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Ongoing management after hemodynamic stabilization includes discontinuing medications that could interfere with coagulation (e.g., aspirin, nonsteroidal antiinflammatory drugs [NSAIDs], inhaled drugs such as N-acetylcysteine, dornase alfa, and some aerosolized antibiotics), and correcting coagulation defects with vitamin K, fresh-frozen plasma, or specific factors as indicated Patients may require transfusions as clinically indicated, bearing in mind that those with severe chronic disease may be awaiting lung transplantation Whenever possible, blood products should be prepared in a manner to minimize the risk of posttransplant complications Treatment with IV antibiotics is appropriate considering most major bleeds are associated with pulmonary exacerbations Placing the bleeding lung in the dependent position may help to prevent aspiration into the as yet uninvolved lung IV therapies to halt bleeding, such as pitressin or octreotide, should be discussed with the pulmonologist Local airway treatment may be indicated in acute life-threatening situation, and include endobronchial tamponade, selective double lumen intubation, and iced saline lavage The need for and timing of embolization and access to surgery must be determined in a timely manner If a surgeon and interventional radiologist are not readily available, referral to another center should be considered Viral Respiratory Tract Infection Simple viral respiratory infections are often inciting events for pulmonary exacerbations CF patients will be more likely to suffer increased and/or prolonged symptoms due to impaired mucociliary clearance and decreased respiratory reserve Whereas CXRs are routinely not indicated for most non-CF patients with what appears to be simple URIs, patients with CF with new respiratory symptoms should have CXR obtained and compared with prior studies If there is suspicion for CF exacerbation, antibiotics should be prescribed as discussed above Wheezing Patients with CF may wheeze secondary to common diagnoses such as acute viral processes, asthma, and foreign bodies In addition, ABPA must be considered in wheezing patients with CF ABPA occurs in 1% to 15% of patients with CF It is an exaggerated type I hypersensitivity reaction to the ubiquitous organism Aspergillus fumigates Clinically, patients present with chronic wheeze that is difficult to control, decline in pulmonary function, chronic cough, and transient infiltrates on CXR Symptoms typically respond well to oral steroids Any CF patient with recurrent wheezing and cough, changes on CXR and declining lung function not responsive to antibiotic therapy and airway clearance should be evaluated for ABPA Diagnostic criteria include elevated total serum IgE level, positive skin reactivity to Aspergillus, and positive specific serum