skip to main content

Massive hemoptysis — ABIM Board MCQ

Instant feedback + full explanation. One question, done properly.

HardPulmonary/Critical CareMassive hemoptysisABIM Board

A 63-year-old man with severe bronchiectasis undergoes CT angiography for hemoptysis, which demonstrates active bleeding into the right lower-lobe bronchus from a hypertrophied bronchial artery. During transport from the scanner, he coughs up an additional 300 mL of bright red blood. His oxygen saturation is 82% despite a nonrebreather mask, and he becomes somnolent and unable to clear blood from his airway. Blood pressure is 132/74 mm Hg. Which of the following is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Place him right-side down, intubate with a large-bore single-lumen endotracheal tube, and mobilize bronchoscopy and interventional radiology

This patient has life-threatening hemoptysis because bleeding is causing severe hypoxemia, impaired consciousness, and inability to clear the airway. The known bleeding lung should be placed dependent—right-side down—to reduce spillover into the unaffected left lung. He requires prompt intubation with a large-bore single-lumen endotracheal tube, which permits suctioning, therapeutic bronchoscopy, and placement of a bronchial blocker if needed; interventional radiology should simultaneously prepare for bronchial artery embolization. Left-side-down positioning would contaminate the good lung. Double-lumen tubes are difficult to place during active hemorrhage and have narrow lumens prone to clot obstruction. Embolization must not precede airway stabilization in a somnolent, profoundly hypoxemic patient. Tranexamic acid may be temporizing but is inadequate as sole initial treatment here.

Reference: Atchinson PRA, et al. The emergency department evaluation and management of massive hemoptysis. American Journal of Emergency Medicine. 2021;50:148-155. https://pubmed.ncbi.nlm.nih.gov/34365064/