Evaluation & management of clinically significant hemoptysis—a clinical practice review

: Hemoptysis is the coughing up of blood, and in certain clinical scenarios, it can be a life-threatening medical emergency. Hemoptysis is a spectrum of disease with massive, or more recently termed life-threating hemoptysis, being the extreme presentation. Unlike hemorrhage in other scenarios, small amounts of bleeding in the airway can lead to clinical instability—especially in individuals with underlying lung disease. Life-threatening hemoptysis is typically fatal, due to hypoxia from asphyxiation and not exsanguination. Management presents multiple diagnostic and therapeutic challenges and requires a multi-disciplinary team including intensivists, interventional pulmonologists, interventional radiologists, and occasionally thoracic surgeons. Initial evaluation should focus on airway management, localization of the hemorrhage, and subsequent hemorrhage control. Flexible and rigid bronchoscopy, bronchial artery embolization, and surgery are all potential treatment options for definitive hemorrhage control; with a variety of adjunctive therapies available to assist with each of these therapeutic options. In this review, we will help define hemoptysis, discuss the potential etiologies and the associated vascular anatomy and pathophysiology. We will discuss the approach to diagnostic evaluation and review the therapeutic options available to physicians. Due to the complex nature of hemoptysis management and paucity of guiding evidence with randomized controlled trials, we hope to summarize the available evidence and provide a comprehensive approach to diagnosis and management.