EM · Haemoptysis
Haemoptysis (including massive haemoptysis)
Also known as Coughing blood · Massive haemoptysis · Pulmonary haemorrhage · Bronchial bleeding
Haemoptysis — the coughing of blood from the respiratory tract, the distinction between the non-massive (the bronchitis, the bronchiectasis, the cancer, the TB, the pneumonia) and the massive (over 100 mL in 24 hours — the life-threatening asphyxiation risk), the emergency management of the massive haemoptysis (the airway protection, the bleeding-side-down positioning, the large endotracheal tube or the double-lumen tube, the bronchoscopy, the bronchial artery embolisation), and the tranexamic acid. ACEM-primary, globally tagged.
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Red flags
- Massive haemoptysis kills by asphyxiation, not by exsanguination — the blood floods the alveoli and the patient drowns in their own blood
- Position the patient with the bleeding side DOWN — gravity keeps the blood in the bleeding lung and protects the good lung
- Use a large endotracheal tube (8.0 mm or above) or a double-lumen tube to allow the bronchoscopy and the lung isolation
- The bronchial artery embolisation is the definitive intervention for the massive haemoptysis — the interventional radiology is activated early
- A haemoptysis in a smoker is a lung cancer until proven otherwise
Meet the patient
A 54-year-old man with known post-tuberculous bronchiectasis is brought in having coughed up 200 mL of bright-red frothy blood in the last hour. He leans forward clutching a bowl, distressed: RR 28, SpO2 88 per cent on room air, gurgling crackles over the right base.[1]
Two questions decide his next ten minutes — which lung is bleeding? and is the airway still his own? Roll him bleeding-side down and the algorithm begins. Everything below hangs off those two questions: the airway, the side, and the definitive embolisation.[3]
References12ShowHide
- [1]Mishra PR, Choudhury K, Gopinath B. Advances and challenges in the management of haemoptysis in the emergency department: A narrative review Lung India, 2026.PMID 42377159
- [2]Samireddypalle Y, Arumulla M, Rahul A, et al. Emergency interventions for massive haemoptysis: a pictorial overview of life-saving endovascular procedures Emerg Radiol, 2025.PMID 40531434
- [3]Cahill BC, Ingbar DH. Massive hemoptysis. Assessment and management Clin Chest Med, 1994.PMID 8200191
- [4]Yoon W. Embolic agents used for bronchial artery embolisation in massive haemoptysis Expert Opin Pharmacother, 2004.PMID 14996632
- [5]Slattery MM, Keeling AN, Lee MJ. Outcome and complications of bronchial artery embolisation for life-threatening haemoptysis Ir J Med Sci, 2009.PMID 18953624
- [6]Alexander GR. A retrospective review comparing the treatment outcomes of emergency lung resection for massive haemoptysis with and without preoperative bronchial artery embolization Eur J Cardiothorac Surg, 2014.PMID 23918766
- [7]Ishikawa H, Hara M, Ryuge M, et al. Efficacy and safety of super selective bronchial artery coil embolisation for haemoptysis: a single-centre retrospective observational study BMJ Open, 2017.PMID 28213604
- [8]Frood R, Karthik S, Mirsadraee S, et al. Bronchial Artery Embolisation for Massive Haemoptysis: Immediate and Long-Term Outcomes-A Retrospective Study Pulm Ther, 2020.PMID 32185642
- [9]Ding WY, Chan T, Yadavilli RK, et al. Aspergilloma and massive haemoptysis BMJ Case Rep, 2014.PMID 24739651
- [10]Ali KNZ, Ravikumar KH, Swaika S. Efficacy of nebulised vs intravenous tranexamic acid in management of non-massive haemoptysis: A randomised controlled trial Lung India, 2026.PMID 42377174
- [11]Bahk JH, Lim YJ, Kim CS. Positioning of a double-lumen endobronchial tube without the aid of any instruments: an implication for emergency management J Trauma, 2000.PMID 11086783
- [12]Dutta N, et al. Diffuse alveolar hemorrhage in rheumatic diseases: Clinical features, diagnosis, and management Rheumatol Immunol Res, 2026.PMID 41969820