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Massive hemoptysis: Initial management

David H Ingbar, MD
Section Editor
Praveen N Mathur, MB;BS
Deputy Editor
Geraldine Finlay, MD


Massive hemoptysis is variably defined as pulmonary bleeding of somewhere between 100 to 600 mLs in a 24 hour period. 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 [1]. 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".)


The initial steps in managing a patient with massive hemoptysis are to ensure adequate oxygenation and to determine if the bleeding is coming primarily from one lung and, if so, which side is the primary source. This determination may be difficult. Occasionally, there is a history of lung disease on the bleeding side or there may be a gurgling sound that can be auscultated, or an abnormal sensation on that side. 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.


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 nonbleeding lung, since spillage of blood into the nonbleeding lung may prevent gas exchange by blocking the airway with clot or filling the alveoli with blood.


Patients with massive hemoptysis who have significant shortness of breath, poor gas exchange, hemodynamic instability, or rapid ongoing hemoptysis should be intubated with a large bore endotracheal tube (size 8 or greater, if possible). In addition, this should be done early in patients with very little cardiopulmonary reserve. The purpose of the large lumen 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 one of the following techniques for intubation and mechanical ventilation:

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Literature review current through: Nov 2017. | This topic last updated: May 24, 2017.
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  1. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000; 28:1642.
  2. Anantham D, Jagadesan R, Tiew PE. Clinical review: Independent lung ventilation in critical care. Crit Care 2005; 9:594.
  3. Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax 2003; 58:814.
  4. Conlan AA, Hurwitz SS, Krige L, et al. Massive hemoptysis. Review of 123 cases. J Thorac Cardiovasc Surg 1983; 85:120.
  5. Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15:147.
  6. de Gracia J, de la Rosa D, Catalán E, et al. Use of endoscopic fibrinogen-thrombin in the treatment of severe hemoptysis. Respir Med 2003; 97:790.
  7. Roberts AC. Bronchial artery embolization therapy. J Thorac Imaging 1990; 5:60.
  8. Cremaschi P, Nascimbene C, Vitulo P, et al. Therapeutic embolization of bronchial artery: a successful treatment in 209 cases of relapse hemoptysis. Angiology 1993; 44:295.
  9. Keller FS, Rosch J, Loflin TG, et al. Nonbronchial systemic collateral arteries: significance in percutaneous embolotherapy for hemoptysis. Radiology 1987; 164:687.
  10. Nath H. When does bronchial arterial embolization fail to control hemoptysis? Chest 1990; 97:515.
  11. Yoon W, Kim JK, Kim YH, et al. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics 2002; 22:1395.
  12. Chun HJ, Byun JY, Yoo SS, Choi BG. Added benefit of thoracic aortography after transarterial embolization in patients with hemoptysis. AJR Am J Roentgenol 2003; 180:1577.
  13. Swanson KL, Johnson CM, Prakash UB, et al. Bronchial artery embolization : experience with 54 patients. Chest 2002; 121:789.
  14. Remy-Jardin M, Bouaziz N, Dumont P, et al. Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography. Radiology 2004; 233:741.
  15. Menchini L, Remy-Jardin M, Faivre JB, et al. Cryptogenic haemoptysis in smokers: angiography and results of embolisation in 35 patients. Eur Respir J 2009; 34:1031.
  16. Woo S, Yoon CJ, Chung JW, et al. Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles. Radiology 2013; 269:594.
  17. Sellars N, Belli AM. Non-bronchial collateral supply from the left gastric artery in massive haemoptysis. Eur Radiol 2001; 11:76.
  18. Vujic I, Pyle R, Parker E, Mithoefer J. Control of massive hemoptysis by embolization of intercostal arteries. Radiology 1980; 137:617.
  19. Jardin M, Remy J. Control of hemoptysis: systemic angiography and anastomoses of the internal mammary artery. Radiology 1988; 168:377.
  20. Chun HJ, Yoo SS, Kim HH, et al. Nonbronchial collateral supply from the hepatic arteries of a patient with hemoptysis. AJR Am J Roentgenol 2003; 180:523.
  21. Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 1999; 115:996.
  22. White RI Jr. Bronchial artery embolotherapy for control of acute hemoptysis: analysis of outcome. Chest 1999; 115:912.
  23. Osaki S, Nakanishi Y, Wataya H, et al. Prognosis of bronchial artery embolization in the management of hemoptysis. Respiration 2000; 67:412.
  24. Barben J, Robertson D, Olinsky A, Ditchfield M. Bronchial artery embolization for hemoptysis in young patients with cystic fibrosis. Radiology 2002; 224:124.
  25. Uflacker R, Kaemmerer A, Neves C, Picon PD. Management of massive hemoptysis by bronchial artery embolization. Radiology 1983; 146:627.
  26. Wong ML, Szkup P, Hopley MJ. Percutaneous embolotherapy for life-threatening hemoptysis. Chest 2002; 121:95.
  27. Zhang Y, Chen C, Jiang GN. Surgery of massive hemoptysis in pulmonary tuberculosis: immediate and long-term outcomes. J Thorac Cardiovasc Surg 2014; 148:651.
  28. Kiral H, Evman S, Tezel C, et al. Pulmonary resection in the treatment of life-threatening hemoptysis. Ann Thorac Cardiovasc Surg 2015; 21:125.
  29. Razazi K, Parrot A, Khalil A, et al. Severe haemoptysis in patients with nonsmall cell lung carcinoma. Eur Respir J 2015; 45:756.