“Massive” haemoptysis

Abstract

Massive haemoptysis is a life-threatening condition requiring immediate and systematic management. Initial steps should focus on airway stabilisation, haemodynamic support and rapid identification of the bleeding source. Due to the complexity in diagnosis and management, along with a high associated mortality rate, massive haemoptysis offers an excellent opportunity for simulation training. Herein we present a simulated case of massive haemoptysis in a hospitalised patient. The scenario is crafted to help learners develop proficiency in the rapid recognition and multidisciplinary management of this high-risk condition, with an emphasis on airway protection and haemodynamic stabilisation. The script is widely adaptable across institutions and medical disciplines, and customisable to the needs of diverse learner populations.

Shareable abstract

We present a simulated case of massive (life-threatening) haemoptysis. The scenario is crafted to cultivate proficiency in the rapid recognition and management of this high-risk condition, and is widely adaptable to diverse learner populations. https://bit.ly/44Dw2rP

Introduction

Massive haemoptysis is a rarely encountered but life-threatening clinical emergency associated with high morbidity and mortality rates. While traditionally defined by the volume of blood expectorated, the clinical relevance often lies in its capacity to cause airway obstruction, impaired gas exchange or haemodynamic instability. Even relatively modest volumes of blood can precipitate catastrophic outcomes in patients with limited cardiopulmonary reserve [1, 2]. While the aetiologies of massive haemoptysis are varied, common causes include bronchiectasis (infectious or non-infectious), bronchogenic carcinoma, pulmonary tuberculosis and fungal infections such as pulmonary aspergillosis [3].

Prompt diagnosis and intervention are essential to mitigate mortality risk. Ideal management strategies centre on securing the airway, stabilising haemodynamics, localising the source of bleeding and addressing the underlying aetiology through a coordinated, multidisciplinary approach often involving clinicians with expertise in pulmonology, critical care, interventional radiology and thoracic surgery. This simulation aims to equip learners with the practical skills for managing massive haemoptysis within a structured and high-fidelity learning environment.

Learning objectives

• 1) Evaluate a patient with haemoptysis and recognise high risk clinical features to classify haemoptysis as massive and life-threatening.

• 2) Stabilise haemodynamics and gas exchange using physical and pharmacological measures including reversal of anticoagulation.

• 3) Coordinate a multidisciplinary approach to manage a patient with massive haemoptysis.

Required personnel

• Learner(s)

• Patient (manikin)

• Nurse (embedded faculty participant)

• Consultants – pulmonary/critical care and interventional radiology (embedded faculty participants)

• Faculty observer(s) to lead debriefing

Required equipment

• High fidelity simulation manikin (A Nasco Life/Form S.A.L.A.D Simulator or similar is optional, but not required)

• Simulated blood (on the manikin's gown and in the airways)

• Intensive care unit (ICU) bed

• ICU monitor with connected blood pressure cuff and pulse oximeter

• Chest radiograph demonstrating right upper lung field consolidation

• Syringes and labels for simulated medications

• i.v. pump and tubing

• Bedside suction setup

Optional equipment for advanced learners

• Airway management/intubation equipment

• Flexible fibreoptic bronchoscope

• Ice-cold saline

• Adrenaline (epinephrine) for bronchoscopic instillation

Brief narrative case description

A 75-year-old male smoker with COPD, recently diagnosed left lower lobe ((LLL) nonsmall cell lung carcinoma (NSCLC), hypertension and paroxysmal atrial fibrillation (on anticoagulation), is admitted to the general medical ward after presenting with several days of flu-like symptoms. Overnight he develops haemoptysis and progressive hypoxia and is transferred to the ICU for closer monitoring.

Critical actions checklist

• 1) Obtains focused history and requests additional history (hospital course, therapies received, quantification of haemoptysis).

• 2) Performs focused physical examination (including vital signs assessment and pulmonary examination).

• 3) Promptly applies supplemental oxygen (avoiding noninvasive positive pressure ventilation).

• 4) Addresses haemodynamic instability with i.v. fluids and/or vasopressors rather than blood products.

• 5) Obtains relevant laboratory tests and imaging (complete blood count, coagulation studies, static chest radiograph).

• 6) Localises side of bleeding and applies appropriate dependent positioning of patient to avoid soiling of the contralateral lung.

• 7) Considers risks/benefits of reversal of anticoagulation and administers appropriate reversal agent(s).

• 8) Recognises haemoptysis as life-threatening, requiring a secure airway, and requests or performs intubation.

• 9) Considers and promptly requests or performs bronchoscopy to localise source and temporise bleeding.

• 10) Appropriately involves pulmonary, interventional radiology and thoracic surgery teams for definitive management of haemoptysis.

Learner preparation

Table 1 provides the details for learner preparation.

TABLE 1.

Initial presentation

Initial vital signs	Temperature 37.2°C, blood pressure 102/64 mmHg, heart rate 125 beats per min (sinus tachycardia), respiratory rate 28 breaths per min, SpO2 90% on room air
Overall appearance	What do learners see when they first enter the room? The patient, portrayed by a manikin, is awake, lying supine, breathing shallowly and rapidly, without accessory muscle use. There are tissues soaked with bright red blood nearby and blood on the manikin's gown. The patient has one 18-gauge antecubital peripheral i.v., and is connected to the telemetry monitor with noninvasive blood pressure cuff cycling every 15 min.
Actors and roles in the room at case start	Who is present at the beginning and what is their role? Who may play them? Primary learner: The primary learner may be in the role of a medical student, resident, fellow or other clinician provider responding to the nurse's call for help. The patient (manikin): Portrayed by a high fidelity simulation manikin (with a simulation staff member providing dialogue). ICU nurse (embedded participant): Portrayed by a simulation staff member. This is the ICU. The nurse was alerted by the patient that he is experiencing increased dyspnoea and increased haemoptysis. The nurse can give additional history if requested.
History of present illness (delivered by ICU nurse)	The patient is a 75 year-old male with a past medical history of COPD, LLL NSCLC (recently diagnosed, pending staging and initiation of treatment), paroxysmal atrial fibrillation on anticoagulation with apixaban, and hypertension who initially presented to the hospital with a 3-day history of fevers, productive cough and generalised weakness. He has been admitted to the general medical ward for the past 24 h for management of COPD exacerbation due to CAP. The patient was transferred to the ICU overnight due to onset of intermittent haemoptysis and progressive dyspnoea. The nurse now calls for help to the bedside because the patient reports severe dyspnoea and recurrent haemoptysis.
Additional information (available if requested)
Further hospital history	The patient was admitted yesterday for i.v. antibiotics and steroids for treatment of COPD exacerbation and CAP. He received ceftriaxone and azithromycin. He continued on his home medications of apixaban and losartan and inhaled medications for COPD. His vital signs over the past 24 h were within normal limits. He did not initially require supplemental oxygen. Total volume of blood expectorated in the past hour is estimated to be 50–100 mL, prior to this haemoptysis was not quantified.
Laboratory results from this morning	Complete blood count: WBC 12.5×109 cells·L−1; Hb 120 g·L−1, haematocrit 36%, platelets 250×109per L Basic metabolic panel: sodium 142 mmol·L−1, potassium 4.5 mmol·L−1, chloride 100 mmol·L−1, bicarbonate 22 mmol·L−1, BUN 10 mmol·L−1, creatinine 100 µmol·L−1
Chest radiograph results from this morning	Known left lower lobe pulmonary mass unchanged compared with admission and last chest radiograph 1 month ago, new left upper lobe opacity similar to admission chest radiograph.
Interventions prior to scene	None
Past medical/surgical history	LLL NSCLC Hypertension Atrial fibrillation COPD (not on home oxygen)
Inpatient medications	Ceftriaxone 1 g i.v. every 24 h Azithromycin 500 mg i.v. every 24 h Apixaban 5 mg twice daily Losartan 50 mg daily Prednisone 40 mg daily Albuterol 2 puffs inhaled every 4 h
Allergies	None
Social history	40-pack-year smoking history 1–2 standard alcoholic beverages per week No recreational substance use
Physical examination
General	Awake, alert, fully oriented, eyes open, rapid shallow breathing, no accessory muscle use, frequent coughing
HEENT	Blood coating the mucosa of the oral cavity
Neck	Supple, full range of motion
Respiratory	Tachypnoeic, decreased breath sounds on the left side, no cyanosis
Cardiovascular	Tachycardia with regular rhythm; no murmurs, rubs, or gallops; no lower extremity oedema
Abdomen	Soft, nondistended, without guarding
Neurological	Moving all extremities spontaneously, no gross focal deficit
Skin	Skin cool to touch
Genitourinary	Unremarkable
Psychiatric	Unremarkable

S_pO2: peripheral oxygen saturation; ICU: intensive care unit; LLL: left lower lobe; NSCLC: nonsmall cell lung carcinoma; CAP: community-acquired pneumonia; WBC: white blood cell count; Hb: haemoglobin; BUN: blood urea nitrogen; HEENT: head, eyes, ears, nose and throat.

ACT 1.

Early haemoptysis (beginning of the scenario)

Change in case	Additional information
Possible interventions	Vital sign monitoring can be adjusted per learner's request
Requests additional history   • Disclose additional history (see table 1)   • Review of systems negative other than details in table 1   • Asks for weight: 75 kg   • Asks for ECG: sinus tachycardia, heart rate 125 beats per min   • Asks for morning chest radiograph: see table 1
Requests laboratory tests: nurse has learner specify the laboratory tests and sends (results available in Act 2)
Asks for i.v. fluids or blood: nurse requests specifics of amount and type, proceed to Act 2
Asks for supplemental oxygen: nurse requests specifics of modality and amount, proceed to Act 2
Requests imaging: nurse requests specific imaging modality, orders placed (results available in Act 2)
Critical actions
Obtains a focused history and requests additional history  • Asks for therapies received including recent medications  • Quantifies haemoptysis
Performs focused physical examination  • Reviews vital signs and recognises hypoxia  • Performs pulmonary auscultation examination  • Examines oropharynx
Applies supplemental oxygen, avoiding noninvasive positive pressure ventilation (NIPPV)

ACT 2.

Initial management (transition 5 min into the case or if specified interventions are performed in Act 1)

Change in case	Additional information
Temperature 37.6°C, blood pressure gradually decreases to 91/48 mmHg, heart rate 130 beats per min (sinus tachycardia), respiratory rate 32 breaths per min, peripheral oxygen saturation (SpO2) gradually decreases to 86%	i.v. access: one 18 gauge forearm i.v., unless changed in Act 1
Physical examination changes
General: Sitting up in respiratory distress, spitting up blood
Respiratory: decreased breath sounds of the left lung
Neurological: awake, alert, no focal deficit
Possible diagnostic interventions
Asks for chest radiograph: chest radiograph shows increased opacification of left lower lung fields
Asks for computed tomography (CT) scan: orders placed, patient currently not stable to transport, not obtained until Act 4
Asks for complete blood count: white blood cell count 13.0×109 cells·L−1; haemoglobin 110 g·L−1, haematocrit 33%, platelets 260×109 per L
Asks for coagulation studies: prothrombin time of 26 s and international normalised ratio of 2.5
Possible therapeutic interventions
Asks for i.v. fluids: nurse will hang specified fluids, blood pressure will increase by 10 mmHg systolic
Asks for blood products: nurse will respond that type and screen is pending and products are being prepared
Asks for vasopressor: nurse will redirect the learner and ask if fluids can be given first; if pressors are given blood pressure will increase by 10 mmHg systolic and the scene will transition to Act 3
Asks for anticoagulation reversal: nurse will request specifics of agent and dosing, and will administer
Asks for tranexamic acid (TXA): nebulised TXA (500 mg/5 mL) is administered and coughing frequency will decrease and vital signs will not deteriorate further until Act 3
Asks for patient to be repositioned to lateral decubitus with right lung upwards: patient will be repositioned
Asks for escalation of supplemental oxygen: high-flow nasal cannula will be applied but SpO2 increases by no more than 5%, transition to Act 3
Asks for NIPPV to be applied: nurse will redirect the learner citing concerns about aspiration
Asks for intubation and/or bronchoscopy: if prior to the above interventions, the nurse responds that the airway team is on the way and prompts the learner to consider additional temporising measures; if after the above interventions, transition to Act 3
Asks for interventional radiology consultation: nurse will respond that consultation is ordered but the patient is too unstable to transport, transition to Act 3
Critical actions
Addresses haemodynamic instability with i.v. fluids and/or vasopressors rather than blood products
Obtains relevant laboratory tests and imaging (complete blood count, coagulation studies, static chest radiography)
Localises side of bleeding and positions accordingly:  • Recognises known LLL mass and new left upper lobe opacity on chest radiography as potential sources of bleeding (with associated pulmonary auscultation findings) and positions patient left lateral decubitus with right lung (unaffected lung) upwards to optimise oxygenation and avoid soiling the contralateral lung
Considers risks/benefits of reversal of anticoagulation and administers appropriate reversal agent(s)

ACT 3.

Massive haemoptysis (transition 10 min into the case or if specified interventions are performed in Act 2)

Change in case
Temperature 37.6°C, blood pressure 90/50 mmHg, heart rate 130 beats per min (sinus tachycardia), respiratory rate 32 breaths per min, SpO2 rapidly declines to 80%
Vital signs remain unstable despite prior interventions
Physical examination changes
General: supine, poorly responsive
Respiratory: decreased breath sounds of the left lung
Neurological: lethargic, poorly responsive
Possible diagnostic interventions
Asks for CT scan: orders placed, patient currently not stable to transport, not obtained until Act 4
Possible therapeutic interventions
Asks for escalation of supplemental oxygen: high-flow nasal cannula will be applied but SpO2 increases by no more than 5%
Asks for NIPPV to be applied: nurse will redirect the learner citing concerns about aspiration
Asks for intubation and/or bronchoscopy:   For novice learners, proceed to Act 4   For advanced learners, intubation equipment and bronchoscope can be provided if available, procedures can be performed, and the scene can proceed to Act 4   Advanced learners may also suggest balloon tamponade or endobronchial blocker placement, which can be performed if the necessary equipment is available; this also triggers progression to Act 4
Asks for interventional radiology consultation: if prior to intubation and bronchoscopy, the nurse will respond that interventional radiology are awaiting patient stabilisation for transport; otherwise proceed to Act 4
Critical actions
Recognises haemoptysis as life-threatening, requiring a secure airway, and requests or performs intubation
Considers and promptly requests or performs bronchoscopy to localise source and temporise bleeding
Appropriately involves pulmonary, interventional radiology and/or thoracic surgery teams for definitive management of haemoptysis

ACT 4.

Conclusion

Change in case

The patient has undergone rapid sequence intubation and bedside bronchoscopy which localises bleeding to the left upper lobe. Topical adrenaline (epinephrine) and ice cold saline have been instilled into the left upper lobe airways and with this and scope tamponade, the bleeding subsides and the patient stabilises. Transport arrives to take the patient to the interventional radiology suite for bronchial artery embolisation (BAE). The simulation ends and debriefing begins. Note: according to the degree of learner expertise and availability of equipment the simulation scenario can be expanded to include the entire intubation and bronchoscopic procedures.

Ideal scenario flow

The learner is called to the bedside, where the nurse provides a brief history. The learner requests additional history, evaluates the patient's vital signs, conducts a focused physical examination, and addresses initial hypoxia and anticoagulation reversal. The learner obtains laboratory tests and imaging, including a chest radiograph (and orders a CT), localising bleeding to the left side and prompting patient repositioning and noninvasive temporising measures. Despite this, the patient deteriorates and the learner recognises haemoptysis as life-threatening or massive. The learner should optimise oxygenation with supplemental oxygen and stabilise haemodynamics with i.v. fluids and/or vasopressors and consult interventional radiology for bronchial artery embolisation. Finally, the learner should request and/or perform intubation and bronchoscopy with additional temporising measures in order to stabilise the patient for safe transport to the interventional radiology suite.

Anticipated management mistakes

• 1) Missing anticoagulation history: If the learner does not recognise the patient has been on anticoagulation, the nurse will mention that the patient is on apixaban and ask if this needs to be addressed.

• 2) Ordering blood products for bleeding and hypotension: If the learner attempts to order blood products initially rather than begin resuscitation with i.v. fluid and/or vasopressors, the nurse will express concern that the patient will deteriorate substantially by the time blood products arrive and are transfused.

• 3) Failure to reposition patient: If the learner does not place the patient in the left lateral decubitus position with the right lung up, the nurse will inquire if there is any way the patient's position can be adjusted to protect his airway.

• 4) Intubating without calling interventional radiology: If the learner calls the airway team to intubate the patient prior to calling interventional radiology, the team will respond to the page but will advise the learner to consider options for definitive management after intubation, prompting the learner to consult interventional radiology.

Debriefing process

There are various methods of effective debriefing after simulation, and ideally debriefing should be tailored to the experience level of the learner(s). For novice learners, this case can be difficult and may require a facilitator-guided, within-event debriefing [4]. This allows the learners, typically medical students or junior residents, to proceed with the simulation until they become “stuck”, at which point the simulation can be paused for immediate, targeted education, following which the case is continued [4].

For advanced learners, we recommend facilitator-guided, post-event debriefing, which is the most common and well-studied method of simulation debriefing [4]. Two suggested post-event debriefing models are the “plus/delta” and “three-phase” debriefing models. The plus/delta method is a straightforward model in which facilitators and participants answer the question “What went well?” in the “plus” column, reinforcing effective decision-making and interventions performed during the simulation; while the “delta” column explores areas for improvement and highlights decisions or actions that should be adjusted. Alternatively, three-phase debriefing, as described by Rudolph et al. [5], consists of three phases: reaction, analysis, summarise. The facilitator begins the debriefing conversation with an open-ended question to gauge reactions, such as “How did that feel?” [5, 6] and guides the debriefing from there. In most cases, we recommend structuring the debriefing conversation by using “Debriefing with good judgment”, employing advocacy and inquiry to understand a learner's frame of mind in leading them to particular actions during the simulation, allowing the facilitator to then collaborate with the learner to strengthen or modify frames as needed [6].

If available, the combination of video playback with the aforementioned structured debriefing techniques, known as video-assisted debriefing, enhances participants' reflection on their performance, leading to improved learning outcomes [7].

Debriefing points and discussion

Recognition of life-threatening or “massive” haemoptysis

Haemoptysis can be a life-threatening event when it causes airway obstruction, severe hypoxia and/or haemodynamic instability. Historically, varying quantities of expectorated blood over varying quantities of time have been suggested to be life-threatening, in a somewhat arbitrary fashion, and the term “massive haemoptysis” suggests that haemoptysis must present in a large volume to be lethal. These have been difficult to apply in clinical practice as quantification of haemoptysis can be unreliable, and even “small” quantities of blood in patients with limited cardiopulmonary reserve can prove devastating.

We use the following criteria to define haemoptysis as life-threatening: any haemoptysis that is >100 mL in 24 h, causes abnormal gas exchange or airway obstruction, or causes haemodynamic instability [8].

Protecting the airway and stabilising haemodynamics and gas exchange

Initial management of life-threatening haemoptysis must include airway protection and stabilisation of haemodynamics and gas exchange.

Positioning

Regardless of intubation status, patients should immediately be placed into a position where the suspected source of bleeding is in the dependent position. This is intended to prevent spillage of blood into the nonbleeding lung and to optimise gas exchange.

Intubation

Early endotracheal intubation should be considered if the patient is unable to oxygenate or ventilate, or loses their ability to expectorate.

• 1) A large bore endotracheal tube (size: 8.5 mm inner diameter or larger) is preferred. This facilitates passage of therapeutic bronchoscopes as well as thrombus extraction [9].

• 2) Unilateral mainstem intubation can be considered to protect the nonbleeding lung. Advantages of unilateral mainstem intubation include effective oxygenation and ventilation of the unaffected lung while awaiting definitive treatment [9]. However, particularly in the setting of a right mainstem intubation, the right upper lobe can be occluded with subsequent atelectasis [9], which can be deleterious in patients with impaired cardiopulmonary reserve. In the case of this patient with a known left lung mass and new left-sided pneumonia, in conjunction with findings on auscultation, the bleeding source is very likely on the left side. Thus, right mainstem bronchus intubation to ventilate the unaffected right lung could be considered, with care being taken to avoid occluding the right upper lobe bronchus.

• 3) Dual lumen endotracheal tubes designed to isolate each lung have historically been used in thoracic surgery; however, their role in massive haemoptysis is limited due to their narrow inner lumen diameters, prohibiting the passage of standard therapeutic flexible bronchoscopes and precluding the evacuation of haemorrhage and blood clots from the airways.

Stabilising haemodynamics

When there is a concern of haemodynamic instability, i.v. fluids and vasopressors should be administered. Blood products should be considered only in cases of severe anaemia due to haemoptysis, which is uncommon as morbidity and mortality in these cases occurs typically as a result of impaired gas exchange and airway obstruction, rather than haemorrhagic shock. Clinicians should make individualised decisions based on the severity of the patient's anaemia, comorbidities and degree of hypotension.

Reversing anticoagulation and antiplatelet agents

The use of anticoagulants and antiplatelet agents for various indications, including stroke prevention in patients with atrial fibrillation and treatment and prophylaxis of venous thromboembolism, is widespread. Consideration must be given to reversal of anticoagulants and antiplatelet agents in patients with life-threatening haemoptysis who are on such medications (table 2).

TABLE 2.

Mechanism of action and reversal agents for anticoagulation and antiplatelet agents

Agent(s)	Mechanism of action	Reversal agent
Warfarin	Vitamin K antagonist (inhibits vitamin K epoxide reductase complex 1)	Vitamin K (i.v.) PCC (e.g. KCENTRA) Fresh frozen plasma
Apixaban, rivaroxaban, edoxaban	Factor Xa inhibitors	Andexanet alfa Four-factor PCC
Dabigatran	Direct thrombin inhibitor	Idarucizumab Haemodialysis
Heparins (UFH and LMWH)	Activates antithrombin III	Protamine sulfate

UFH: unfractionated heparin; LMWH: low molecular weight heparin; PCC: prothrombin complex concentrate.

Patients may also be on antiplatelet agents such as aspirin (irreversible COX-1 inhibitors), P2Y12 inhibitors (e.g. clopidogrel, prasugrel, ticagrelor and cangrelor), glycoprotein IIb/IIIa inhibitors or phosphodiesterase inhibitors. Unfortunately, these agents lack specific reversal agents. Platelet aggregation recovery time may range between 4 and 5 days for most antiplatelet agents [10]. Typically suggested reversal agents include desmopressin (DDAVP) and platelet transfusions. DDAVP facilitates factor VIII and von Willebrand factor release, leading to improved platelet adhesion. Platelet transfusion is reserved for severe bleeding, and its success is dependent on the type of antiplatelet agent and the time of the last dose; nonetheless, it can be considered on a case-by-case basis and may be a viable option in select patients [11].

TXA inhibits plasminogen activation. In contrast to i.v. or p.o. administration in cases of trauma or menorrhagia, it is administered via nebulisation in cases of life-threatening haemoptysis. In a comparison trial between i.v. and nebulised TXA, the nebulised TXA group had a significantly higher haemoptysis cessation at 30 min (72.72%) than the i.v. TXA group (50.91%) [12]. It is an effective and safe option for most patients.

Bronchoscopy

Fibreoptic bronchoscopy allows for identification of the source of bleeding, removal of blood and thrombus from the airways, and facilitates endobronchial interventions [9]. Bronchoscopic interventions include ice-cold saline irrigation with normal saline at 4°C, vasoconstriction with bronchoscopic instillation of adrenaline (epinephrine), and scope or balloon tamponade. Balloon tamponade involves the placement of a Fogarty balloon catheter inserted through a flexible bronchoscope, applying direct pressure on the site of bleeding by inflating the balloon or cuff in an effort to tamponade the bleeding. These balloon catheters are inserted by direct visualisation and use the working channel of the bronchoscope, thus requiring the bronchoscope to remain in place [13]. In comparison, endobronchial blockers are inserted through the endotracheal tube and once in position and inflated, the endotracheal tube can be removed and the endobronchial blocker can remain in place. However, these catheters can migrate with cough or suctioning, and may require monitoring for correct placement with serial bronchoscopies. Once the patient is stabilised and bleeding has been controlled, the endobronchial blocker may be removed. Finally, rigid bronchoscopy can also be considered depending on availability of equipment and expertise, as this provides a larger passage for suctioning and clearance of large clots.

Arteriography and embolisation

There are two vascular systems that supply the lungs, the pulmonary and bronchial artery systems. In 90% of patients with life-threatening haemoptysis, the source of bleeding is the high pressure bronchial arteries [9]. In inflammatory states, there can be hypertrophy and tortuosity of the bronchial arteries [9]. If ruptured, the underlying high pressure system can lead to the rapid bleeding seen in life-threatening haemoptysis.

For definitive treatment, BAE is a widely used procedure typically performed by experts in interventional radiology. CT chest angiography imaging can assist with localisation prior to BAE, but only if the patient is stable to undergo CT imaging. Femoral catheter angiography is performed under fluoroscopic guidance prior to embolisation to assess for tortuous arteries or extravasation. BAE has been reported to be successful in as many as 94% of cases of massive haemoptysis [9, 14, 15], and has a relatively benign safety profile. In cases of haemoptysis that are refractory to BAE or occur as a result of trauma, surgical intervention (typically lobectomy) may be necessary [9, 15].

Conclusion

Massive haemoptysis is a rare but life-threatening condition requiring immediate recognition and intervention. Given its high mortality risk and the complexity of management, simulation-based training is essential to prepare clinicians for the required rapid decision-making and coordination of care. We describe a simulated case of life-threatening haemoptysis that provides an immersive learning opportunity, reinforcing critical airway management, optimisation of gas exchange, haemodynamic stabilisation and multidisciplinary collaboration. Its structured yet flexible design allows adaptability across institutions and diverse learner populations. By incorporating this simulation into training programmes, institutions can enhance preparedness for this challenging clinical emergency.