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Life-threatening haemoptysis in bronchiectasis — MRCEM SBA MCQ

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HardRespiratory emergenciesLife-threatening haemoptysis in bronchiectasisMRCEM SBA

A 56-year-old woman with bronchiectasis confined to the right lower lobe attends the emergency department after coughing up approximately 180 mL of fresh blood in 20 minutes. Bedside bronchoscopy localises active bleeding to the right lower lobe. Bleeding continues despite suction, and she is becoming exhausted; her SpO₂ is 88% despite oxygen through a reservoir mask. Anaesthetic and interventional radiology teams are available. What is the most appropriate immediate management plan?

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Correct answer: B — Position her right side down, arrange anaesthetic airway protection and request urgent bronchial artery embolisation.

This is life-threatening haemoptysis: bleeding is ongoing, oxygenation is failing and the patient is becoming exhausted. Bronchoscopy has identified the right lung as the source, so placing it dependent helps limit contamination of the left lung. Continuing haemorrhage and hypoxia require immediate anaesthetic airway support; bronchial artery embolisation is the recommended first-line definitive treatment when significant haemoptysis persists in bronchiectasis. Resuscitation and appropriate intravenous antibiotics can proceed alongside these priorities. ([nwmcfc.nhs.uk](https://nwmcfc.nhs.uk/wp-content/uploads/pdf-guidelines/B1.5-Haemoptysis-Website.pdf)) A reverses the positioning and exposes the non-bleeding left lung to blood. C correctly prioritises the airway but selects resection ahead of embolisation; surgery is more pertinent when embolisation fails or a specific surgical indication exists. D includes a reasonable adjunct, tranexamic acid, but reassessment must not delay airway protection and definitive haemorrhage control in this deteriorating patient. E mistakes a useful investigation for the immediate priority: CT angiography may help plan treatment once the airway is secure, but sending a hypoxic patient with uncontrolled airway bleeding for imaging first is inappropriate. ([nwmcfc.nhs.uk](https://nwmcfc.nhs.uk/wp-content/uploads/pdf-guidelines/B1.5-Haemoptysis-Website.pdf))

Reference: British Thoracic Society guideline for bronchiectasis in adults (2018) — https://bmjopenrespres.bmj.com/content/5/1/e000348 Haemoptysis, sections 2–4 (Date not stated in document) — https://nwmcfc.nhs.uk/wp-content/uploads/pdf-guidelines/B1.5-Haemoptysis-Website.pdf The pulmonary physician in critical care: Assessment and management of massive haemoptysis (2003) — https://thorax.bmj.com/content/58/9/814