Management of haemoptysis

Coughing up blood (haemoptysis) is a frightening symptom, and may be serious although often it is trivial. The management of mild haemoptysis is usually reassurance and investigation. The BMJ provide a guide for assessing haemoptysis.

  • Massive haemoptysis:  >300 ml blood in 24 hours
  • Moderate:  >3 episodes in one week, of 100 ml/day
  • Mild:   <100 ml/day

CASE: Betancourt et al, 2015

Tranexamic acid

While barely studied for this indication, tranexamic acid (usually given orally) can arrest haemoptysis. A typical dose is 500-1000 mg three times daily, for 5-7 days. Caution is required in older patients because it promotes clotting. It is useful for mild and moderate haemoptysis, but less so for massive haemoptysis. Side effects include:

CommonNausea, vomiting, diarrhoea, abdominal pain
UncommonGiddiness, restlessness, psychiatric disturbances
Very uncommonThrombocytopaenia, coagulation defects, prolonged bleeding times, intravesicular clotting, hypotension on rapid IV infusion, hydrocephalus, colour vision problems
RareThromboembolism, skin rashes, retinopathy, visual impairment, acute renal cortical necrosis, myocardial infarction, cerebral ischaemia, headaches, central venous stasis retinopathy

Bronchial artery embolisation

Massive haemoptysis requires immediate admission to hospital, humidified oxygen and maintaining the patient upright. Ice compression over the affected area of the chest may allow contribute to bronchial and intercostal artery arterial vasoconstriction. Tranexamic acid and octreotide infusion (50-100 μg/hour up to 2 days) can be administered; an alternative is terlipressin (2 mg IV, every 4 hours, for up to 72 hours). Blood transfusion is also usually necessary. Early angiography and embolisation (or emergency surgical resection) are then required, once the patient is partially stabilised. Massive haemoptysis is an unpredictable disease and rapid interventions are required.

Bronchial artery embolisation (BAE) is a minimally invasive procedure used to control massive or recurrent haemoptysis as a bridge to more definite therapy. It is also performed for patients who are too unwell to undergo surgery. The immediate success of the procedure is reported to be above 80%. However, repeated interventions are often required, especially if fungal infection is not controlled, as recurrence of haemoptysis is common. Major complications (< 1%) include dissection of a bronchial artery, bronchial arterial perforation, transient quadriplegia, transient ischaemic attack, stroke or disseminated infection. Minor complications (30%) include chest pain, dysphagia and fever (Maghrabi and Denning, 2017).

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