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1. Admission to ICU and observe
Initial management of hemoptysis includes identification of which lung is bleeding and if the bleeding is massive, placing the bleeding lung in the dependent position to protect the other lung (1). If the airway is compromised, an airway needs to be established by intubation and mechanical ventilation. Any coagulation abnormalities should be reversed. Bronchoscopy to assess and control bleeding should be performed. Balloon tamponade, iced saline lavage, topical vasoconstrictor coagulant, laser therapy, and electrocautery can all be performed to control the bleeding.
Differing thresholds for massive hemoptysis varying from 100-600 ml have been proposed although none has been universally accepted (1). However, the amount of blood is probably approaching 300 ml with her hemoptysis prior to admission. For this reason close observation in the ICU is warranted. She was relatively stable and clearing the blood by coughing and endotracheal intubation does not seem clinically necessary at this time. An emergency thoracotomy would be inappropriate since the bleeding site is not yet identified and she is a Jehovah’s Witness eliminating transfusion as a possibility.
Overnight she had no further hemoptysis. The thoracic CT scan was repeated (Figure 5).
Figure 5. Selected view of thoracic CT scan (Panel A) showing a possible new opacity in the left lower lobe compared to the previous CT scan (Panel B).
What should be done at this time? (click on correct answer to move to next panel)