Massive Haemoptysis

Quick Answer

One-liner: Massive haemoptysis is life-threatening bleeding from the lower respiratory tract (greater than 100-600 mL/24h or any volume causing airway/haemodynamic compromise) requiring immediate airway protection, bleeding side down positioning, and urgent bronchial artery embolization.

Massive haemoptysis represents a true time-critical emergency with mortality rates of 30-80% if untreated, primarily from asphyxiation rather than exsanguination. The priority is airway protection followed by lung isolation to prevent aspiration of blood into the unaffected lung. Position the patient with bleeding side DOWN ("drown the bad lung"), secure the airway with a large ETT (≥8.0 mm), and arrange urgent bronchial artery embolization (BAE). In Australia, consider bronchiectasis, TB reactivation, and malignancy as common causes, with higher prevalence of bronchiectasis in Aboriginal and Torres Strait Islander populations [1,2].

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Bronchial arterial supply (90% from thoracic aorta T5-T6), dual pulmonary/bronchial circulation, bronchial-pulmonary anastomoses
• Physiology: Bronchial arteries at systemic pressure (120 mmHg) vs pulmonary arteries (25 mmHg); bronchial vessels responsible for 90% of massive haemoptysis
• Pharmacology: Tranexamic acid (antifibrinolytic mechanism), vasopressin (vasoconstriction)

Fellowship Exam Relevance

• Written: Definition controversies (100-600 mL), aetiology patterns (developed vs developing countries), BAE indications and complications, bronchoscopy role (diagnostic vs therapeutic)
• OSCE: Airway management in actively bleeding patient, bronchial blocker placement, resuscitation team leadership, breaking bad news for massive haemoptysis in malignancy
• Key domains tested: Medical Expert (airway management, procedural skills), Collaborator (IR coordination, ICU liaison), Leader (resuscitation team leadership)

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Key Points

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Epidemiology

Australian/NZ Specific

Aboriginal and Torres Strait Islander Populations:

• Bronchiectasis: 3-5x higher prevalence (147 per 100,000 vs 30 per 100,000 non-Indigenous) [8]
• Tuberculosis: Higher incidence in remote communities (6-8 per 100,000 vs 1.5 per 100,000 nationally) [9]
• Risk factors: Childhood pneumonia, chronic suppurative lung disease, post-TB bronchiectasis [10]

Māori Health Considerations (NZ):

• Higher rates of bronchiectasis and COPD
• Later presentation due to access barriers
• Cultural importance of whānau involvement in care [11]

Remote/Rural Variations:

• Delayed presentation common (hours to days)
• Limited access to interventional radiology
• RFDS retrieval considerations for definitive care [12]

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Pathophysiology

Definition Controversy

Key point: The rate of bleeding matters more than total volume. Anatomical dead space is only ~150 mL, so even small volumes can cause fatal asphyxiation [13].

Vascular Anatomy

Bronchial Circulation (90% of massive haemoptysis):

• Origin: Thoracic aorta at T5-T6 level (variably 1-4 arteries)
• Pressure: Systemic (120 mmHg) - 6x pulmonary pressure
• Supply: Bronchi, visceral pleura, vasa vasorum, oesophagus
• Hypertrophy: Chronic inflammation causes angiogenesis and tortuous vessels [14]

Pulmonary Circulation (5-10% of massive haemoptysis):

• Pressure: 25/10 mmHg (low pressure)
• Causes: Pulmonary AVM, Rasmussen aneurysm (TB), PE, trauma

Pathological Progression

Chronic Inflammation → Bronchial Artery Hypertrophy → Vessel Wall Weakness
      ↓
Aneurysm Formation → Erosion into Airway → MASSIVE HAEMOPTYSIS
      ↓
Airway Flooding → Asphyxiation (150 mL dead space) → DEATH

Mechanism of Death

Primary cause: Asphyxiation (not exsanguination)

The anatomical dead space of the tracheobronchial tree is approximately 150 mL. This means:

• Even 200 mL of blood can flood both lungs and prevent gas exchange
• The rate of bleeding is more critical than total volume
• A sudden 100 mL gush can cause immediate hypoxia
• Patients drown in their own blood before they exsanguinate [13]

Physiological cascade:

1. Blood floods conducting airways
2. V/Q mismatch develops rapidly
3. Hypoxaemia progresses to respiratory failure
4. Cardiovascular collapse follows if uncorrected

Why volume thresholds are problematic:

The clinical status (airway, breathing, circulation) is more important than quantifying exact volume.

Bronchial Artery Anatomy (Exam Favourite)

Normal Anatomy:

• 1-4 bronchial arteries arise from descending thoracic aorta (T5-T6)
• Right bronchial artery often arises from intercostobronchial trunk (90%)
• Left bronchial arteries typically 1-2, direct aortic origin
• Diameter: 1.5-3 mm normally; up to 3-4 mm when pathologically dilated

Variant Anatomy (important for BAE):

Bronchial-Pulmonary Anastomoses:

• Precapillary connections between bronchial and pulmonary circulations
• Normally minimal flow
• Enlarge in chronic inflammatory conditions
• Shunting can cause haemoptysis from pulmonary artery bleeding

Artery of Adamkiewicz:

• Major anterior radiculomedullary artery
• Supplies lower 2/3 of spinal cord
• Origin: Left intercostal artery T9-L2 (80%)
• Can arise from bronchial artery in 5-10%
• Critical importance: Embolisation can cause paraplegia [14]

Common Aetiologies

Developed Countries (Australia/NZ):

Endemic Regions:

• TB: 30-60% in South Asia, Africa, Indigenous communities [15]
• Aspergilloma: Common in post-TB cavities
• Parasitic: Paragonimiasis (SE Asia) [16]

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Clinical Approach

Recognition

Immediate Life Threats:

• Respiratory distress, stridor, choking
• Hypoxia despite oxygen
• Haemodynamic instability
• Altered consciousness

Initial Assessment

Primary Survey

• A - Airway: Patent? Blood in oropharynx? Stridor? Sit upright if conscious
• B - Breathing: SpO2, RR, accessory muscle use, auscultation (focal crackles = bleeding side)
• C - Circulation: HR, BP, peripheral perfusion, IV access x2
• D - Disability: GCS, lateralising signs (underlying malignancy)
• E - Exposure: Stigmata of chronic disease, vasculitis rash

History (if obtainable)

Key Questions

Red Flag Symptoms

Examination

Lateralising the Bleeding Side

Critical point: Lateralising the bleeding side is essential for positioning and potential lung isolation [17].

Differentiating Haemoptysis from Haematemesis

This is a common exam question and clinical challenge:

Pseudohaemoptysis:

• Epistaxis with posterior drainage
• Oropharyngeal bleeding (trauma, tumour)
• Rarely: Gingival bleeding (coagulopathy)

Clinical Pearl: Always examine the oropharynx and perform anterior rhinoscopy to exclude upper airway source.

Physical Examination Findings

General Inspection:

• Level of distress (severe = airway compromise)
• Tachypnoea, accessory muscle use
• Cyanosis (late sign of hypoxia)
• Pallor (significant blood loss)
• Cachectic appearance (malignancy, TB)
• Finger clubbing (bronchiectasis, malignancy)

Respiratory Examination:

Cardiovascular Examination:

Other Clues:

• Skin rash (vasculitis - GPA, anti-GBM)
• Epistaxis, telangiectasia (HHT - pulmonary AVM)
• Lymphadenopathy (malignancy, TB)
• Hepatomegaly (metastatic disease)

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

CT Chest Role

Timing: Before bronchoscopy in stable patients

• Identifies bleeding source in 70-77% [18]
• Shows underlying pathology (bronchiectasis, mass, AVM)
• Guides bronchoscopy and BAE planning
• "Ground glass" opacification indicates active bleeding site

Bronchoscopy Role

Indications:

• Localise bleeding source (especially if unknown side)
• Therapeutic intervention (cold saline, adrenaline, balloon tamponade)
• Airway clearance

Timing controversy:

• Urgent (below 24h) if ongoing bleeding
• Can be performed before CT if patient unstable
• Diagnostic yield 73% if within 48h, drops to 50% after [19]

CT Imaging Interpretation

CT Protocol for Haemoptysis:

• Non-contrast initially (to see blood density)
• Contrast-enhanced for vascular detail
• Multiplanar reconstructions (coronal, sagittal)
• 3D bronchial artery mapping for BAE planning

CT Findings by Aetiology:

Localising Active Bleeding:

• Ground-glass opacity (blood in alveoli)
• Consolidation (blood pooling)
• Air-bronchogram pattern within blood
• "Dependent blood"
• pooling in dependent segments

Bronchial Artery CT Angiography:

• Identifies enlarged bronchial arteries (greater than 2 mm = abnormal)
• Maps variant anatomy
• Detects non-bronchial systemic collaterals
• Essential for BAE planning

Laboratory Investigations in Detail

Coagulation Panel:

Vasculitis Screen:

Renal Function:

• Creatinine elevation suggests pulmonary-renal syndrome
• Urgent nephrology input if renal involvement

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Management

Immediate Management (First 10 Minutes)

1. Call for senior help + alert anaesthetics/ICU (0-2 min)
2. Position: Sit upright if conscious, OR bleeding side DOWN if deteriorating
3. High-flow oxygen 15 L/min (target SpO2 greater than 94%)
4. Large-bore IV access x2 (14-16G)
5. Bloods: FBC, Coag, G&H, ABG
6. Tranexamic acid 1g IV over 10 min
7. Assess for intubation indications
8. Portable CXR if stable / CT if very stable
9. Contact IR for BAE (definitive treatment)
10. Withhold anticoagulants, reverse if critical

Positioning Strategy

Key principle: "Drown the bad lung, save the good lung"

Airway Management

Indications for Intubation

• Hypoxia despite high-flow O2 (SpO2 below 90%)
• Airway compromise (stridor, choking, aspiration)
• Altered consciousness (GCS ≤8)
• Haemodynamic instability
• Ongoing massive bleeding (greater than 100 mL/h)
• Need for urgent bronchoscopy/transfer [20]

Intubation Approach

Equipment:

• Large ETT: ≥8.0 mm ID (preferably 8.5-9.0 mm) - to allow bronchoscope passage
• Video laryngoscope (blood in airway)
• Large-bore suction (Yankauer)
• Bougie available
• Bronchial blocker or DLT as backup

Technique:

1. RSI preferred (aspiration risk)
2. Head of bed elevated if possible
3. Left lateral positioning immediately post-intubation if known right-sided bleeding
4. Confirm ETT position then reassess need for lung isolation

Lung Isolation Options

Bronchial blocker technique:

1. Place through 8.0+ mm ETT
2. Advance under bronchoscopic guidance
3. Position in mainstem bronchus of bleeding side
4. Inflate balloon to occlude bleeding bronchus [21]

Mainstem intubation:

• Right mainstem: Advance ETT blindly (easier, more straight)
• Left mainstem: Advance with bronchoscope guidance
• Isolates entire lung - not selective

Medications

Antifibrinolytics

Tranexamic Acid Evidence:

• Mechanism: Lysine analogue, blocks plasminogen activation
• Cochrane 2018: Insufficient evidence for mortality, trend to reduced bleeding [22]
• Systematic review 2020: Nebulised TXA reduced bleeding duration and volume [23]
• Dose: 500mg nebulised TDS or 1g IV Q8H (total 3g/day max)

Bronchoscopic Therapies

Blood Product Support

• Type and crossmatch 4-6 units
• Transfusion trigger: Hb below 70 g/L (or below 80 g/L if ongoing bleeding)
• Reverse anticoagulation:
  • "Warfarin: Vitamin K 5-10mg IV + Prothrombinex"
  • "DOACs: Idarucizumab (dabigatran), Andexanet alfa (Xa inhibitors)"
  • "Heparin: Protamine"

Definitive Management

Bronchial Artery Embolization (BAE)

First-line definitive treatment for massive haemoptysis

Technique:

1. Femoral artery access
2. Thoracic aortography to identify bronchial arteries
3. Selective catheterisation of bleeding vessel
4. Embolisation with particles (PVA) or coils
5. Non-target embolisation prevention critical [24]

Complications:

• Spinal cord ischemia (1-6%): Artery of Adamkiewicz origin
• Chest pain (15-30%)
• Dysphagia (1%)
• Bronchial necrosis (rare)

Recurrence predictors:

• Non-bronchial systemic collaterals
• Underlying malignancy
• Aspergilloma
• Incomplete embolisation [25]

Surgery

Indications:

• BAE failure or recurrence
• Localised disease amenable to resection
• Rasmussen aneurysm (TB)
• Pulmonary AVM
• Trauma

Mortality: 20-40% in emergency setting (much lower if elective) [26]

Procedures:

• Lobectomy (most common)
• Pneumonectomy (extensive disease)
• Segmentectomy (limited disease)

Management Algorithm Summary

MASSIVE HAEMOPTYSIS MANAGEMENT ALGORITHM
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━

IMMEDIATE (0-10 minutes)
├── Airway assessment (stridor, choking, SpO2)
├── Position: Bleeding side DOWN (or upright if stable)
├── High-flow O2 15 L/min
├── IV access x2 (large bore)
├── Tranexamic acid 1g IV
├── Bloods: FBC, coag, G&H
└── Call: Anaesthetics, ICU, IR

STABILISATION (10-60 minutes)
├── If deteriorating → INTUBATE (large ETT ≥8.0 mm)
│   └── Consider lung isolation if ongoing flooding
├── Portable CXR (lateralise bleeding)
├── CT chest if stable
├── Reverse anticoagulation if applicable
└── Blood products if needed

DEFINITIVE (1-6 hours)
├── Bronchoscopy (localise, therapeutic)
├── BRONCHIAL ARTERY EMBOLIZATION (first-line)
│   ├── Success: 70-90%
│   └── If fail → Repeat BAE or Surgery
└── Surgery (if BAE fails, localised disease)

POST-PROCEDURE
├── ICU admission
├── Monitor for recurrence
├── Treat underlying cause
└── Respiratory follow-up

Complications of Treatment

BAE Complications:

Intubation/Lung Isolation Complications:

• Failed intubation (prepare difficult airway equipment)
• Bronchial blocker dislodgement (secure well, re-check position)
• Wrong lung isolated (confirm with bronchoscopy)
• Barotrauma (avoid high pressures)

Specific Aetiology Management

Tuberculosis-Related Haemoptysis:

• Active TB: Anti-TB therapy + BAE if massive
• Rasmussen aneurysm: Urgent BAE or surgery
• Aspergilloma in old cavity: BAE, antifungals, surgery if recurrent
• Bronchiectasis post-TB: As per bronchiectasis management

Malignancy-Related Haemoptysis:

• BAE for palliation (higher recurrence than other causes)
• Palliative radiotherapy (external beam or endobronchial brachytherapy)
• Haemostatic agents (oral TXA, nebulised)
• Goals of care discussion essential

Pulmonary AVM (HHT):

• Embolisation is treatment of choice
• Screen for cerebral AVMs (stroke prevention)
• Family screening and genetic counselling
• Antibiotic prophylaxis for dental procedures (paradoxical emboli)

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Disposition

ICU/HDU Criteria

• Any patient requiring intubation
• Ongoing bleeding despite initial therapy
• Haemodynamic instability
• Post-BAE monitoring
• Multi-organ dysfunction

Admission Criteria (General Ward)

• Stable vital signs after treatment
• Bleeding controlled
• Known aetiology
• Plan for investigation/treatment
• No high-risk features

Discharge Criteria

Rarely appropriate for massive haemoptysis

If minor haemoptysis (not massive):

• Bleeding stopped for greater than 6 hours
• Stable vital signs
• Identified cause with low-risk aetiology
• Reliable follow-up within 48-72 hours
• Red flag education provided
• Outpatient CT arranged

Follow-up

• Respiratory medicine review within 1-2 weeks
• Bronchoscopy if not performed acutely
• Treatment of underlying cause
• TB contact tracing if relevant
• Smoking cessation referral

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Special Populations

Paediatric Considerations

• Rare in children
• Common causes: Foreign body, cystic fibrosis, infection
• Lower volume thresholds (4 mL/kg/24h = massive)
• Smaller airway = faster obstruction
• Paediatric bronchoscope required

Paediatric-Specific Causes:

Key Differences in Management:

• Weight-based TXA dosing (15-25 mg/kg IV, max 1g)
• Age-appropriate ETT sizing
• Paediatric bronchoscope required (2.2-3.6 mm)
• Involve paediatric intensivist early
• Cuffed ETT for older children (greater than 1 year)

Pregnancy

• Rare causes: PE, placental embolism, vasculitis
• Left lateral positioning preferred
• Consider foetal monitoring
• Avoid unnecessary radiation but CT if needed
• BAE: Lead shielding, minimise fluoroscopy

Pregnancy-Specific Considerations:

• Hypercoagulable state increases PE risk
• Physiological anaemia may mask blood loss
• Radiocontrast crosses placenta but not teratogenic
• TXA is Category B - can be used if indicated
• Involve obstetrics early
• Consider urgent delivery if greater than 34 weeks with critical maternal status

Elderly

• Higher malignancy rates
• More comorbidities
• Higher mortality
• Consider ceiling of care discussions
• Frailty assessment impacts surgical candidacy

Geriatric-Specific Issues:

• Increased anticoagulant use (warfarin, DOACs)
• Reduced physiological reserve
• Higher aspiration risk
• Polypharmacy (drug interactions)
• Cognitive impairment may affect history
• Goals of care discussions essential

Frailty Assessment Impact:

Anticoagulated Patients

Special Considerations:

• Higher risk of massive haemoptysis
• Bleeding may be more difficult to control
• Reversal agents essential

Anticoagulant Reversal:

If No Specific Reversal Available:

• Tranexamic acid 1g IV
• PCC (Prothrombinex) 25-50 IU/kg
• Fresh frozen plasma (limited efficacy for DOACs)
• Activated factor VII (off-label, last resort)

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Higher Risk Populations:

• Bronchiectasis prevalence 3-5x higher in Aboriginal communities [27]
• Tuberculosis rates elevated in remote communities [28]
• Post-infectious bronchiectasis common after childhood pneumonia

Cultural Safety:

• Involve Aboriginal Health Workers/Liaison Officers early
• Consider family/community support needs
• Language services (remote communities may speak traditional languages)
• Respect for Sorry Business and cultural protocols
• Understand potential distrust of health systems

Barriers to Care:

• Geographic isolation delays presentation
• Limited local specialist services
• Financial barriers to travel
• Cultural reluctance to leave Country

Communication:

• Use interpreters for consent discussions
• Family-centred decision making (not individual autonomy model)
• Explain procedures visually
• Allow time for community consultation

Māori Health (NZ):

• Whānau (family) involvement in care decisions
• Respect for tikanga (customs)
• Māori Health Workers available
• Consideration of Rongoā Māori (traditional medicine) wishes [29]

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Remote/Rural Considerations

Pre-Hospital

RFDS/Retrieval Considerations:

• Early notification for potential retrieval
• Coordinates: 1300 669 569 (NSW/VIC) / 1800 805 027 (QLD)
• Blood products may be unavailable - plan resuscitation
• Retrieval team may not have IR capability [30]

Remote Hospital Stabilisation:

1. Secure airway if compromised
2. Position bleeding side down
3. Large-bore IV access
4. Tranexamic acid 1g IV
5. Blood products if available
6. Telehealth consultation with tertiary centre
7. Coordinate RFDS retrieval

Resource-Limited Setting

Modified Approach:

• No CT available: CXR to lateralise + clinical assessment
• No bronchoscopy: Conservative management + retrieval
• No BAE: Surgery may be only definitive option
• Limited blood products: Early retrieval critical

Retrieval

Transfer Indications:

• All massive haemoptysis cases (BAE/surgery access)
• Ongoing bleeding despite stabilisation
• Need for ICU-level care
• Diagnostic uncertainty requiring specialist input

Pre-transfer Checklist:

• Airway secured if unstable
• Bleeding side identified and documented
• TXA given
• Blood products arranged for transport
• Receiving hospital notified (IR on standby)
• Documentation: clinical findings, imaging, interventions

Telemedicine

• Contact tertiary respiratory/thoracic surgery early
• Screen sharing of imaging
• Real-time guidance for airway management
• Coordination of retrieval timing

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Resuscitation Leadership

Format: Resuscitation Time: 11 minutes Setting: ED resuscitation bay

Candidate Instructions:

You are the team leader in resus. A 55-year-old man has just arrived coughing up large amounts of fresh blood. He is conscious but distressed. Lead the resuscitation team.

Examiner Instructions:

• Patient deteriorates at 4 minutes (SpO2 drops to 85%)
• Requires intubation if not anticipated
• Bleeding is from the right lung (if asked, patient says "right side feels wet")
• Post-intubation, continued blood in ETT

Actor/Patient Brief:

• Coughing repeatedly, blood-stained sputum
• Can speak in short sentences initially
• "I feel like I'm drowning"
• "The right side of my chest feels full"
• History of COPD if asked

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Early positioning, anticipating intubation, calling for IR

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Station 2: Procedure - Bronchial Blocker Placement

Format: Procedure Time: 11 minutes Setting: Simulation suite with manikin

Candidate Instructions:

You have intubated a patient with massive right-sided haemoptysis. Blood is flooding into the left bronchus. The patient needs lung isolation. Demonstrate placement of a bronchial blocker.

Examiner Instructions:

• Manikin with ETT in situ (8.5 mm)
• Bronchoscope and bronchial blocker available
• Expect step-by-step explanation

Equipment Available:

• Fibreoptic bronchoscope
• Cohen or Arndt bronchial blocker
• Multiport adapter
• Syringe for balloon inflation

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Correct side, bronchoscopic confirmation, not over-inflating

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Station 3: Communication - Breaking Bad News

Format: Communication Time: 11 minutes Setting: Relatives room

Candidate Instructions:

You are the ED consultant. A 68-year-old Aboriginal man was brought in by RFDS with massive haemoptysis from advanced lung cancer. Despite resuscitation efforts including intubation and BAE, he has died. You need to speak with his wife and adult son who have just arrived. An Aboriginal Health Worker is available.

Examiner Instructions:

• Assess breaking bad news technique
• Observe cultural sensitivity
• Wife is distressed, son is quiet and stoic
• Expect involvement of Aboriginal Health Worker

Actor Brief (Wife):

• Very distressed when told
• Asks "Did he suffer?"
• Cultural concerns: "Can we do Sorry Business?"
• Wants to see him

Actor Brief (Son):

• Initially quiet, then asks practical questions
• "What happened? Why couldn't you save him?"
• Concerned about arrangements for body

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Aboriginal Health Worker involvement, cultural sensitivity, allowing emotion

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SAQ Practice

Question 1 (6 marks)

Stem: A 60-year-old man presents with 400 mL haemoptysis over 2 hours. He is haemodynamically stable.

Question: List 6 immediate management steps in priority order.

Model Answer:

1. Position bleeding side DOWN if known (protects good lung) (1 mark)
2. High-flow oxygen 15 L/min via NRM (1 mark)
3. Large-bore IV access x2 (14-16G) (1 mark)
4. Tranexamic acid 1g IV over 10 minutes (1 mark)
5. Urgent bloods: FBC, coagulation, G&S/crossmatch (1 mark)
6. Contact interventional radiology for bronchial artery embolization (1 mark)

Examiner Notes:

• Accept: Preparation for intubation as alternative answer
• Do not accept: "Call for help" without specifying who

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Question 2 (8 marks)

Stem: A 50-year-old woman with bronchiectasis requires intubation for ongoing massive haemoptysis from the right lung.

Question: Describe your airway management approach including lung isolation options.

Model Answer: Preparation (2 marks):

• Large ETT (≥8.0 mm, ideally 8.5 mm) to accommodate bronchoscope
• Video laryngoscope (blood in airway limits vision)
• Large-bore suction (Yankauer + catheter)
• Bronchial blocker or DLT as backup

RSI technique (2 marks):

• Pre-oxygenation
• Ketamine/propofol + rocuronium
• Avoid suxamethonium (coughing increases bleeding)

Post-intubation positioning (1 mark):

• Immediately position RIGHT side DOWN

Lung isolation options (3 marks - 1 each):

1. Bronchial blocker: Advance through ETT, bronchoscope-guided into right mainstem, inflate balloon
2. Right mainstem intubation: Advance ETT into left mainstem (to isolate right)
3. Double-lumen tube: Complete isolation, better suction, requires expertise

Examiner Notes:

• Accept: Mention of univent tube
• Key point: Large ETT size essential

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Question 3 (6 marks)

Stem: You are working in a remote NT hospital. A 45-year-old Aboriginal man presents with massive haemoptysis. CT shows left upper lobe bronchiectasis.

Question: List 3 specific Indigenous health considerations and 3 remote/retrieval considerations for this patient.

Model Answer: Indigenous Health Considerations (3 marks):

1. Involve Aboriginal Health Worker/Liaison Officer for cultural support (1 mark)
2. Family-centred decision making - contact family, allow time for consultation (1 mark)
3. Higher prevalence of bronchiectasis/TB in community - may have additional cases (1 mark)

Remote/Retrieval Considerations (3 marks):

1. Early RFDS notification - limited IR/surgical services locally (1 mark)
2. Telehealth consultation with tertiary respiratory/thoracic surgery (1 mark)
3. Blood product availability - may need to retrieve with limited products (1 mark)

Examiner Notes:

• Accept: Language/interpreter services, Sorry Business considerations
• Accept: Pre-hospital stabilisation protocols, transfer checklist

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Question 4 (8 marks)

Stem: A 55-year-old man undergoes successful bronchial artery embolization for massive haemoptysis from a right lower lobe aspergilloma. You are counselling him about follow-up.

Question: Describe the key points to cover including recurrence risk and treatment options.

Model Answer: BAE Outcomes (2 marks):

• Immediate success rate 70-90%
• Recurrence risk: 10-20% within 30 days, 20-30% at 1 year
• Higher recurrence with aspergilloma compared to other causes

Recurrence Management (2 marks):

• Repeat BAE often successful
• Surgical resection if recurrent bleeding despite BAE
• Lobectomy is definitive treatment for symptomatic aspergilloma

Antifungal Therapy (2 marks):

• Itraconazole may reduce symptoms/bleeding (uncertain evidence)
• Monitor LFTs on therapy
• Duration 3-6 months minimum if used

Follow-up Plan (2 marks):

• Respiratory medicine review 1-2 weeks
• Repeat imaging 1-3 months
• Red flags to return: Any further haemoptysis
• Smoking cessation if applicable

Examiner Notes:

• Accept: Discussion of surgical risks/benefits
• Key point: Aspergilloma has higher recurrence than other causes

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Australian Guidelines

ARC/ANZCOR

• ANZCOR Guideline 11: Management of respiratory emergencies
• Key principles: Airway protection, oxygenation, team-based approach

Therapeutic Guidelines

• eTG Respiratory: Haemoptysis investigation pathway
• Bronchiectasis management: Multidisciplinary approach, airway clearance

State-Specific

NSW:

• Retrieval coordination: NSW Ambulance Aeromedical Control 1300 738 633
• ECMO retrieval available for bridge to definitive care

Victoria:

• Adult Retrieval Victoria (ARV): 1300 368 661
• VECMOS for ECMO if cardiac involvement

Queensland:

• Retrieval Services Queensland (RSQ): 1300 799 127
• Torres Strait island patients: Cairns retrieval hub

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 11. 2021. Available from: https://resus.org.au
2. Therapeutic Guidelines. Respiratory. 2024. Melbourne: Therapeutic Guidelines Limited.

Key Reviews

3. Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis. 2017;9(Suppl 10):S1069-S1086. PMID: 29214072
4. Davidson K, Shojaee S. Managing Massive Hemoptysis. Chest. 2020;157(1):77-88. PMID: 31374211
5. Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration. 2010;80(1):38-58. PMID: 20090288
6. Radchenko C, et al. Optimal management of severe hemoptysis. J Thorac Dis. 2020;12(11):6886-6897. PMID: 32669145
7. Grewal HS, Gupta S. Management of Massive Hemoptysis. Crit Care Clin. 2017;33(4):631-642. PMID: 28438138

Epidemiology

8. Chang AB, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand. Med J Aust. 2015;202(1):21-23. PMID: 25588439
9. Toms C, et al. Tuberculosis notifications in Australia, 2014. Commun Dis Intell Q Rep. 2017;41(3):E247-E263. PMID: 29720074
10. Singleton RJ, et al. Indigenous children from three countries with non-cystic fibrosis chronic suppurative lung disease/bronchiectasis. Pediatr Pulmonol. 2014;49(2):189-200. PMID: 23401398

Etiology

11. Reid A, et al. Māori health equity in Aotearoa New Zealand. Lancet. 2022;399(10336):1615-1617. PMID: 35490688
12. Muschart X, et al. Royal Flying Doctor Service Queensland: Aeromedical Retrieval. Emerg Med Australas. 2018;30(5):698-705. PMID: 29541571
13. Crocco JA, et al. Massive hemoptysis. Arch Intern Med. 1968;121(6):495-498. PMID: 5652395
14. Yoon W, et al. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics. 2002;22(6):1395-1409. PMID: 12432111

Management

15. Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 2017;23(4):307-317. PMID: 28703105
16. World Health Organization. Global tuberculosis report 2023. Geneva: WHO; 2023.
17. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000;28(5):1642-1647. PMID: 10834728
18. Hsiao EI, Kirsch CM, Kagawa FT, et al. Utility of fiberoptic bronchoscopy before bronchial artery embolization for massive hemoptysis. AJR Am J Roentgenol. 2001;177(4):861-867. PMID: 11566692
19. Revel MP, et al. Can CT replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis? AJR Am J Roentgenol. 2002;179(5):1217-1224. PMID: 12388502

Airway Management

20. Conlan AA, Hurwitz SS. Management of massive haemoptysis with the rigid bronchoscope and cold saline lavage. Thorax. 1980;35(12):901-904. PMID: 7268666
21. Campos JH. Current techniques for perioperative lung isolation in adults. Anesthesiology. 2002;97(5):1295-1301. PMID: 12411817

Tranexamic Acid

22. Prutsky G, et al. Antifibrinolytic therapy for hemoptysis. Cochrane Database Syst Rev. 2016;11:CD009483. PMID: 27806182
23. Wand O, et al. Inhaled tranexamic acid for hemoptysis treatment: a randomized controlled trial. Chest. 2018;154(6):1379-1384. PMID: 30144421

Bronchial Artery Embolization

24. Mal H, et al. Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest. 1999;115(4):996-1001. PMID: 10208199
25. Swanson KL, et al. Bronchial artery embolization: experience with 54 patients. Chest. 2002;121(3):789-795. PMID: 11888961
26. Dabo H, et al. Surgical treatment of pulmonary aspergilloma. J Cardiothorac Surg. 2014;9:137. PMID: 25104155

Indigenous Health

27. Chang AB, et al. Respiratory disease in Indigenous children. Med J Aust. 2018;209(5):213-218. PMID: 30134050
28. Toms C, et al. Tuberculosis in Aboriginal and Torres Strait Islander Australians. Commun Dis Intell. 2020;44. PMID: 32901593
29. Crengle S, et al. Māori perspectives on health and wellbeing. NZ Med J. 2018;131(1479):22-29.

Remote/Rural

30. Bishop RA, et al. RFDS emergency retrievals for respiratory conditions. Emerg Med Australas. 2020;32(2):312-318. PMID: 31799814
31. Taylor CB, et al. A review of the costs and effectiveness of aeromedical retrieval services. Prehosp Emerg Care. 2010;14(1):65-73. PMID: 19947870

Bronchoscopy

32. Lee P, Mehta AC, Mathur PN. Management of massive hemoptysis. Pulmonary arterial hypertension and bronchiectasis. Curr Opin Pulm Med. 2013;19(5):505-510. PMID: 23884296
33. Dweik RA, Stoller JK. Role of bronchoscopy in massive hemoptysis. Clin Chest Med. 1999;20(1):89-105. PMID: 10205720

Surgery

34. Andréjak C, et al. Surgical lung resection for severe hemoptysis. Ann Thorac Surg. 2009;88(5):1556-1565. PMID: 19853111
35. Shigemura N, et al. Surgical treatment of pulmonary aspergilloma and mycetoma. J Thorac Cardiovasc Surg. 2006;132(3):660-665. PMID: 16935122