Management of endobronchial hemorrhage

Recognition and management of catheter-induced pulmonary artery rupture

BACKGROUND

Catheter-induced pulmonary artery rupture is a well-recognized complication of invasive monitoring, but the risk has not diminished. Although commonly associated with cardiopulmonary bypass, injuries also occur in intensive care. Definitive proof requires pulmonary angiography or autopsy. Many cases are never reported, and lesser injuries are probably under-diagnosed.

METHODS

Seven cases fulfilling accepted diagnostic criteria discovered over 2 years are described in four groups illustrating the common modes of presentation: hemoptysis with hypoxemia, exsanguination, delayed recurrent hemorrhage, and bleeding with cardiopulmonary bypass.

RESULTS

One patient had a planned elective operation deferred. Four patients were being monitored in intensive care. Two of them died of pulmonary artery rupture. Two other patients had bleeding on weaning from cardiopulmonary bypass. One settled with conservative treatment, the other survived after extracorporeal life support. Recognition and management are discussed, emphasizing means of avoiding pulmonary resection.

CONCLUSIONS

Catheter-induced pulmonary artery rupture is unavoidable. Constant awareness is essential. A plan of management is presented. Extracorporeal life support may help to avoid pulmonary resection. Early pulmonary angiography is advocated for accurate diagnosis and to enable treatment by embolization.

Decreasing the risk of pulmonary artery rupture with a pressure relief balloon

A pressure relief balloon has been recommended as one way to decrease catheter-related pulmonary artery rupture (PAR). There are approximately 1 to 2 PARs per 1,000 pulmonary artery catheter (PAC) insertions, resulting in significant morbidity and mortality. A new pressure relief balloon (PRB) introduced by Biosensors International (Singapore) was studied for its efficacy in increasing safety during PAC flotation balloon (FB) inflations. Ten human placentae were used for the experiment. The Biosensors PACs and the commonly used Baxter-Edwards (Irvine, CA) catheters were placed in placental veins and their FBs were gradually inflated with a maximum of 1.5 mL of air. Data revealed that PRBs consistently inflated when resistance was met by FBs and inflation pressure reached 1,000 mmHg. When PRBs were removed, the FBs inflated asymmetrically and distended beyond the catheter lumen or protruded through the vessel wall, causing bleeding upon deflation. Without the PRB, pressures reached up to 1,700 mmHg. In addition, the PRB gave visual evidence of resistance to the FB. In conclusion, the PRB is a safety device that limits overinflation of the distal PAC balloon, thus preventing vessel rupture. The device deserves serious consideration and outcome analysis.