Lung cancer is a silent killer. Symptoms are present in only approximately 40% of patients in a population screened for lung cancer who have radiographic changes.¹ Even in those patients with symptoms, these are usually nonspecific, and clues to the existence of an underlying lung cancer may be gleaned only from the patient’s history. A history of long-standing cigarette smoking, age greater than 40 years, significant weight loss, and a chronic cough are clinical pointers worth noting.

Although some degree of hemoptysis may be the presenting complaint in 29% of patients with lung cancer, the degree of hemoptysis varies considerably.² Most commonly, patients report a discrete episode of blood-streaked sputum at least once before seeing a physician. Often this is attributed to chronic bronchitis, especially in the face of a normal recent chest radiograph. Since a chest computed tomography (CT) scan has been shown to be much more sensitive for detecting underlying pulmonary lesions compared with a plain chest radiograph, a chest CT scan should be obtained in all patients with a history of hemoptysis.³

A more severe hemoptysis can be seen with the expectoration of clots after a vigorous coughing episode. It is surprising how many patients will continue to downplay the significance of more severe episodes of hemoptysis or fail to seek urgent medical attention. The expectoration of clots is not considered pathognomonic for lung cancer. Massive hemoptysis (by definition, >200 mL per day), although less common with lung cancer, can occur in up to 20% of patients in whom lung cancer is the cause.⁴ Furthermore, it has been reported to be fatal in up to 50% of patients with lung cancer and demands serious and immediate attention in a hospital setting.⁵

The single most common cause of streaky hemoptysis in the United States is acute bronchitis. The most common cause of the expectoration of clot or massive hemoptysis, however, is lung cancer, especially in patients older than 50 years who have a long-standing smoking history. Other causes of hemoptysis, which cannot be ignored, include tuberculosis, chronic bronchitis, bronchiectasis, pneumonia, pulmonary infarction, lung abscess, aspergilloma, arteriovenous malformation of the lung, mitral stenosis, and bronchial adenoma. Lung cancer should be ruled out before considering other causes.

Massive hemoptysis must be considered a surgical emergency. The potential for imminent loss of life dictates attention first to preservation of the airway, breathing, and circulation (the ABCs of resuscitation). In the face of massive hemoptysis, the patient should be intubated with a single-lumen endotracheal tube (ET). A plain chest radiograph and urgent flexible bronchoscopy frequently can be used to determine which side of the airway is the source of bleeding. If the ET can be guided selectively into the contralateral airway, it can preserve the life of the patient, even if the ipsilateral airway completely fills with blood and clots. Intravenous (IV) access with two large-bore catheters should be established quickly. A large amount of clot in the proximal airway may necessitate urgent tracheotomy to save the patient from drowning and asphyxiation. This maneuver will facilitate the expeditious removal of large clots and blood from the trachea. Once the ABCs of resuscitation are secured, efforts should be directed toward establishing a diagnosis.

A plain chest radiograph should be obtained in any patient presenting with hemoptysis. The simple fact that disease can be seen within one or the other lung field can provide invaluable information for the ongoing care of the patient. It should be noted, however, that up to 5% of patients with a history of hemoptysis and an underlying cancer may have a normal chest radiograph.⁶

Traditionally, flexible bronchoscopy has been considered as the next diagnostic test to perform in a patient who presents with hemoptysis. The likelihood of localizing a bleeding site is considerably higher if bronchoscopy is undertaken during or within 48 hours of an event.⁷ Furthermore, emergency bronchoscopy after intubation can be used to guide the ET into either the left or the right main stem bronchus. In this way, the affected side can be isolated from the healthy lung.⁸ Early bronchoscopy does not guarantee that an endobronchial bleeding site will be identified. In one study, no discrete bleeding source was found in approximately half of patients.⁸

A high-resolution chest CT is an important tool for identifying the source of bleeding and possibly may replace bronchoscopy as the first-line procedure.⁹ In one study, when the chest radiograph was nonspecific, chest CT was found to be diagnostic in 43% and bronchoscopy in only 14% of patients.¹⁰ In this same study, the site of bleeding was localized by chest CT scan in 52% compared with 23% by bronchoscopy. In reality, bronchoscopy and CT scanning should be viewed as complementary studies when used to identify the source of hemoptysis. While CT scan can visualize parenchymal abnormalities in the periphery of the tracheobronchial tree as well as the presence of extraluminal disease, the bronchoscope is better suited for diagnosing endobronchial tumors and subtle airway abnormalities such as mucosal edema. Some of these bronchoscopic findings may not be obvious on a standard chest CT scan. Thus, CT scanning of the chest and bronchoscopy have greater sensitivity and specificity when used in combination.

The management of hemoptysis depends on the rate of bleeding and the underlying cardiopulmonary status of the patient. In a few cases, bleeding into the airway may be brisk, having the potential to be fatal within minutes. Patients may succumb rapidly, not from exsanguination and shock, but from drowning and asphyxiation. Selecting the appropriate therapeutic maneuvers to institute from the outset requires sound clinical judgment and skill. Practicing the basic maneuvers during training sessions increases the probability of successful management of the airway in the face of massive hemoptysis if the bleeding site is known.

In the face of catastrophic massive hemoptysis, the patient should be positioned with the bleeding lung in a dependent position to protect the normal lung. Once the patient is intubated, the bronchoscope is advanced into the airway in an attempt to keep at least one side of the airway patent and free from occluding clots. In all cases, bronchoscopy is central to the management of these patients. If visualization is completely obscured by blood, the bronchoscope should be passed toward the side opposite from the presumed bleeding. Once passed down to the distal airway, the flexible bronchoscope can serve as a stylet to guide the tip of the ET beyond the carina and to selectively intubate the mainstem bronchus of the nonbleeding lung. The balloon on the ET occludes the unaffected mainstem bronchus, preventing blood from entering the distal airway. In this way, the surgeon establishes control of the patient’s airway and breathing. The next step is to support the circulation with IV access and transfused blood as needed.