#EMConf: Massive Hemoptysis

What makes massive hemoptysis massive? - Classic teaching is 100 cc/h but really it's an amount of blood that is causing hemodynamic instability, airway obstruction or abnormal gas exchange. 

Why did this patient go into cardiac arrest? - Asphyxiation as the tracheobronchial tree can hold ~ 200 cc. 

Why does this patient have massive hemoptysis? - Likely secondary to the fungus ball eroding into bronchial artery.

  • 90% of bleeds secondary to involvement of the high pressure bronchial arteries.
  • 10% of massive hemoptysis involve pulmonary arteries which give off larger volumes but at lower pressures.

What are some etiologies for massive hemoptysis?

  • The Big 3 for massive hemoptysis are:
    • Infection: TB, Pneumonia, Lung Abscess, Cavitary lesion like Mycetoma
    • Mass/ Neoplasm
    • Bronchiectasis
  • Other etiologies include PE, AVM, Connective Tissue Disease, Diffuse Alveolar Hemorrhage, Trauma


  • More on management and the resolution of this case to be discussed next week.
  • ABC's
    • Airway or Asphyxiation 
    • Reverse coagulopathy, resuscitate for hemorrhage 
  • Localize the bleed
  • Refractory hypoxemia on mechanical ventilation is a shunt problem; some ARDS maneuvers are applicable in this situation
  • Early consultation
    • Pulmonary for bronchoscopy
    • IR and CTA when stable for embolization
    • Thoracic Surgeon
  • Consider systemic TXA