massive hemoptysis / nahid sherbini

HEMOPTYSIS

Dr Nahid Sherbini

Consultant IM & Pulmonary

KFH ,Medina ,SA

Definition of Hemoptysis

• The spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage.

Stedman TL. Stedman’s Medical dictionary. 27th ed. Philidelphia: Lipincott Williams & Wilkins, 2000

Severity Classification

GRADE AMOUNT /24 HRS

Mild < 50 ml

Moderate 50 - 200 ml

Severe**/Major* > 200 ml * 150 ml per 12 hrs or**>400 ml per 24 hrs

Massive > 600 ml

Life-threatening 200 ml/h or 50 ml/h with respiratory failure.

*Corey R, Hla KM.Am J Med Sci 1987; 294:301–309.**de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F. Respir Med 2003; 97: 790–795#Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 1982; 84: 829–833.

 Massive hemoptysis

• Up to 1000 mL (1)

• Either ≥500 mL of expectorated blood over a 24 h or bleeding at a rate ≥100 mL/h, regardless of whether abnormal gas exchange or hemodynamic instability exists. (2)

(1)Major and massive hemoptysis: reassessment of conservative management.-Corey R, Hla Am J Med Sci. 1987;294(5):301.(2)Uptodate.inc

Bronchial arteries (90%)

Pulmonary arteries

Source of bleeding

*Remy J, Remy-Jardin M, Voisin C: Endovascular management of bronchial bleeding; in Butler J (ed): The Bronchial Circulation. New York, Dekker, 1992, pp 667–723.

Bronchial arteries • Systemic pressureBronchi, vagus nerve, posterior mediastinum, and esophagus.

6

2 Left bron.art

1 Rt.bron.art

T5 -T6

Figure 1.  Diagrams illustrate the types of bronchial arterial supply: Type I, two bronchial arteries on the left and one on the right that manifests as an ICBT (40.6% of cases); Type II,

one on the left and one ICBT on the right (21.3%); Type III, two on t...

Yoon W et al. Radiographics 2002;22:1395-1409

©2002 by Radiological Society of North America

Pulmonary arterial system

• RV• Low pressure system• 8-25mmHg .

Causes

Infectious• Tuberculosis

• Fungal infections

• Necrotizing pneumonia and lung abscess

• Bacterial endocarditis with septic emboli

• Parasitic (paragonimiasis, hydatid cyst)

It is the most common cause of hemoptysis worldwide with 2 billion people infected worldwide with 5-10% developing disease (Public Health Reports. Vol. 3. New York: World Health Organization; 1996: p. 8–9.)

Neoplastic

• Bronchogenic carcinoma

• Endobronchial tumors e.g carcinoid

• Metastasis

•Bronchiectasis –CF

•Bullous emphysema

•Alveolar hemorrhage and underlying causes

Pulmonary

Vascular

• Pulmonary artery aneurysm (Rasmussen aneurysm, mycotic, arteritis)

• Bronchial artery aneurysm

• PE

• Pulm HTN

•Airway-vascular fistula

•AV Malformations

•MS

•LVF

Vasculitis

• Wegener’s granulomatosis

• Goodpasture’s syndrome

• Behçet’s disease

• SLE

•Coagulopathy /Platelet disorders

•Uremia/ Platelet dysfunction

•Anticoagulant therapy

Haematological

RISK FACTORS FOR MORTALITY

1. Infiltrates involving 2 or more quadrants on an admission CXR

2. Bleeding from the pulmonary artery

3. Cancer

4. Aspergillosis

5. Alcoholism

6. Mechanical Ventilation

& Aspiration in to contralateral lung *

Early prediction of in-hospital mortality of patients with hemoptysis: an approach to defining severe hemoptysis.Fartoukh M, Khoshnood B, Parrot A, Khalil A, Carette MF, Stoclin A, Mayaud C, Cadranel J, Ancel PY -Respiration. 2012;83(2):106.

Predictors of Mortality

71% in patients who lost =>600 ml of blood in 4 h

22% in patients with =>600 ml within 4–16 h

5% in those with 600 ml of within 16–48 h

Life-threatening massive : 5 to 15%.

• *Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis. Arch Intern Med 1968;121: 495–498.

MANAGEMENT

Air way

Breathing

Circulation

Provide suction.

Provide O2

crystalloid solutions AND blood products

INITIAL STEPS

1. IDENTIFY WHICH SIDE IS BLEEDING2. POSITION THE PATIENT3. ESTABLISH A PATENT AIRWAY4. INSURE ADEQUATE GAS EXCHANGE5. INSURE ADEQUATE CVS FUNCTION6. CONTROL THE BLEEDING

DIAGNOSTIC MODALITIES

History• Does the patient have known pulmonary, cardiac, or renal

disease?- smoke?• Prior hemoptysis, other pulmonary symptoms, or

infectious symptoms?• FH of hemoptysis, brain aneurysms, epistaxis, or GI ? a

skin rash?• Exposed to asbestos?• Bleeding disorder? DVT risk?• DRUGS?• Has the patient had (TB) or been exposed to TB?

Physical Examination

• Telangiectasias • A skin rash,Splinter hemorrhages ,Needle tracks IE• An audible chest bruit or murmur that increases with

inspiration a large pulmonary AV malformation.• P2, TR or PR, or RV lift • Heart murmurs MS , CHD• DVT signs

Laboratory tests 

• Type and cross-matching • CBC ,COAG• Electrolytes, BUN• ABG• Liver function tests • Urinalysis• Special tests

CXR

• Site of bleeding in 33–82% *of cases.

• Underlying cause in 35%**.

• Rarely normal

*Khalil A, Soussan M, Mangiapan G, Fartoukh M, Parrot A, Carette MF: Utility of high-resolution chest CT scan in the emergency management of hemoptysis in the intensive care unit: severity, localization and aetiology. BJR 2007; 80: 21–25.

**Hirshberg B, Biran I, Glazer M, Kramer MR:Hemoptysis: etiology, evaluation, and outcome in a tertiary referral hospital. Chest 1997; 112: 440–444.

Bronchoscopy 

• Flexible bronchoscopy is the initial diagnostic procedure of choice :

performed at the bedside, it is readily available, and it is highly successful at localizing the bleeding site if it is performed while the patient is bleeding.• Intubation should be considered .

Massive hemoptysis. Assessment and management. Cahill BC, Ingbar DHClin Chest Med. 1994;15(1):147.

CT SCAN

• Superior to CXR

• Correct localization in 70–88.5% of cases*

Multidetector CT - bronchial and nonbronchial systemic arteries .

• Better than bronchoscopy for determining the cause of bleeding.

*Haponik EF, Britt EJ, Smith PL, Bleecker ER:Computed chest tomography in the evaluation of hemoptysis: impact on diagnosis and treatment. Chest 1987; 91: 80–85.

Figure 9.  Bronchial artery.

Yoon W et al. Radiographics 2002;22:1395-1409

©2002 by Radiological Society of North America

Figure 8.  Bronchial artery.

Yoon W et al. Radiographics 2002;22:1395-1409

©2002 by Radiological Society of North America

Arteriography 

• Persistent bleeding following bronchoscopy.• The preceding bronchoscopy may be helpful in

identifying the area of bleeding assisting the radiologist in locating the precise bleeding site.

• Therapeutic embolization is possible during the diagnostic arteriography procedure.

Figure 10c.  Value of preliminary thoracic aortography.

Yoon W et al. Radiographics 2002;22:1395-1409

©2002 by Radiological Society of North America

Clues to bronchial artery as the source of bleeding:

Parenchymal hypervascularityVascular hypertrophy

aneurysm

The identification of extravasated dye --INFREQUENT Bronchopulmonary shunting

Neovasculirization

BRONCHOSCOPIC AND AIRWAY MANAGEMENT

• IDENTIFY WHICH SIDE IS BLEEDING

•POSITION THE PATIENT• ESTABLISH A PATENT AIRWAY• INSURE ADEQUATE GAS EXCHANGE• INSURE ADEQUATE CVS FUNCTION

• CONTROL THE BLEEDING

Protection of nonbleeding lung

If bleeding side is known

Keep patient at:

-Rest

-Lateral decubitus

-Bleeding side down

Rt.Main bronchus

Left main brochus flooded with blood

• IDENTIFY WHICH SIDE IS BLEEDING• POSITION THE PATIENT

•ESTABLISH A PATENT AIRWAY

• INSURE ADEQUATE GAS EXCHANGE• INSURE ADEQUATE CVS FUNCTION

•CONTROL THE BLEEDING

CONTROL THE BLEEDING

• Non-surgical

Blood products

Bronchoscopic measures

BAE

• Surgery

Bronchoscopic Measures

Endobronchial

>Unilateral lung vent

>Double-lumen ETT

>Balloon tamponade

Bronchial irrigation

Vasoconstrictive agents

Lasers

Thermal Therapy

Selective Intubation

SINGLE LUMEN ETT

Selectively intubate

the non bleeding lung.

Selective intubation of L Main bronchus in R sided massive hemoptysis

Selective Intubation

DOUBLE LUMEN ETT

Specially designed for selective intubation of the right or left main bronchi

Last option in an asphyxiating pt.

FOB - diagnostic

• Identifies the site of bleeding in 73–93%*

Early versus delayed. (<24 hrs)

*Hsiao EI, Kirsch CM, Kagawa FT, Wehner JH, Jensen WA, Baxter RB: Utility of fiberoptic bronchoscopy before bronchial

artery embolization for massive hemoptysis. AJR Am J Roentgenol 2001; 177: 861–867.

RIGID BRONCHOSCOPE

RIGIDADVANTAGES

•Larger lumen- packing/clearing clots

• Improved suctioning

• Better clearance

• Improved visualization

• Continuous OPENING FOR airway

FLEXIBLEADVANTAGES

•Performed at bedside

•Access:UL/distal orifices

•CAN DO Lavage

•Topical anaesthesia

DISADVANTAGES

• Poor visibility of peripheral lesions and UL

• GA

• DISADVANTAGES

• Poor suction

• Air way patency is not good

RIGID FLEXIBLE

Cold-Saline Lavage

• Lavage: Normal saline at 4 ° C , 50 mL aliquots

• It Stopped the bleeding with massive hemoptysis obviating the need for emergency thoracotomy.*

Rigid scope is better over FOB

*Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R: Massive hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg 1983; 85: 120–124.

Topical Vasoconstrictive Agents

• Topical epinephrine

(1: 20,000)

Effective :

mild to moderate.

Not really useful:

massive bleeding*

Side effects

-Tachyarrythmias

- HTN

• Newer agents: ADH derivative

- ornipressin

* Cahill BC, Ingbar DH: Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15: 147–167.

Other

Tranexamic Acid

• Antifibrinolytic drug

• Route : PO ,IV & Topical (recently)

• Endobronchial :*

DOSE: 500–1,000 mg

• Response time: seconds

* Solomonov A, Fruchter O, Zuckerman T,Brenner B, Yigla M: Pulmonary hemorrhage: a novel mode of therapy. Respir Med 2009; 103: 1196–1200.

Fibrinogen/Thrombin

• Local application

• Immediate arrest of bleeding.

• Initial strategy before BAE.*

• Alternative treatment when endovascular procedures cannot be performed.

*Wong LT, Lillquist YP, Culham G, DeJong BP, Davidson AG: Treatment of recurrent hemoptysis in a child with cystic fibrosis by repeated bronchial artery embolizations and long-term tranexamic acid. Pediatr Pulmonol 1996; 22: 275–279

Balloon Tamponade

• Life threatening hemoptysis.

• 4 Fr 100 cm Fogarthy balloon catheter by FOB.

• Inflated for 24-48 hrs

* Hiebert C: Balloon catheter control of lifethreatening hemoptysis. Chest 1974; 66: 308– 309.

Advantages:• Air way protection

• Allows gas exchange

• Supports patient before embolization or surgery

Disadvantages:• Ischemic mucosal injury

• Post obstructive pneumonia.

Endobronchial Airway Blockade(Silicone Spigot)

Temporary management.

• Silicone spigot is placed endobronchially .

Stabilizes patient before BEA

• *Dutau H , Palot A, Haas A, Decamps I, Durieux O: Endobronchial embolization with a silicone spigot as a temporary treatment for massive hemoptysis. Respiration 2006; 73: 830–832.

A rigid bronchoscope initially allowed aspiration of blood and removal of clots followed by cold saline and topical vaso active agents ,clearing the vision to place spigot

posterior segment of the right upper lobe

Silicon spigots of various sizes

Distal end of flexibe biopsy forceps with Spigot in place

6-mm silicone spigot

posterior segment of the right upper lobe

A rigid bronchoscope initially allowed aspiration of blood and removal of clots followed by cold saline and topical vaso active agents ,clearing the vision to place spigot

Following this procedure, the patient underwent BAE, and the spigotwas removed 2 h later.

6-mm silicone spigot in place

posterior segment of the right upper lobe

Bronchoscopy-Guided Topical Hemostatic Tamponade(THT)

• Oxidized regenerated cellulose mesh

Saturates with blood-->brownish or black gelatinous mass -->clot.

• Successful in life threatening hemoptysis.

• Immediate arrest of bleed: 98%(56 of 57)

*Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC: Bronchoscopy-guided topical hemostatic tamponade therapy for the Management of life-threatening hemoptysis. Chest 2005; 127: 2113–2118.

Bronchoscopy-Guided Topical Hemostatic Tamponade(THT)

56

Bronchoscopy-Guided Topical Hemostatic Tamponade(THT)

Endobronchial view of a bleeding subsegmental bronchus before THT

During bronchoscopy guided THT

Bronchoscopy-Guided Topical Hemostatic Tamponade(THT)

Disavantages:

• Not suitable for proximal sites, trachea.

Patients who cannot tolerate occlusion.

Recurrence of hemoptysis

Endobronchial Sealing with Biocompatible Glue

• Material: n-butyl cyanoacrylate(adhesive)

• Injected into the bleeding airway through a catheter via a flexible FOB.

• Used in mild hemoptysis.

• * *Parthasarathi Bhattacharyya et al Bronchoscopy Centre, Calcutta, India(CHEST 2002; 121:2066–2069)

Endobronchial Sealing with Biocompatible Glue

60

Laser Photocoagulation

• Nd-YAG laser

• Effective in: Bronchoscopically visible source.

MECHANISM:• Photocoagulation of the bleeding mucosa with resulting

hemostasis.

Achieves photoresection and vaporization

*Dumon JF, Reboud E, Garbe L, Aucomte F, Meric B: Treatment of tracheobronchial lesions by laser photoresection. Chest 1982; 81: 278–284.

Argon Plasma Coagulation(APC)

• TYPE : Thermal tissue destruction

• Non contact electrocoagulation tool*.

• Used:

In bronchoscopically visible areas of sources of bleed

62

*Keller CA, Hinerman R, Singh A, Alvarez F: The use of endoscopic argon plasma coagulation In airway complications after solid organ transplantation. Chest 2001; 119: 1968–1975.

APC machine

63

Flooding of the bron.intermed.

Suctioning airway clearance visualization

Coagulation and devascularizationof tissues

Carbonization of the bleeding site

• Once desired desiccation (dry) is done ,deeper penetration

and damage to further tissue SHOULD stopped.*

• Used for superficial and spreading lesions.

Advantages of APC over YAG laser.:

• It provides easy access to lesions.

• Allows homogeneous tissue desiccation.

Endobronchial Electrocautery

• TYPE: Thermal tissue destruction

• Coagulation mode: contact

• Readily available• .

Contact probes Electro cautery machine

Probe through working channel

• Indications :

- Bleeding, endobronchial growth & benign tumours.

• Less expensive alternative to laser.

• Control of haemoptysis using endobronchial electro cautery was achieved in 75%* of the cases

Homasson JP: Endobronchial electrocautery. Semin Respir Crit Care 1997; 18: 535– 543

Bronchial Artery Embolization

• Temporary or definitive

• Immediate control: 57–100% of patients**

Embolization : bronchial and nonbronchial

Long-term control: 70%-88%

*Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann Radiol (Paris) 1974; 17: 5–16. **Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 33–37.

BAE

In a study conducted in China

mortality has come down from 15 % (1995-1999)* to 0 % (2000-2005) with BAE.

*Shigemura N, Wan IY, Yu SCH: Multidisciplinary management of life-threatening massive hemoptysis: a 10-year experience Ann Thorac Surg 2009; 87: 849–853.

INDICATIONS

To Stabilize patients before surgical resection or medical treatment

As a definitive therapeutic approach in patients:

Who refuse surgery

Who are not candidates for surgery Where surgery is contraindicated

PROCEDURE

Identification of the bleeding vessel by selective bronchial artery cannulation.

Injection of particles in to the feeding vessel.

MATERIALS USED

Catheters

Embolizing materials or particles

Figure 2.  Right intercostobronchial artery.

Yoon W et al. Radiographics 2002;22:1395-1409

©2002 by Radiological Society of North America

Figure 3.  Common bronchial trunk.

Yoon W et al. Radiographics 2002;22:1395-1409

©2002 by Radiological Society of North America

Catheters: Reverse-curved

catheters (Mikaelson, Simmons I, SOS Omni)

Forward-looking

catheters (Cobra, HIH,RC)

Sizes: 4, 5, or 5.5 Fr

are routinely used.

Mikaelson catheter

Cobra type: curved catheter

• Most commonly used

• Microcatheter

• Superselective

catherization

• Less complications

Cobra type catheter

Embolizing materials:

Absorbable gelatin sponge

• Gelfoam

• Pledgets (1 to 2 mm)

• Thrombin

• Glue

• Recently approved

-Embospheres,

-Spherical Poly vinyl alcohol(PVA) particles

Right

Left

Abnormal circulation

Pre-embolisation bronchial angiogram

No abnormal circulation

Post embolisation

Bronchial artery aneurysm

Hypervascular lesion with aneurysm

Pre embolisation Post embolisationPVA particles

No hypervascular lesion & aneurysm

Super selective Embolization of intercostal artery

Hypervascular areas and a small amount of pulmonary arterial shunting

Decreased vasularity

POST EMBOLIZATIONPRE EMBOLIZATION

Radicular arteries

INTERCOSTAL ARTERY

Micro catheter passed beyond radicular artery

Left upper lobe bronchial artery

After embolization

Decreased vascularity & hypertrophyTortous and hypertrophied vessel

Before embolization

More About Materials

PVA particles (350-500 mic)

Most common & Safe

• Liquid embolic agents

-ischemic necrosis

Stainless steel platinum coils

-occlude more proximal vessels.

Particles > 200 to 250 micr.m should be used

IF LESS (Tissue infarction)

AVM • Metallic coils (steel, titanium, or platinum) or detachable

balloons, coils should be 2 mm wider than the feeding artery .

• If steel coils are used, MRI of the brain DELAYED. 6W

• Other : polyvinyl alcohol, wool coils, and Amplatzer vascular plugs. Amplatzer plugs are relatively new. In one study, Amplatzer plugs were used to successfully occlude 120 out of 161 PAVM (75 %) in 69 patients .

Figure 17b.  Coil embolization.

Yoon W et al. Radiographics 2002;22:1395-1409

©2002 by Radiological Society of North America

BEA

• Success rates : 64% to 100%.

• Recurrent non-massive bleeding :16–46%

• Technical failure: 13%

83

Complications of BAE

• Transversemyelitis

• Neurological (Para paresis)

• Intimal tears

• Chest pain

• Pyrexia

• Haemoptysis

• Systemic embolisation

• Vessel perforation

84

Acute Complications of BAE

1. Pleuritic chest pain 5 - 13 %

2. Transient air embolization 5%

3. Radiographic pulmonary infarction 3%

4. TIA 1%

5. Distal migration of the detachable balloon 1%

6. DVT 2ry to the angiography catheter 1.5 %

7. Stroke <0.5 %

8. Reflux of the embolization coil

9. Arterial wall damage with potential perforation .

Long-term outcomes

• Stroke and/or cerebral abscess 2%.

• The onset of pulmonary hypertension or the worsening of prior pulmonary hypertension.

SURGICAL MANAGEMENT

• Localized lesions

• Mortality : 1% to 50%

• Mortality :upto 40% (emergency procedure)

Indications of surgery

Procedure of choice in:

• Bronchial adenoma

• Aspergilloma

• Hydatid cyst

• Iatrogenic pulmonary rupture

• Chest trauma

• AV malformations

Contra indications for Surgery

• Unresectable carcinoma

• Inability to lateralize the bleeding site

• Diffuse disease

• Multiple AVM

• Cystic fibrosis

• Marginal pulm. Reserve

• Non-localizing bronchiectasis

90

Life Threatening hemoptysis

Pulmonary isolation & identification of bleeding source

(Radiological/Bronchoscopic means:CT Chest,Balloon bronchial blockers)

Rigid Bronchoscopy

Surgery BAE

(Delayed TREATMENT)

Follow up at OPD

SUCCESS

FAILURE