Medic Basics

Airway and respiratory

Massive Hemoptysis Algorithm

Protect the good lung, secure the airway, stop the source

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Call for help: what is the airway doing?

  • Call the rapid response team, the most experienced airway operator, pulmonology (bronchoscopy), interventional radiology and thoracic surgery
  • Life-threatening: over 100 mL/h or 500 mL in 24 hours, or any amount that floods the airway or drops SpO₂ (Kathuria 2020)
  • Bleeding side down if the side is known: it keeps blood out of the good lung
  • 100% O₂, two suction setups, monitor; two large-bore IVs; type and crossmatch, CBC, coagulation, fibrinogen
  • Make sure it is hemoptysis: blood from the nose, mouth or stomach can look the same

Bleeding from a tracheostomy → step 2Airway failing: SpO₂ falling, cannot clear the blood, tiring → step 3Airway holding for now → step 4

2 Tracheostomy bleed: does cuff overinflation stop it?

  • Suspect a tracheo-innominate fistula: bright red or pulsatile bleeding, mostly within 3–4 weeks of placement, often after a small sentinel bleed
  • Call the airway expert, ENT or thoracic surgeon and the OR; activate the massive transfusion protocol
  • Overinflate the trach cuff with a syringe, well past the usual volume, to press on the bleed
  • Suction and 100% O₂ through the trach

Bleeding stops → step 5Still bleeding → step 6

3 Intubate with a large tube: is the good lung protected?

  • Most experienced operator; RSI; two suction setups; bronchoscope at the bedside
  • Endotracheal tube 8.0 or larger so a therapeutic bronchoscope fits
  • Keep the bleeding side down; suction through the tube; 100% O₂

Blood still flooding the good lung, SpO₂ falling → step 7Oxygenating → step 4

4 Reverse anticoagulation; give tranexamic acid

  • Warfarin: 4F-PCC 25–50 units/kg by INR plus vitamin K 10 mg IV slowly
  • Dabigatran: idarucizumab 5 g IV; apixaban or rivaroxaban: 4F-PCC 50 units/kg
  • Heparin: protamine 1 mg per 100 units given in the last 2–3 hours (max 50 mg), slowly
  • Tranexamic acid 1 g IV over 10 minutes; nebulized 500 mg is an off-label option (studied only in smaller bleeds)
  • Platelets under 50,000: transfuse; shock: massive transfusion protocol

Next: find the source → step 8

5 Straight to the operating room

  • Go even if the bleeding has stopped; no detour to CT with a pulsatile bleed
  • Keep the cuff overinflated or the finger in place; massive transfusion running
  • The surgeon controls the innominate artery (sternotomy and ligation, or a stent graft as a bridge)

End of this path.

6 Still bleeding: tube from above, finger through the stoma

  • Oral intubation by the airway expert, cuff advanced below the bleeding point as the trach is removed
  • Finger through the stoma into the space in front of the trachea; press the artery forward against the back of the sternum (Utley)
  • Oral route impossible: a cuffed tube through the stoma with the cuff below the bleed
  • Keep the pressure on all the way to the OR

Next: operating room → step 5

7 Isolate the bleeding lung

  • Right lung bleeding: advance the tube into the left mainstem over a bronchoscope
  • Left lung bleeding: right mainstem intubation (may block the right upper lobe) or a bronchial blocker in the left mainstem
  • Double-lumen tube only by an expert: hard to place in a bloody airway, and the narrow lumens clog
  • Confirm position by bronchoscopy; recheck SpO₂ and breath sounds after every move

Next: reverse anticoagulation → step 4

8 Find the source: CT angiography or bronchoscopy first?

  • About 90% comes from the bronchial arteries; CT angiography finds the site in 70–88% and usually shows the cause
  • Pulmonary artery sources (PA catheter injury, Rasmussen aneurysm) need pulmonary angiography or surgery, not bronchial embolization

Stable enough to travel: CT angiography, then embolization → step 9Unstable or still flooding: bronchoscopy first → step 10

9 Bronchial artery embolization: has the bleeding stopped?

  • First-line definitive treatment for most: immediate control in 70–99% (Kathuria 2020)
  • Airway secured first if unstable; travel with suction, a bag and the blocker in place
  • Afterward: groin checks; chest pain or trouble swallowing are common and brief; new leg weakness can be spinal cord ischemia: report at once

Bleeding stopped → step 11Still bleeding or bleeds again → step 12

10 Bronchoscopy to slow the bleeding

  • Rigid bronchoscopy in the OR suctions best; flexible through the 8.0 tube at the bedside
  • Iced saline (4 °C) in 50 mL aliquots; dilute epinephrine or tranexamic acid into the bleeding segment
  • Balloon tamponade with a bronchial blocker or Fogarty catheter, left in place until embolization
  • Visible tumor: ablation or cautery; other options include oxidized cellulose mesh and stents

Next: bronchial artery embolization → step 9

11 After the bleeding stops

  • Rebleeding is common (10–57% after embolization): report any fresh blood at once
  • Hold anticoagulants and antiplatelets until the team decides
  • Treat the cause: airborne isolation until TB is excluded; care for bronchiectasis, cancer, aspergilloma or vasculitis
  • Aspirated blood can worsen gas exchange and cause pneumonia over the next days

End of this path.

12 Surgery

  • Thoracic surgery for bleeding that embolization and bronchoscopy cannot control, chest trauma or pulmonary artery rupture
  • Lobectomy or pneumonectomy goes better once the bleeding is temporized
  • Refractory hypoxemia: ECMO has bridged selected patients (case series)

End of this path.

Drugs in this algorithm

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