the 100 mg/mL injection, nebulised three times daily in adults; the nebulised route is not established in children, so use the intravenous route.Doctor / Nurse
  • Step down orally once settled: tranexamic acid 1 g three times daily in adults, 15-25 mg/kg three times daily to a maximum of 1 g per dose in children.
  • Stop and reverse every anticoagulant, antiplatelet and non-steroidal anti-inflammatory drug: warfarin needs phytomenadione 5-10 mg by slow IV injection plus four-factor prothrombin complex concentrate 25-50 units/kg, or fresh frozen plasma 15 mL/kg if PCC is unavailable; unfractionated heparin needs protamine sulfate 1 mg per 100 units of heparin given in the preceding hour to a maximum of 50 mg by slow IV injection; enoxaparin needs protamine 1 mg per 1 mg of enoxaparin given within 8 hours to a maximum of 50 mg, which is partial reversal only.Doctor / NurseNot available at your setup — Blood & blood products.
  • Transfuse blood, not crystalloid: packed red cells for hypotension, tachycardia, continuing large-volume loss, or haemoglobin below 70 g/L (below 80 g/L in ischaemic heart disease); child 10 mL/kg repeated as guided by response.Doctor / NurseNot available at your setup — Blood & blood products.
  • Correct the coagulation: fresh frozen plasma 15 mL/kg if the INR is above 1.5 or after 4 units of red cells (child 15 mL/kg); platelets, one adult therapeutic dose, if the platelet count is below 50 x 10^9/L or on antiplatelet therapy with life-threatening bleeding (child 10-15 mL/kg).Doctor / NurseNot available at your setup — Blood & blood products, Coagulation (PT/INR).
  • Use crystalloid only as a holding measure: 250-500 mL boluses in an adult and 10 mL/kg in a child, reassessed after each, because over-resuscitation causes dilutional coagulopathy.Doctor / Nurse
  • Intubate early rather than late — for exhaustion, falling conscious level, SpO2 below 90% on high-flow oxygen, inability to clear blood despite suction, or a bleeding rate that cannot be kept ahead of — because the laryngeal view deteriorates as bleeding continues; use the largest tube that will pass, 8.0-8.5 mm internal diameter in an adult, so clot can be suctioned and a bronchoscope passed later.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • Rapid sequence induction drugs: ketamine 1-2 mg/kg IV preserves blood pressure in hypovolaemia, with rocuronium 1.2 mg/kg IV or suxamethonium 1-1.5 mg/kg IV; midazolam 0.05-0.1 mg/kg IV is an alternative, and propofol and thiopentone are best avoided.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • Paediatric intubation: doses are identical per kilogram except suxamethonium 2 mg/kg IV in infants under 1 year, with atropine 20 micrograms/kg IV (minimum 100 micrograms) for bradycardia; tube size is (age divided by 4) plus 4 mm uncuffed, or (age divided by 4) plus 3.5 mm cuffed.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • If bleeding cannot be controlled, isolate the lung: a divided double-lumen tube allows protected ventilation of the unaffected lung but needs expertise and its narrow lumens occlude with clot; a bronchial blocker preserves suction access but may migrate; deliberate selective mainstem intubation is crudest but fastest — advancing a tube to about 28-30 cm at the teeth with absent left-sided breath sounds isolates a bleeding left lung, while isolating a bleeding right lung requires bronchoscopic guidance.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
  • Terlipressin is a second-line adjunct only in an adult with no vascular contraindication: 1-2 mg IV bolus then 1-2 mg every 4-6 hours, avoided in ischaemic heart disease, peripheral vascular disease, arrhythmia and pregnancy, and not recommended in children.Doctor / Nurse
  • Arrange bronchial artery embolisation — the definitive treatment for massive haemoptysis of bronchial arterial origin, effective initially in 85% of cases; bronchoscopic measures (iced saline lavage, topical adrenaline 1 in 20 000, topical tranexamic acid, fibrin or thrombin sealant, Fogarty or Arndt endobronchial balloons) buy time before it.Doctor / Nurse
  • Treat the underlying disease, which is what prevents recurrence: in bronchiectasis haemoptysis often responds to treatment of the infection with co-amoxiclav 1.2 g IV every 8 hours (child 30 mg/kg IV 8-hourly), or ceftriaxone 2 g IV once daily (child 50-80 mg/kg) plus clindamycin 600 mg IV every 8 hours (child 7.5 mg/kg) or metronidazole 500 mg IV every 8 hours where anaerobic cover is needed for abscess or necrotising pneumonia.Doctor / Nurse
  • Supportive care that changes outcome: transfuse to physiology rather than a threshold, warm blood and fluids, monitor for hypocalcaemia and hypothermia after large-volume transfusion, withhold chest physiotherapy during active bleeding, use mechanical rather than pharmacological thromboprophylaxis until bleeding stops, avoid NSAIDs and use paracetamol instead (adult 1 g every 6 hours, maximum 4 g daily; child 15 mg/kg every 6 hours, maximum 60 mg/kg daily), and institute airborne infection control where tuberculosis is plausible.

Caution— what harms

  • Never nurse or transport the patient with the bleeding lung uppermost, and never lay them supine — the commonest reason a patient with unilateral bleeding deteriorates is contamination of the contralateral, previously normal lung.
  • Non-invasive ventilation and CPAP have no role: the patient cannot protect the airway and a tight mask over a mouth full of clot obstructs clearance.
  • Do not move an actively bleeding patient with an unprotected airway to a CT scanner, and never let awaiting a CT result delay antifibrinolytic therapy, transfusion or correction of coagulation.
  • Do not withhold treatment for diagnosis: the initial goal of management of massive haemoptysis is therapeutic, not diagnostic — the patient dies of asphyxia, not blood loss, because the anatomical dead space of the adult tracheobronchial tree is only about 150 mL.
  • Withhold antitussives while the airway is unprotected and the patient is clearing blood effectively — cough is their only means of clearing the airway, and suppressing it invites asphyxia; consider codeine or low-dose morphine only in the intubated patient, once bleeding has settled, or in palliation.
  • Do not flood the patient with crystalloid, which dilutes clotting factors and produces a dilutional and consumptive coagulopathy on top of the bleed.
  • Thrombolysis is absolutely contraindicated in massive haemoptysis, and massive haemoptysis contraindicates both anticoagulation and thrombolysis even when pulmonary embolism coexists — use mechanical measures including an inferior vena caval filter until bleeding is controlled.
  • Fresh frozen plasma does not reverse a direct oral anticoagulant: record the time of the last dose and use idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors where available; otherwise supportive care, tranexamic acid and transfusion.
  • A normal chest radiograph is not reassurance: flexible bronchoscopy reveals endobronchial cancer in 3-6% of patients with haemoptysis and a normal, non-lateralising film, nearly all smokers over 40 with more than a week of symptoms.
  • Do not attribute haemoptysis to COPD without thorough investigation, and never let a single episode of blood-streaked sputum in a smoker go uninvestigated — haemoptysis is the only symptom that is a specific predictor of lung cancer.
  • Beware the falsely reassuring picture in special groups: in the elderly, rate-limiting drugs blunt the tachycardic response so a normal heart rate is falsely reassuring; children compensate and then crash, so blood pressure falls late and a pale, tachycardic, cool-peripheried child with a normal blood pressure has already lost a substantial volume.
  • Remember the occult presentations: diffuse alveolar haemorrhage causes dyspnoea, falling haemoglobin and diffuse infiltrates with little or no expectorated blood, and in children bleeding may present instead as iron-deficiency anaemia with pulmonary infiltrates or as haematemesis.
  • In an intubated patient, sudden desaturation with rising airway pressure and a silent hemithorax usually means clot occluding the tube or a main bronchus — suction down the tube before any other manoeuvre.
  • Know the hazards of the definitive treatments: bronchial artery embolisation can cause spinal cord infarction and paraplegia because the anterior spinal artery arises from a bronchial artery in up to 5% of people, and rebleeding occurs in up to 20% within a year; single-lung ventilation causes profound hypoxaemia and buys minutes only; and unrecognised, uncontained pulmonary tuberculosis exposes everyone in the vicinity.

Refer / escalate

Call for help and arrange urgent transfer to a centre with bronchoscopy and interventional radiology the moment bleeding is haemodynamically significant or threatens ventilation, when the rate is accelerating, after any sentinel bleed from a cavity, mycetoma, central tumour or aortic graft, when SpO2 falls below 90% on high-flow oxygen or the patient cannot clear blood, and for any haemoptysis with haematuria and a rising creatinine, which is a pulmonary-renal syndrome and both a bleeding and an immunological emergency.

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