Ans. c. CT chest is the first investigation done (Ref: Harrison 19/e p246 18/e p285; Sabiston 19/e p1589)Massive hemoptysis maybe defined as greater than 500 to 600 ml. of blood loss from the lungs in 24 hours. '-Sabiston 19/e p1589'Massive hemoptysis is one of the most dreaded of all respiratory emergencies and can have a variety of underlying causes. In 90% of cases, the source of massive hemoptysis is the bronchial circulation. ''For most patients, the next step in evaluation of hemoptysis should be a standard chest radiograph. If a source of bleeding is not identified on plain film, a CT of the chest should be obtained.'- Harrison 18/e p285'If all of these studies are unrevealing, bronchoscopy should be considered. Rigid bronchoscopy with an 8.5-mm or larger bronchoscope is needed.Harrison 18/e p285'As most large-volume hemoptysis arises from an airway lesion, it is ideal if the site of the bleeding can be identified either by chest imaging or bronchoscopy (more commonly rigid than flexible).'- Harrison 18/e p285Massive HemoptysisHemoptysis of >200-600 cc in 24 hoursQMassive hemoptysis should be considered a medical emergency.Diagnostic Evaluation:For most patients, the next step in evaluation of hemoptysis should be a standard chest radiographQ.If a source of bleeding is not identified on plain film, a CT of the chestQ should be obtained.If all of these studies are unrevealing, bronchoscopy should he considered.Rigid bronchoscopy with an 8.5-mm or larger bronchoscope is needed.Treatment:Large-volume, life-threatening hemoptysis generally requires immediate intervention regardless of the causeQ.The first step is to establish a patent airway usually by endotracheal intubation and subsequent mechanical ventilationQ.As most large-volume hemoptysis arises from an airway lesion, it is ideal if the site of the bleeding can be identified either by chest imaging or bronchoscopy (more commonly rigid than flexible) QIf the bleeding does not stop with therapies of the underlying cause and passage of time, severe hemoptysis from bronchial arteries can be treated with angiographic embolization of the culprit bronchial arteryQ.