Because rapid and effective treatment of massive hemoptysis is critically important, the patient should be admitted to intensive care. Airway control
Death from hemoptysis is not usually caused by blood loss, but rather from asphyxia produced by flooding of the airways and alveoli with aspirated blood. Therefore control of the airway is the most important aspect of initial management. Supplemental oxygen should be administered, and pulse oximetry or arterial blood gases monitored. The head of the bed should be lowered to promote drainage of blood from the airway. If the side of origin of the bleeding is known, the patient should be positioned with the affected side down to prevent spill-over into the non-involved lung.
If bleeding does not subside promptly, the patient should be intubated using an endotracheal tube with an internal diameter of at least 8 mm which is large enough to permit passage of suction catheters or a flexible bronchoscope. If the risk of asphyxiation is imminent and the side of bleeding is known, a standard endotracheal tube can be advanced into the main bronchus of the non-involved side and this side can be ventilated and protected from aspiration of blood from the contralateral side. This procedure can be performed blind or with the aid of a bronchoscope. The use of double-lumen endotracheal tubes (Carlens' or Robertshaw's tubes) has little advantage over selective main bronchial intubation. Moreover, their use is associated with possible complications, the need for frequent checking for positioning, and the potential for erosion of bronchial mucosa in the mechanically ventilated patient. Because of the small lumen of these tubes, suctioning of the airways is also difficult.
Mechanical ventilation is often needed because patients frequently have underlying lung disease with decreased lung reserves. Positive end-expiratory pressure has been advocated as a possible therapeutic modality, by attempting to accomplish tamponade of the bleeding vessel (particularly if it is a pulmonary artery) with positive intrathoracic pressures. However, care must be taken not to worsen hemodynamics or ventilation-perfusion mismatch in localized lung disease.
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