Massive Haemoptysis

Blood coughed from the airway. Most haemoptysis is small-volume and the job is a diagnosis; massive haemoptysis is an airway emergency and the job is a position and a phone call. Patients drown before they exsanguinate — the lethal problem is blood…

Bleeding side DOWN — they drown before they exsanguinate

The pathway

1 · Decide whether this is massive

Definitions vary — more than 100–200ml in 24 hours, or any volume causing hypoxia, haemodynamic compromise or airway threat
The physiology matters more than the millilitres: a small volume in a poor lung can be fatal
Confirm it is coughed and not vomited or from the nose

2 · Position: bleeding side DOWN

In LIFE-THREATENING haemoptysis where the bleeding side is known, lie the patient with that lung DEPENDENT — gravity keeps blood out of the good lung
Work out the side first: ask which side feels wet, listen, and use the CXR or previous imaging. If the side is genuinely unknown, do not guess — positioning the wrong way round directs blood into the good lung
This is for the patient who is drowning, not for a streak of blood in the sputum
High-flow oxygen, suction to hand

3 · Call for help early

Critical care, respiratory and interventional radiology — in parallel, not in sequence
Thoracic surgery where available
This is a small number of people who all need to know at once; do not work through them one at a time

4 · Resuscitate and reverse

Large-bore access, group and save and crossmatch
FBC, clotting, fibrinogen
Major or life-threatening bleeding on anticoagulation → urgent reversal, by agent and local protocol. This is often the whole story
Smaller bleeds are an individual hold-and-reassess decision, weighing the indication against the bleeding — not automatic reversal
Tranexamic acid — nebulised or IV; evidence is modest but the risk is low

5 · Find the source

Contrast-enhanced CT / CT angiography using the haemoptysis or bronchial-arterial protocol agreed with radiology and IR — this is NOT the standard PE CTPA question, because embolisation targets bronchial and other systemic arteries
Bronchoscopy — diagnostic and therapeutic, usually in a controlled setting
Common causes: bronchiectasis, TB, malignancy, infection, PE, vasculitis, anticoagulation
Pulmonary-renal syndrome — haemoptysis with an AKI and haematuria is vasculitis until excluded

6 · And for the small ones

Unexplained haemoptysis at age 40 or over is a suspected cancer pathway referral — regardless of smoking history (NICE NG12), and even if it has stopped
CXR, FBC, clotting, and a plan
A normal CXR does not exclude malignancy — the referral is still warranted
Recurrent small-volume bleeding needs a CT, not reassurance

Drugs

Drug	Dose	Route	Notes
Tranexamic acid	1g IV, or 500mg nebulised	IV / NEB	Modest evidence, low risk. Do not let it displace the position, the call or the reversal.
Reversal agents	Per agent and local protocol	IV	For major or life-threatening bleeding. Vitamin K and PCC for warfarin; agent-specific reversal for DOACs, with haematology. A small stable bleed does not automatically earn reversal.
Oxygen	High-flow	INH	And suction. The problem is ventilation, not just loss.

When to escalate

Life-threatening haemoptysis — critical care, respiratory and interventional radiology in parallel, now,Hypoxia or airway soiling — anaesthetics for intubation. Airway isolation technique is their decision, not yours to specify,Haemoptysis with AKI and haematuria — pulmonary-renal syndrome, involve renal and rheumatology,Major or life-threatening haemoptysis on an anticoagulant — urgent reversal per agent and local protocol. A small stable bleed is a hold-and-reassess decision, with an owner for the restart

Reference: British Thoracic Society guidance on haemoptysis investigation; NICE NG12 suspected cancer recognition and referral (haemoptysis). Local massive haemorrhage and difficult airway policies take precedence.

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