When a patient presents with massive hemoptysis, the initial steps are to correctly position the patient, establish a patent airway, insure adequate gas exchange and cardiovascular function, and control the bleeding . These steps are reviewed here. Other aspects of massive hemoptysis (ie, definition, etiologies, diagnostic evaluation, and definitive treatment) are discussed separately. (See "Overview of massive hemoptysis" and "Massive hemoptysis: Causes".)
IDENTIFY WHICH SIDE IS BLEEDING
The initial step in managing a patient with massive hemoptysis is to determine if the bleeding is coming primarily from one lung and, if so, which side is the primary source. This may be difficult. Occasionally, on the bleeding side there is a history of lung disease or there may be a gurgling sound that can be auscultated, or an abnormal sensation. However, many signs are misleading because they occur away from the actual bleeding site. As an example, upper lobe hemorrhage may manifest wheezing, rhonchi, or air space disease in the lower lobe, due to the accumulation of blood in the lower lobe with gravitational pooling.
POSITION THE PATIENT
Patients with massive hemoptysis should be immediately placed into a position in which the presumed bleeding lung is in the dependent position. A patient whose right lung is bleeding should be placed in the right-side down decubitus position, whereas a patient whose left lung is bleeding should be placed in the left-side down decubitus position. The purpose of these positions is to protect the non-bleeding lung, since spillage of blood into the non-bleeding lung may prevent gas exchange by blocking the airway with clot or filling the alveoli with blood.
ESTABLISH A PATENT AIRWAY
Patients with massive hemoptysis who have severe shortness of breath, poor gas exchange, hemodynamic instability, or rapid ongoing hemoptysis, should be intubated with a large bore endotracheal tube (size 8.0 or greater, if possible). The purpose of the large size is to facilitate interventional and diagnostic bronchoscopy.
When the bleeding is coming from one lung, it may be possible to protect the nonbleeding lung from spillage by using of one of the following techniques for intubation and mechanical ventilation: