In this episode of Hospital Medicine Unplugged, we dive into massive hemoptysis—stabilize fast, protect the airway, localize the bleed, and stop it for good.

We start with the killer reality: mortality isn’t from bleeding out, it’s from asphyxiation. Even small volumes can flood the airways and crash oxygenation. Massive hemoptysis = ≥200 mL/24 h or any volume causing respiratory/hemodynamic compromise.

Immediate moves:
• Airway first—large-bore cuffed ETT, consider selective mainstem if bleeding side known.
• Positioning: bleeding lung down.
• Oxygen + resuscitation, reverse coagulopathy, crossmatch blood.
• Call the multidisciplinary team early—pulmonology, IR, thoracic surgery.

Diagnostics after stabilization:
• CXR to check tube, look for opacification (≥2 lung zones = ↑mortality).
• CTA chest = gold standard for localizing bleed and guiding embolization.
• Bronchoscopy (rigid or flexible) in unstable patients—suction clots, tamponade, balloon occlusion, topical hemostatics.

Definitive hemorrhage control:
• Bronchial artery embolization (BAE) = first-line: >85% immediate success, lower morbidity/mortality than surgery, recurrence 10–20%. Risk: rare spinal cord ischemia.
• Bronchoscopy interventions: tamponade, thermal therapies, topical vasoconstrictors—best for central bleeds or temporization.
• Surgery (lobectomy/pneumonectomy): reserved for refractory/recurrent bleeding or surgically correctable pathology; high risk if emergent, better outcomes when delayed after stabilization.

Adjunctive therapies:
• Tranexamic acid (TXA): nebulized (500 mg TID) shows promise in RCTs for moderate/non-massive hemoptysis; IV or nebulized use in massive cases = temporizing, not definitive.
• Topical iced saline, epinephrine, hemostatic mesh during bronchoscopy.
• Supportive: O₂, hemodynamic support, transfusion, immunosuppression for DAH, infection control.

Monitoring & complications:
• ICU-level monitoring—continuous SpO₂, ECG, serial Hgb/coags, suction output.
• Watch for recurrence (esp. early post-BAE), aspiration, airway trauma, infection, embolization complications, surgical morbidity.

Prognosis:
• Mortality 20–38%, higher in malignancy (up to 100%).
• BAE improves survival vs emergent surgery, but recurrence remains common.
• Long-term outcomes hinge on etiology (bronchiectasis, TB, malignancy).

Bottom line: Airway, positioning, and multidisciplinary activation save lives. CTA + BAE is the definitive play, bronchoscopy stabilizes, surgery is last resort. Adjuncts buy time, not cure. Act fast, escalate smart, and never underestimate the asphyxiation risk.