Current Pulmonology Reports

https://doi.org/10.1007/s13665-019-00234-x

INTERVENTIONAL PULMONOLOGY (G CHENG, SECTION EDITOR)

Hemoptysis: Rethinking Management

Bonnie R. Wang 1 & Kale S. Bongers 1 & Jose Cardenas-Garcia 1

# Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Purpose of Review Hemoptysis is a distressing symptom that necessitates urgent investigation. Despite its prevalence, there is
frequent uncertainty regarding the etiology, clinical trajectory, and therapeutic management of hemoptysis. We aim to discuss the
causes, diagnostic workup, and pragmatic management strategies for cases of massive and non-massive hemoptysis.
Recent Findings Bronchoscopic techniques to control hemoptysis is an emerging area of study. Fogarty balloons and
endobronchial blockers are often deployed to isolate the bleeding lung. Depending on the source of bleeding, a
variety of endobronchial medical therapies, thermal technologies, and selective sealing methods can be utilized for
hemostasis.
Summary Initial management of a patient presenting with hemoptysis consists of ensuring adequate airway protection
and stabilization of hemodynamics. Following this, hemoptysis can be evaluated and controlled by bronchoscopy,
embolization, and/or surgery. Additional research is needed to determine optimal timing of bronchoscopy and if
differences in hemostatic techniques result in differences in outcomes, especially for cases of massive hemoptysis.

Keywords Hemoptysis . Massive hemoptysis . Interventional pulmonary . Bronchoscopy

Introduction there is no clear consensus on the definition of massive

Hemoptysis, defined as the expectoration of blood from the low-
er respiratory tract, accounts for up to 15% of consults to
Pulmonary and Thoracic Surgery teams [1, 2]. Mortality related
to hemoptysis reaches up to 10% if early and adequate
protocoled management is lacking [3]. Here, we aim to review
the definition, etiology, and assessment of hemoptysis, with a
special focus on recent advances in the management of
hemoptysis.
Classification of Hemoptysis: Massive Versus
Non-massive
Massive hemoptysis is not uncommon and may be seen
in 10–15% of cases of hemoptysis [4]. Unfortunately,
This article is part of the Topical Collection on Interventional
Pulmonology
* Jose Cardenas-Garcia
jdecard@med.umich.edu
1 spective classification, the definition based on effect is less
Divison of Pulmonary and Critical Care, Department of Medicine,
University of Michigan, SPC 5360, 39160 Taubman Center, Ann
Arbor, MI 48109, USA
hemoptysis. This is due to the use of arbitrary cutoff
values of blood volume and difficulty estimating expec-
torated volume. No definition takes into account clini-
cally important determinants of mortality and morbidity
including the rate of bleeding, ability to maintain airway
patency, and severity of cardiopulmonary co-morbidities
[4].
Based on the physiological premise that the average
dead space of the major airways in adults is approxi-
mately 150 mL, most experts define massive hemoptysis
as the expectoration of 150 mL of blood over a 1-h
period or alternatively, 600 mL over 24 h [5]. This type
of hemoptysis is life-threatening due to risk of asphyxia
from clot formation and subsequent central airway ob-
struction, rather than due to exsanguination [2]. Non-
massive hemoptysis is consequently defined as hemop-
tysis volumes of less than 150 mL/1 h or 600 mL/24 h.
Alternatively, others have proposed that the categorization
of hemoptysis be based on the magnitude of effect. Massive
hemoptysis has been defined by the following sequelae: trans-
fusion, hospitalization, intubation, aspiration and airway ob-
struction, hypoxemia, and/or death [6, 7]. Due to the retro-
commonly used due to its limited utility in guiding early
management.
 Curr Pulmonol Rep

Anatomical Considerations Table 1 Causes of hemoptysis

Tumors Malignant: lung cancer, bronchial adenomas,

Approximately 90% of cases of hemoptysis originate and metastatic disease
from high-pressure, low-flow bronchial arteries. The to the lungs/airways (including lung cancer,
bronchial arterial circulation originates from the de- thyroid, breast,
renal, colon, melanoma)
scending aorta, most commonly at the level of the 5th Benign: carcinoid tumor (typical and atypical)
to 6th thoracic vertebral bodies [8]. In a minority of Bronchiectasis
cases (5%), part of the blood supply of the anterior Infections Mycobacterial (especially tuberculosis)
spinal artery arises from bronchial vessels. This detail Aspergillosis
is crucial to examine prior to bronchial arterial emboli- Necrotizing bacterial pneumonias and lung
zation to avoid unintended spinal infarction and paraly- abscesses
sis [9]. Vascular Pulmonary arterial aneurysm
Pulmonary sequestration
About 5% of hemoptysis cases stem from the non- Tracheo-vascular fistulas
bronchial systemic circulation (intercostal arteries, coronary Arteriovenous malformation
arteries, axillary/subclavian arteries, and upper and inferior Iatrogenic
phrenic arteries) [10]. Bleeding from low-pressure, high- Vasculitis Granulomatosis with polyangiitis
flow pulmonary vasculature accounts for the remaining 5% Behcet’s disease and Hughes-Stovin syndrome
Takayasu’s arteritis
of cases [11]. Systemic lupus erythematosis
Diffuse alveolar hemorrhage (due to
infection/capillaritis)
Trauma Post-transbronchial biopsies and trans-tracheal
Causes of Hemoptysis aspirates
Post-traumatic hematoma
Pulmonary erosion from a rib fragment
Mechanisms of bleeding are attributed to the weakening
Cardiovascular Eisenmenger’s syndrome
of blood vessel walls from inflammation and neovascu- abnormalities Mitral stenosis
larization [12]. Inflamed vessels become tortuous and Bronchial circulation Dieulafoy’s syndrome
enlarged with increased blood flow, and the risk of rup- abnormality Bronchial artery hemangioma
ture into the airway lumen subsequently increases [1, 4]. Coagulopathy Von Willebrands’ disease
Clinical history, physical examination, and imaging Hemophilia
studies are important initial steps to distinguish between Anticoagulant therapy
Thrombocytopenia, platelet dysfunction
the multitude of potential inflammatory, infectious, and Disseminated intravascular coagulation
malignant sources of bleeding (Table 1). Others Foreign body
Greater than 80% of cases of hemoptysis are non- Broncholith
massive in nature and secondary to bronchiectasis, Catamenial endometriosis
chronic bronchitis, or lung cancer [4]. Massive hemop- Cryptogenic
tysis accounts for a minority of cases. Tuberculosis is
the most common cause of massive hemoptysis world-
wide. Other leading etiologies of massive hemoptysis Clinical Assessment
are due to bronchiectasis, mycetoma, necrotizing pneu-
monia, and malignancy [4, 13]. A detailed history and physical examination can help direct
While most cases of massive hemoptysis originate subsequent steps in caring for patients with hemoptysis. There
from the bronchial arteries, the pulmonary artery circu- are four important questions a clinician should ask when en-
lation can cause striking problems. Massive hemoptysis countering patients with suspected hemoptysis:
of pulmonary artery (PA) origin should be considered if
PA pseudoaneurysm, PA aneurysm, or the presence of
the PA in the inner wall of a cavity are seen during Is It True Hemoptysis?
multi-detector computed tomography angiography
(MDCTA) [11]. Hypertrophy of bronchial arteries on Pseudohemoptysis (gastrointestinal, nasal, or oropharyngeal
CT angiography along with concerning PA signs merits source of bleeding) may mimic hemoptysis in up to 10% of
treatment of both systems [11]. cases [15]. A thorough history and physical exam of the oral
Despite thorough workup including CT imaging and bron- and nasal passages should be performed to avoid inaccurate or
choscopy, a definitive cause cannot be established in up to delayed diagnoses and unnecessary procedures. Hemoptysis
30% of cases of hemoptysis [14]. usually appears bright red due to its frequent origin from the
Curr Pulmonol Rep
bronchial arterial circulation. Conversely, hematemesis tends
to be acidic and appears dark and coffee ground in appearance
with oxygen saturation closer to that of venous blood [16]. If
extra-pulmonary etiologies of bleeding are suspected, otolar-
yngology or gastroenterology consultation is essential for di-
agnosis and management [2].
Is the Patient Able to Maintain a Patent
Airway?
Not all patients who cough up blood should be immediately
intubated. The cough reflex can often clear the majority of the
blood in the conducting airways more effectively than thera-
peutic bronchoscopy. The optimal time for intubation remains
an individualized clinical decision but should be pursued if
there are signs of deterioration or fatigue, cardiopulmonary
decline, or the need for diagnostic or therapeutic procedure.
Is It Life-threatening (Massive)?
Distinguishing between massive and non-massive hemoptysis
is important as different pathways are recommended to diag-
nose and manage bleeding (Figs. 1 and 2).
What Is the Source/Etiology and Site
of Bleeding?
Once airway and hemodynamic assessment and stabilization
are performed, care should move forward with imaging stud-
ies to help determine the side, site, and etiology of the bleed-
ing. The nature of the bleeding source, severity of bleeding,
and feasibility of therapeutic options are important issues to
think through.
Initial Management
Hemoptysis of any volume is alarming to both patients and
medical staff. Particularly in cases where hemoptysis is of
large volume or patient trajectory is expected to worsen, prep-
aration for stabilization and workup are vital. The following
initial management steps are recommended:
– Assessment of airway security and hemodynamic
status
– Bedrest in lateral decubitus position with the bleeding
side placed in the dependent position to minimize con-
tamination into the contralateral lung
– Establishment of two large bore peripheral IVs for fluid
resuscitation and/or transfusion and contrast injection
– Close monitoring of vital signs (blood pressure, heart and
respiratory rate, and oxygen saturation)
– Review of medications; hold antiplatelet/anticoagulation
therapy
– Correction of coagulopathy
– Basic laboratory testing (type and screen/cross, cell blood
count, comprehensive metabolic panel, coagulation pro-
file, urine analysis)
– NPO status in the event of intubation, bronchoscopy, and/
or arteriography
– Avoidance of aggressive chest physiotherapy
– Early multidisciplinary collaboration between
Pulmonary, Interventional Radiology and Thoracic
Surgery
Imaging Studies
Chest x-rays are often the initial test for investigation as they
can be rapidly performed. The site of bleeding can be identi-
fied by chest radiography in 43–84% of patients with hemop-
tysis [17–19]. A normal chest x-ray, however, does not rule
out pathology, and workup usually proceeds with computed
tomography (CT) of the chest. CT is more sensitive than chest
x-ray and has higher diagnostic yields of 67–89% [13, 17–19].
Chest CTs can reveal bronchiectasis, interstitial lung disease,
or vascular abnormalities that are not well seen on chest x-
rays. Chest CTs additionally offer visualization of peripheral
lesions, intra-luminal and extra-luminal extent of disease, and/
or extra-pulmonary etiologies of hemoptysis [20]. CTs serve
as roadmaps for bronchoscopists and interventional radiolo-
gists if intervention is required. Computed tomography stud-
ies of the chest and bronchoscopy are often complementary,
with diagnostic yields of both studies combined ranging from
84 to 93% [17, 18].
Multi-detector computed tomography angiography
(MDCTA) is useful for visualizing bronchial and non-
bronchial systemic arteries. MDCTA utilizes two-
dimensional detector array technology to acquire multiple
slices or sections simultaneously and offers detailed images
of the vasculature due to higher image speed acquisition, high
speed of bolus contrast administration, and reduction in mo-
tion artifacts [21, 22]. In one study, 31/31 (100%) of bronchial
arteries and 16 of 26 (62%) non-bronchial systemic arteries
causing hemoptysis in 22 patients seen during angiography
were detected on MDCTA [21].
Bronchoscopy
Bronchoscopy is a safe and relatively inexpensive procedure
that allows for rapid identification and potential control of the
 Curr Pulmonol Rep

Fig. 1 Management of massive

hemoptysis

Fig. 2 Management of non-

massive hemoptysis
Curr Pulmonol Rep
source of bleeding. Since the majority of non-massive hemop-
tysis cases are secondary to bronchitis, infections, and bron-
chiectasis, not all patients will require bronchoscopy [13].
Bronchoscopy is warranted if any of the following are present:
massive hemoptysis, evidence of endobronchial disease, risk
factors for malignancy, persistent imaging abnormalities de-
spite therapy, or recurrent episodes of hemoptysis.
Bronchoscopy offers multiple, distinct advantages, including
the ability to:
– Identify the anatomic site and side of bleeding in pa-
tients with bilateral parenchymal abnormalities on
chest CT [23, 24]
– Assess the severity and nature of the source of bleeding
(examples include endobronchial lesions, central vascular
fistulas such as Dieulafoy’s lesions of the airway, paren-
chymal lesions) [23]
– Collect samples for cytology, microbiology, and patho-
logic analysis
– Evaluate the feasibility of and perform therapeutic inter-
ventions [23]
– Guide definitive therapies such as bronchial artery embo-
lization or surgery by directing interventional radiology
to the segments of interest or identifying endobronchial
sites of disease that may impact surgical resection [24]
The type of bronchoscopy depends on operator expe-
rience and institutional resources. If a therapeutic bron-
choscopic intervention is planned, rigid bronchoscopy is
preferred to secure the airway and isolate the non-
bleeding bronchus to allow for adequate oxygenation
and ventilation. A rigid bronchoscope can be utilized
for mechanical tamponade and has a larger diameter
working channel to more effectively suction blood and
simultaneously deliver therapies [25]. Patients must be
able to tolerate general anesthesia and be hemodynami-
cally stable for transfer to an endoscopy or operating
room.
Prior to any bronchoscopic intervention, the operator must
thoroughly review all available images, confirm proper func-
tionality of tools, and develop a plan of action with nursing
and anesthesiology teams. The experienced bronchoscopist
should be a master at basic techniques of suctioning and main-
taining clear operative field and have advanced skills includ-
ing clot evacuation, deployment of endobronchial blockers,
and electrosurgery resection [26]. Closed loop communication
with anesthesia and the nursing team is essential to a good
outcome.
Securing and Isolating the Airways
The first step prior to any bronchoscopic intervention is to
secure the airway, either with a rigid bronchoscope or a large
8.5-–9.0-mm endotracheal tube. Afterwards, blood should be
cleared from the non-bleeding lung. This simple but important
maneuver is designed to minimize desaturations and extend
the time available for performing therapeutic interventions on
the bleeding side. From time to time during the procedure,
clearance of blood and clots should be repeated to aid in ox-
ygenation and ventilation. A common mantra of a good bron-
choscopist is “keep your good lung up and clean.”
Past practices such as double-lumen endotracheal tube
(DLT) placement or selective lung intubation are not recom-
mended. Placement of a DLT is not advised as it results in
interruption of airway security via removal of an already pres-
ent endotracheal tube. Each lumen of a DLT is too narrow to
allow for the passage of diagnostic or therapeutic broncho-
scopes. Moreover, there is no consensus on the optimal size
of DLT that should be deployed in emergency situations or
whether a right- or left-sided DLT is more effective. If a right-
sided DLT is used, additional time for positioning is required,
and right upper lobe collapse and obstruction are possible
complications. Overall, placement of a DLT is time consum-
ing and highly dependent on operator skill and training [27].
One study has suggested that the use of DLT may increase
morbidity and mortality in cases of hemoptysis [28].
Another former strategy to achieve selective lung iso-
lation involves advancing an endotracheal tube into ei-
ther main stem bronchus. In cases of left-sided hemop-
tysis, past practice involved advancement of a single-
lumen endotracheal tube into the right main stem bron-
chus in hopes of isolating the “good” lung.
Unfortunately, due to the shorter length of the right
main stem bronchus, the balloon of the endotracheal
tube can occlude the right upper lobe takeoff and lead
to collapse of the right upper lobe. There are risks of
desaturation from blocking a whole lobe of the “good”
lung as well as risks of lung hyperinflation and pneu-
mothorax [29].
The preferred method of lung isolation is applying
balloon occlusion via an endobronchial blocker until
bleeding has stopped and/or definitive therapy can be
performed. There are a variety of different brands of
endobronchial blockers (Arndt, Cohen, EZ, Fuji) avail-
able on the market (Fig. 3). We use the Arndt
endobronchial blocker at our institution, and the setup
is shown in Fig. 4. Bronchoscopic guidance of the
Arndt endobronchial blocker through an endotracheal
tube is shown in Fig. 5. The balloon is inflated in the
bleeding bronchial area of interest and left in place for
24–48 h. The balloon is subsequently deflated under
both controlled conditions and direct visualization via
f l e x i b l e b r o n c h o s c o p y. F a m i l i a r i t y w i t h t h e
endobronchial blockers at the operator’s institution is
important. These devices should be available in all in-
tensive care units and bronchoscopy suites.

Fig. 3 Various types of endobronchial blockers. Reproduced with permission of the © ERS 2019
If endobronchial blockers are not available and a
more temporary and emergent blockade is necessary,
the operator can deploy a Fogarty balloon by advancing
it directly through the working channel of a broncho-
scope or advancing it parallel to the bronchoscope with
forceps guidance (Figs. 6 and 7). If a Fogarty balloon is
used, we recommend attaching it to a three-way stopcock and
a 3-cc syringe to minimize inadvertent deflation of the balloon
(Fig. 8). The Fogarty balloon should be replaced by a more
secure endobronchial blocker to avoid unintended dis-
lodgment and proximal migration prior to patient trans-
port [27, 30].
Fig. 4 Arndt endobronchial blocker setup
Curr Pulmonol Rep
Therapeutic Interventional Pulmonary
Options
If the source of bleeding is endoscopically visible in the cen-
tral airways, the bronchoscopist can achieve local hemostasis
by using a variety of thermal technologies including laser,
argon plasma coagulation, or electrocautery [31–37].
Debridement using forceps or cryotherapy can be performed
in conjunction with thermal technology. There is no definitive
advantage of one type of thermal therapy over another. The
choice of thermal technologies is dependent on the training of
the bronchoscopist and institutional resources. Regardless of
the type of thermal technology used, thorough knowledge and
understanding of the electrosurgical unit and its components,
the mechanism of action of each technology, and good team
dynamics with effective communication are essential to
Fig. 5 Bronchoscopic guidance of Arndt endobronchial blocker through
an endotracheal tube
Curr Pulmonol Rep

Fig. 6 Fogarty balloon advanced directly through the bronchoscope

preventing complications and electrosurgery-related injuries.

Specific details of each technology are beyond the scope of
this article but can be reviewed elsewhere [38].
If the source of bleeding is localized to the periphery, the
Fig. 8 Fogarty balloon set up with a 3-cc syringe, three-way stopcock,
bronchoscopist can tamponade the bleeding subsegmental
and Fogarty balloon
bronchus with the bronchoscope. Suctioning at this time is
not recommended. Suctioning can mimic a flutter valve mech-
bleeding, but these medications are not FDA approved for
anism in the airway and bring additional blood towards the
use in the USA [45]. Our own practice is to use epinephrine
camera, further obscuring endoscopic views [39]. Instillation
1:100,000 in 2-mL aliquots to stimulate clot formation and
of a hemostatic agent is the next step. Data supporting the
removal.
instillation of hemostatic agents (epinephrine, cold saline,
Selective segmental sealing should follow. Methods of
thrombin +/− fibrinogen, cyanoacrylate or tranexamic acid)
sealing include endobronchial blockers, Fogarty balloons,
to stop parenchymal bleeding are derived from small case
cyanoacrylate-based glue, oxidized regenerated cellulose
series [40–44]. In one study, an average volume of 500 ml
(ORC) mesh, or silicone Watanabe. We find that placement
of cold saline at 4 °C was instilled in 23 patients to stop
of ORC mesh, also known as Surgicel, to be the most effec-
bleeding [41]. There is concern about the generalizability of
tive, simple method of achieving hemostasis [46]. We suggest
this technique given the large amount of saline required to
using oval cup forceps to deploy the ORC mesh into the
achieve hemostasis, increasing the risk of respiratory compro-
bleeding segmental bronchus since alligator or needle forceps
mise. ADH derivatives including ornipressin and terlipressin
can become entangled in the mesh and lead to dislodgement.
have been used in Europe to stop bronchoscopy-related
The use of glue for hemoptysis of parenchymal origin is an-
ecdotal. Watanabe silicone spigots are not currently available
in the United States and their deployment is time consuming
[42, 47]. Techniques and steps of deployment of each of these
methods are reviewed elsewhere [48–50].

Outcomes of Hemoptysis

Massive hemoptysis due to lung cancer has a much poorer

Fig. 7 Forceps guidance of Fogarty balloon through an endotracheal tube
prognosis than hemoptysis from other causes. A prior study
revealed a mortality rate of 80% if hemoptysis was secondary
to malignancy and if the volume of blood lost was greater than
1000 ml/24 h [51]. Superior outcomes are expected in cases of
hemoptysis secondary to bronchiectasis, lung abscess, or nec-
rotizing pulmonary infections, with some series quantifying
mortality less than 1% [52].
The mortality associated to hemoptysis is correlated with
the volume of blood expectorated (58% vs 9% if the rate is

greater or less than 1000 ml/24 h respectively), the rate of
bleeding, the amount of blood retained within the lungs, and
premorbid respiratory reserve, independent of the etiology of
bleeding [51, 52].
Management Controversies
Timing of Bronchoscopy
Timing of bronchoscopy depends on the severity of bleeding,
clinical status of the patient, and availability of bronchoscopy
resources.
For cases of massive hemoptysis, bronchoscopy can pro-
vide diagnostic information regarding lateralization and etiol-
ogy of bleed. Biopsies can be obtained if needed, and thera-
peutic options can be delivered depending on the etiology.
Bronchoscopy offers the ability to control bleeding with
endobronchial blockers and thermal technologies which can
either be definitive or serve as a bridge to additional therapy
with bronchial artery embolization, radiation, or surgery. In
cases of life-threatening hemoptysis, we find that early bron-
choscopy is a useful tool for diagnosis and treatment.
For non-massive cases of hemoptysis, early bronchoscopy is
not superior to imaging in discovering the cause of hemoptysis.
Early bronchoscopy within 48 h of hemoptysis starting or stop-
ping was not statistically associated with higher diagnostic
yield [53••, 54]. In the ED setting of one study, MDCTA com-
pared with clinical examination, chest x-ray, and bronchoscopy
was equally effective in determining lateralization of bleed
[55]. Furthermore, MDCTA was more effective in determining
the cause of hemoptysis, and results of MDCTA changed man-
agement in 22% of cases [55]. This is likely because most cases
of non-life-threatening hemoptysis are due to bronchitis, infec-
tions, bronchiectasis, and malignancy which can be analyzed
via imaging. The indications to proceed with bronchoscopy in
patients with non-massive hemoptysis are described in the
above “Bronchoscopy” section [5, 56].
Use of ECMO in Hemoptysis
Veno-venous extracorporeal membrane oxygenation (V-V
ECMO) may be an advanced rescue option for certain patients
with massive hemoptysis causing severe upper or central air-
way obstruction. In the setting of refractory hypoxemic respi-
ratory failure limiting definitive intervention to achieve hemo-
stasis, V-V ECMO can provide short-term stabilization while
lifesaving procedures are being performed [57–60]. Veno-
arterial ECMO can provide both respiratory and circulatory
support for those with respiratory and hemodynamic failure
from massive hemoptysis [61].
Ongoing bleeding or a high risk for bleeding are often
relative contraindications for ECMO, as systemic
Curr Pulmonol Rep
anticoagulation is required to maintain circuit patency and
avoid systemic thromboembolism. This creates a challenging
risk-benefit analysis in cases of massive hemoptysis. There are
case reports documenting successful use of ECMO either with
or without systemic anticoagulation therapy while the pa-
tient’s hemoptysis was treated [57–63]. Some authors argue
that modern ECMO technology does not require the higher
levels of anticoagulation used in the past and that lower acti-
vated clotting time thresholds are acceptable [62].
Judicious patient selection for ECMO remains important.
Important factors and criteria to consider include severe respi-
ratory failure despite maximal conventional therapy, high pre-
dicted mortality, reversibility of pathologic process, co-mor-
bidities, and complications of critical illness [64, 65]. The
decision to implement systemic anticoagulation should be per-
sonalized for each individual depending on severity of hemop-
tysis, overall risk for thromboembolism, likelihood of success-
ful definitive intervention, and estimated duration of time on
ECMO.
Use of Anti-fibrinolytic Therapy in Hemoptysis
Studies examining the use of tranexamic acid (TXA), a syn-
thetic lysine analogue that binds to plasminogen to block fi-
brinolysis, to control hemoptysis are limited by the heteroge-
neous study populations as well as variable dosages and du-
ration of TXA administered [66, 67]. In 2013, Moen et al.
examined 13 studies in a meta-analysis and found variable
results that suggested benefit with TXA use in reducing the
duration and volume of bleeding, although two cases of pul-
monary embolism occurred [66]. A 2016 Cochrane review of
two randomized controlled trials concluded that while there
was insufficient evidence to recommend anti-fibrinolytic ther-
apy to treat hemoptysis from any cause, there was an overall
trend toward reduction in bleeding time [67]. A small study of
patients with cystic fibrosis complicated by hemoptysis
showed cessation in bleeding over a median of 2 days with
systemic anti-fibrinolytic therapy although other treatment
modalities were utilized, and one patient experienced a case
of recurrent venous thromboembolism [68].
Other options for administration consist of endobronchial
instillation of TXA during bronchoscopy and nebulized TXA.
Endobronchial administration of tranexamic acid has been
used as a third-line approach after cold saline and adrenaline
to manage bronchial bleeding [69]. Wand et al. randomized 47
patients with non-massive hemoptysis to receive nebulized
TXA versus placebo and found that the nebulized TXA group
experienced a higher rate of hemoptysis resolution and lower
expectorated blood volume [70••]. The rate of interventional
bronchoscopy and angiographic embolization, a secondary
endpoint, was lower in the TXA group [70••].
Most published anti-fibrinolytic studies exclude cases of
massive hemoptysis, which continues to be an area of
Curr Pulmonol Rep
uncertainty. TXA therapy likely provides benefit, but further
studies examining the optimal patient, dose of TXA, method
of administration, and duration of treatment are needed.
Multidisciplinary Management of Hemoptysis
Bronchial Artery Embolization
Bronchial artery embolization (BAE) through interventional
radiology is a common intervention for massive hemoptysis,
and is generally preferred over surgical or conservative mea-
sures [71]. In this procedure, the bleeding vessel is identified,
often through MDCTA [72, 73]. Through selective bronchial
artery cannulation, the bronchial artery is embolized with coil
[74], foam [73], or gelatin, although most commonly polyvi-
nyl alcohol [75, 76••]. When a bleeding vessel can be identi-
fied, success rate of the procedure is high (70–99%), although
recurrence commonly occurs (10–55%) due to recanalization,
new collaterals, or incomplete embolization [76••, 77, 78].
Patient selection can be important to BAE outcomes;
aspergilloma, for instance, has recurrence rates of hemoptysis
approaching 100% after BAE [77]. In addition, unfavorable
anatomy may lead to increased adverse events, such as spinal
cord ischemia, or incomplete control of bleeding [47, 79].
Radiation Therapy
While its role in acute, massive hemoptysis is not supported
by data, external beam radiation therapy can be beneficial in
treating non-massive hemoptysis in patients with non-small
cell lung cancer. One trial comparing 17 Gy divided over
two fractions with 30 Gy in 10 fractions showed resolution
of non-massive hemoptysis in 79% and 84%, respectively
[80]. Similarly, several other protocols giving 30–40 Gy over
2–4 weeks showed improvement in 73–77% of patients with
NSCLC [81]. Smaller case series have shown efficacy of ra-
diation in the treatment of mycetoma [82]. While efficacious,
the median time to improvement was over 140 days [80],
limiting the use of radiation therapy in cases of acute large-
volume hemoptysis.
The addition of high-dose rate brachytherapy to external
beam radiation, however, is associated with an increased risk
of fatal hemoptysis, although this is based on somewhat lim-
ited data [83]. While guidelines recommend against the regu-
lar use of brachytherapy, it may be useful in specific circum-
stances, such as uncontrolled endobronchial disease [84].
Surgery
Surgery for hemoptysis is usually limited to localized lesions.
In addition, other indications for surgical intervention include
bleeding from leaking aortic aneurysms, chest injuries,
arteriovenous malformations, tracheoarterial fistulas, hydatid
cysts, iatrogenic PA rupture, bronchial adenomas, or bleeding
mycetoma [52, 85]. Mortality is variable, between 1 and 50%,
although this may be due to institutional heterogeneity in case
selection; more recent case series generally suggest lower
mortality [52, 86, 87]. Emergent surgery for hemoptysis is
associated with poorer outcomes [86].
Conclusion
Hemoptysis can present as a self-limited problem to a life-
threatening emergency. Prompt assessment of airway security
and stabilization of hemodynamics are crucial before
embarking on a diagnostic pathway to localize the site and
identify the etiology of bleeding. Control of bleeding is para-
mount and requires multidisciplinary collaboration between
Pulmonology, Interventional Radiology, and Thoracic
Surgery to coordinate effective therapeutic strategies.
Bronchial artery embolization remains the cornerstone of
treatment for many causes of hemoptysis, but endobronchial
blockers and thermal technologies are available as additional
management options.
Compliance with Ethical Standards
Conflict of Interest BRW, KSB and JDC: This work in original and all
authors meet the criteria for authorship, including acceptance of respon-
sibility for the scientific content of the manuscript. This paper is not under
consideration in any other Journal and all the authors have read and
approved the content of the manuscript. No potential conflict of interest
exists with any companies or organizations whose products or services
may be discussed in this article. This paper has not been funded by the
National Institutes of Health (NIH), the Wellcome Trust, or their agencies.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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