Level 1 of 6Core
Haemoptysis: from blood-streaked sputum to massive haemorrhage
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Prove it is haemoptysis first (blood from below the vocal folds): inspect the nares, gums and oropharynx with a torch in the first minute. Haemoptysis follows coughing and is bright red, frothy, alkaline, mixed with sputum; haematemesis follows retching and is dark red or coffee-ground and acidic; epistaxis blood is non-frothy and clotted.
- Severity is defined by three signs, not the reported volume: elevated pulse, hypotension and decreased oxygen saturation. Massive haemoptysis is any amount that is haemodynamically significant or threatens ventilation.
- Where a numerical trigger is wanted use the lowest: more than 150 mL in 24 hours, or 100 mL/hour or more (child: more than 8 mL/kg in 24 hours) — and watch the trend, not the total: 100 mL then 400 mL will need an airway within minutes.
- Danger signs in order of how fast they kill: inability to clear blood from the airway (gurgling, weak cough, pooling), SpO2 below 90% on a reservoir mask, exhaustion or drowsiness, tachycardia with hypotension, inability to speak full sentences. Never dismiss a sentinel bleed from a cavity, mycetoma, central tumour or aortic graft because it stopped.
- Find the bleeding side: ask which side it feels like — patients localise correctly more often than appreciated — and auscultate for unilateral coarse crackles or gurgling. Take a chest radiograph in every case (its greatest immediate value is lateralisation), but a normal film is not reassurance.
- Send blood immediately: full blood count, clotting screen and INR, urea, electrolytes and creatinine, and cross-match early. Ask about anticoagulants and antiplatelets — they convert a trivial bleed into a lethal one.Not available at your setup — Coagulation (PT/INR).
Manage now— do this, in order
- Position first — gravity is the most valuable free intervention: bleeding lung dependent (down) if the side is known, upright if not. Never nurse or transport with the bleeding lung uppermost and never supine — contamination of the good lung is how patients deteriorate.
- High-flow oxygen 15 L/min via non-rebreathe reservoir mask, target SpO2 94-98% (COPD target 88-92% is corrected once bleeding is controlled — hypoxaemia kills far sooner than hypercapnia). Set up continuous wide-bore suction with a second unit available, because clot blocks suckers. NIV and CPAP have no role.
- 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 (max 1 g) then 15 mg/kg 8-hourly (max 1 g/dose). Nebulised tranexamic acid 500 mg three times daily is an adjunct in adults, never a substitute.Doctor / Nurse
- Stop and reverse every anticoagulant, antiplatelet and NSAID: warfarin — phytomenadione 5-10 mg slow IV plus prothrombin complex concentrate 25-50 units/kg (FFP 15 mL/kg if PCC unavailable); unfractionated heparin — protamine 1 mg per 100 units given in the preceding hour, max 50 mg; enoxaparin — protamine 1 mg per 1 mg given within 8 hours, max 50 mg (partial only). FFP does not reverse a DOAC — use idarucizumab (dabigatran) or andexanet alfa (Xa inhibitors) where available.Doctor / NurseNot available at your setup — Blood & blood products.
- Transfuse blood, not crystalloid: packed red cells for hypotension, tachycardia, continuing loss, or haemoglobin below 70 g/L (below 80 in ischaemic heart disease); child 10 mL/kg. FFP 15 mL/kg if INR above 1.5 or after 4 units of red cells; platelets if below 50 x 10^9/L. Crystalloid only as a holding measure — 250-500 mL boluses (child 10 mL/kg), because flooding dilutes clotting factors.Doctor / NurseNot available at your setup — Blood & blood products.
- Intubate early rather than late — for exhaustion, falling conscious level, SpO2 below 90% on high-flow oxygen, or inability to clear blood — with the largest tube that will pass (8.0-8.5 mm in an adult) so clot can be suctioned. RSI: ketamine 1-2 mg/kg IV with rocuronium 1.2 mg/kg IV or suxamethonium 1-1.5 mg/kg IV; avoid propofol and thiopentone. If bleeding cannot be controlled, isolate the lung — advancing the tube to 28-30 cm at the teeth isolates a bleeding left lung.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
- Arrange bronchial artery embolisation — the definitive treatment for massive haemoptysis of bronchial arterial origin, effective initially in 85%. Bronchoscopic measures (iced saline lavage, topical adrenaline 1 in 20 000, topical tranexamic acid, endobronchial balloons) buy time before it.
- Withhold antitussives while the airway is unprotected — cough is the patient's only means of clearing blood. Thrombolysis is absolutely contraindicated, and do not move an actively bleeding patient with an unprotected airway to a CT scanner: the initial goal is therapeutic, not diagnostic — patients asphyxiate, they do not exsanguinate.
Thresholds for massive haemoptysis — use the lowest
| Source | Threshold |
|---|---|
| Harrison's | > 150 mL/24 h, or ≥ 100 mL/hour |
| CMDT | > 200-600 mL/24 h |
| Kumar & Clark | > 200 mL/24 h |
| Paediatric | > 8 mL/kg/24 h |
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, when SpO2 falls below 90% on high-flow oxygen or the patient cannot clear blood, and for any haemoptysis with haematuria and rising creatinine — a pulmonary-renal syndrome.
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