Massive hemoptysis occurs in about 5–15 % of all admissions for hemoptysis [1, 2]. Mortality was 7 % in a single center retrospective review of 1,087 patients [2] but has been reported as high as 75 % when the volume of hemoptysis exceeds 600 ml in 24 h. The wide range of mortality likely reflects the lack of a standard definition of massive hemoptysis as well as the variability in underlying etiology [3–5].

A scoring system to identify risk for mortality was derived from a 14 year experience of 1,087 patients admitted for hemoptysis, 717 of whom were admitted to the Intensive Care Unit (ICU), and 10 % of whom demonstrated massive hemoptysis with a mean cumulative volume of >200 ml. Risk factors include chronic alcoholism, ≥2 chest x-ray quadrants involved, pulmonary artery involvement, cancer, aspergillus infection or mycetoma, and initial mechanical ventilation. Two or more risk factors demonstrated a higher mortality [2]. (These risk factors are noted in the clinical algorithm, Fig. 26.4).

Hemoptysis, including massive hemoptysis, usually originates from pathology that involves the high pressure bronchial arterial supply (90 %) [6, 7]. The bronchial artery or arteries originate from the descending thoracic aorta (DTA) at thoracic vertebral level T3-8 most often T5-6. While the most common pattern is a right and left bronchial artery arising from the DTA, variability is extensive, and commonly involves a right bronchial artery arising from an intercostal artery (also-called intercostobronchial trunk) or 2 right bronchial arteries arising from the DTA and/or intercostobronchial trunk. Left bronchial arteries can also arise from intercostobronchial trunks [7]. The spinal artery of Adamkiewicz supplies the distal thoracic and lumbar spinal cord and originates from an intercostal artery at thoracic vertebral level T9-12 in 75 % of patients. However, it infrequently originates between T5-T8 and may be occluded during embolization of the bronchial artery resulting in spinal cord ischemia or infarction [8].

The pulmonary artery infrequently is the source of hemoptysis. Infection, malignant disease, traumatic injuries (e.g. Swan Ganz catheter balloon rupture of PA) and arteriovenous malformations are the most common causes for pulmonary arterial bleeding [6, 9–11]. Rarely hemoptysis may involve non-bronchial or pulmonary arteries. Non-bronchopulmonary arteries may enter the lung via transpleural adhesions as a result of chronic inflammation or congenital anomalies and may anastomose with the pulmonary artery circulation [9, 10]. Other potential nonbronchial arterial sources include the aorta (ruptured aneurysm), intercostal arteries, coronary, thyrocervical, pericardiodiaphragmatic, musculophrenic, and inferior phrenic arteries. Diffuse alveolar hemorrhage syndromes are rarely a cause of massive hemoptysis.

Many diseases have been associated with massive hemoptysis and vary by geographic region. Tuberculosis continues to be a major cause of massive hemoptysis world-wide. Bronchiectasis, malignancy, trauma, pneumonia, and mycetoma are the most causes of massive hemoptysis in the USA [12, 13] (Table 26.1).

The etiology for hemoptysis will direct treatment decisions. Systemic diseases such as vasculitis will require anti-inflammatory or immunosuppression whereas coagulopathies will require reversal of coagulation abnormalities [13–19]. Focal lung or bronchial conditions causing massive hemoptysis may require either bronchoscopic intervention or bronchial artery embolization (BAE) as a first approach.

Plain radiographs will not permit localization of bleeding site in upwards of 35 % of patients [20]. Multidetector CT angiography is capable of ascertaining the site of bleeding and/or suggesting a diagnosis in more than 80 % of patients and the yield may be higher with the use of reformatted image techniques [21]. Further, CT angiography is helpful to guide bronchial artery embolization [6, 7, 9, 20].

Several algorithms have been developed to provide guidance for an approach to severe or massive hemoptysis and most agree that an initial multidisciplinary approach is indicated with immediate evaluation by pulmonology, interventional radiology and thoracic surgery [22–25]. We propose the following:

The initial survey should include a simple “ABC” assessment: Airway, Blood loss, and Clinical condition.

The decision regarding immediate airway management should be determined. Adequate intravenous access should be established with at least two large bore IV lines. Fluid resuscitation should be initiated, if indicated. A complete blood count, testing for coagulopathies, and cross match for transfusion should be obtained. In addition, perform electrocardiogram and obtain cardiac biomarkers.

Position: The patient should be positioned with the presumed side of bleeding dependent (lateral decubitus) to reduce the likelihood of flooding of the unaffected lung with blood. However, lateral decubitus position with the bleeding side down may worsen hypoxemia (due to increased perfusion to poorly aerated lung) [26].