Multidisciplinary management of life-threatening massive hemoptysis: a 10-year experience

Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management

Massive hemoptysis is a time critical airway emergency in the perioperative setting, with an associated mortality exceeding 50%. Causes of hemoptysis in the perioperative setting include procedural complication, coagulopathy, malignancy, chronic lung disease, infection, left-sided cardiac disease, pulmonary vascular disease and autoimmune disease. A rapid and coordinated multidisciplinary response is required to secure the airway, isolate the lung, ensure adequate oxygenation and ventilation, identify the underlying cause and initiate specific systemic, bronchoscopic, endovascular, or surgical treatment. This review examines the etiology, pathophysiology, as well as approach to management and interventions in perioperative massive hemoptysis.

Hemoptysis in Cancer Patients

Hemoptysis in cancer patients can occur for various reasons, including infections, tumors, blood vessel abnormalities and inflammatory conditions. The degree of hemoptysis is commonly classified according to the quantity of blood expelled. However, volume-based definitions may not accurately reflect the clinical impact of bleeding. This review explores a more comprehensive approach to evaluating hemoptysis by considering its risk factors, epidemiology and clinical consequences. In particular, this review provides insight into the risk factors, identifies mortality rates associated with hemoptysis in cancer patients and highlights the need for developing a mortality prediction score specific for cancer patients. The use of hemoptysis-related variables may help stratify patients into risk categories; optimize the control of bleeding with critical care; implement the use of tracheobronchial or vascular interventions; and aid in treatment planning. Effective management of hemoptysis in cancer patients must address the underlying cause while also providing supportive care to improve patients' quality of life.

Is VATS suitable for lung diseases with hemoptysis? Experience from a hemoptysis treatment center in China

BACKGROUND

Surgery is crucial in the treatment of the potentially fatal pulmonary hemoptysis condition. Currently, most patients with hemoptysis are treated by traditional open surgery (OS). To illustrate the effectiveness of video-assisted thoracic surgery (VATS) for hemoptysis, we developed a retrospective study of surgical interventions for lung disease with hemoptysis.

METHODS

We collected and then analysed the data, including general information and post-operative outcomes, from 102 patients who underwent surgery for a variety of lung diseases with hemoptysis in our hospital between December 2018 and June 2022.

RESULTS

Sixty three cases underwent VATS and 39 cases underwent OS. 76.5% of patients were male (78/102). Comorbidities with diabetes and hypertension were 16.7% (17/102) and 15.7% (16/102) respectively. The diagnoses based on postoperative pathology included aspergilloma in 63 cases (61.8%), tuberculosis in 38 cases (37.4%) and bronchiectasis in 1 case (0.8%). 8 patients underwent wedge resection, 12 patients underwent segmentectomy, 73 patients underwent lobectomy and 9 patients underwent pneumonectomy. There were 23 cases of postoperative complications, of which 7 (30.4%) were in the VATS group, significantly fewer than 16 (69.6%) in the OS group (p = 0.001). The OS procedure was identified as the only independent risk factor for postoperative complications. The median (IQR) of postoperative drainage volume in the first 24 h was 400 (195-665) ml, which was 250 (130-500) ml of the VATS group, significantly less than the 550 (460-820) ml of the OS group (p < 0.05). The median (IQR) of pain scores 24 h after surgery was 5 (4-9). The median (IQR) of postoperative drainage tube removal time was 9.5 (6-17) days for all patients, and it was 7 (5-14) days for the VATS group, which was less than 15 (9-20) days for the OS group.

CONCLUSION

VATS for patients with lung disease presenting with hemoptysis is an effective and safe option that may be preferred when the hemoptysis is uncomplicated and the patient's vital signs are stable.

Evaluation and Treatment of Massive Hemoptysis

Massive hemoptysis is appropriately defined as life-threatening hemoptysis that causes airway obstruction, respiratory failure, and/or hypotension. Patients with this condition die from asphyxiation, not hemorrhagic shock. Any patient who presents with life-threatening hemoptysis requires immediate treatment to secure the airway and stabilize hemodynamics. Early activation and coordinated response from a multidisciplinary team is critical. Once the airway is secure and appropriate resuscitation is initiated, priorities are to localize the source of the bleeding and gain hemorrhage control. Nonsurgical control of hemorrhage is superior to surgery in the acute situation.

Six Cases of Hemoptysis with Angiogenesis from Non-Bronchial Systemic Arteries

BACKGROUND Although bronchial arteries are the most common cause of hemoptysis, other systemic arteries can cause hemoptysis and are potential pitfalls for successful embolization. CASE REPORT We present 6 cases of hemoptysis showing vascularization from systemic arteries other than bronchial arteries that presented to our department between 2013 and 2020. Chronic inflammatory diseases such as tuberculosis and pulmonary aspergillosis were the underlying diseases in 4 of the 6 cases. In all 6 cases, the lesions were close to the pleura. The abnormal non-bronchial systemic arteries were the internal thoracic artery in 4 cases, intercostal artery in 2 cases, lateral thoracic artery in 2 cases, and the subclavian, thyrocervical, and inferior phrenic arteries in 1 case each, all of which formed a shunt with the pulmonary artery. Additionally, depending on the location of the lesion, the non-bronchial systemic arteries near the lesion proliferated into the lung parenchyma through the adherent pleura. CONCLUSIONS When lesions are in contact with the pleura, various non-bronchial systemic arteries near the lesion can develop in the pulmonary parenchyma via the adherent pleura, which can cause hemoptysis. In patients with hemoptysis, it may be useful to evaluate chest contrast-enhanced computed tomography and angiography, while always accounting for the potential involvement of non-bronchial systemic arteries to ensure a safer and more reliable treatment.

Life-Threatening Hemoptysis in a Pediatric Referral Center

OBJECTIVES

Hemoptysis is uncommon in children, even among the critically ill, with a paucity of epidemiological data to inform clinical decision-making. We describe hemoptysis-associated ICU admissions, including those who were critically ill at hemoptysis onset or who became critically ill as a result of hemoptysis, and identify predictors of mortality.

DESIGN

Retrospective cohort study. Demographics, hemoptysis location, and management were collected. Pediatric Logistic Organ Dysfunction-2 score within 24 hours of hemoptysis described illness severity. Primary outcome was inhospital mortality.

SETTING

Quaternary pediatric referral center between July 1, 2010, and June 30, 2017.

PATIENTS

Medical/surgical (PICU), cardiac ICU, and term neonatal ICU admissions with hemoptysis during or within 24 hours of ICU admission.

INTERVENTIONS

No intervention.

MEASUREMENTS AND MAIN RESULTS

There were 326 hemoptysis-associated ICU admissions in 300 patients. Most common diagnoses were cardiac (46%), infection (15%), bronchiectasis (10%), and neoplasm (7%). Demographics, interventions, and outcomes differed by diagnostic category. Overall, 79 patients (26%) died inhospital and 109 (36%) had died during follow-up (survivor mean 2.8 ± 1.9 yr). Neoplasm, bronchiectasis, renal dysfunction, inhospital hemoptysis onset, and higher Pediatric Logistic Organ Dysfunction-2 score were independent risk factors for inhospital mortality (p < 0.02). Pharmacotherapy (32%), blood products (29%), computerized tomography angiography (26%), bronchoscopy (44%), and cardiac catheterization (36%) were common. Targeted surgical interventions were rare. Of survivors, 15% were discharged with new respiratory support. Of the deaths, 93 (85%) occurred within 12 months of admission. For patients surviving 12 months, 5-year survival was 87% (95% CI, 78-92) and mortality risk remained only for those with neoplasm (log-rank p = 0.001).

CONCLUSIONS

We observed high inhospital mortality from hemoptysis-associated ICU admissions. Mortality was independently associated with hemoptysis onset location, underlying diagnosis, and severity of critical illness at event. Additional mortality was observed in the 12-month posthospital discharge. Future directions include further characterization of this vulnerable population and management recommendations for life-threatening pediatric hemoptysis incorporating underlying disease pathophysiology.

Embolotherapy in Bronchial Hemorrhage

Hemoptysis, defined as bleeding into the tracheobronchial tree, is a serious symptom that can cause asphyxiation if inadequately treated. Massive hemoptysis carries a very high mortality risk, and therefore, a prompt multidisciplinary approach to hemoptysis is highly encouraged. Bronchial artery embolization has evolved as the mainstay of treatment in control of hemoptysis. It is a low-risk procedure that carries high initial clinical success rates. Despite relatively high recurrence rates, it can be repeated until the underlying disease process can be definitively treated.

Randomised trial of first-line bronchial artery embolisation for non-severe haemoptysis of mild abundance

Background

Whereas first-line bronchial artery embolisation (BAE) is considered standard of care for the management of severe haemoptysis, it is unknown whether this approach is warranted for non-severe haemoptysis.

Research question

To assess the efficacy on bleeding control and the safety of first-line BAE in non-severe haemoptysis of mild abundance.

Study design and methods

This multicentre, randomised controlled open-label trial enrolled adult patients without major comorbid condition and having mild haemoptysis (onset <72 hours, 100–200 mL estimated bleeding amount), related to a systemic arterial mechanism. Patients were randomly assigned (1:1) to BAE associated with medical therapy or to medical therapy alone.

Results

Bleeding recurrence at day 30 after randomisation (primary outcome) occurred in 4 (11.8%) of 34 patients in the BAE strategy and 17 (44.7%) of 38 patients in the medical strategy (difference −33%; 95% CI −13.8% to −52.1%, p=0.002). The 90-day bleeding recurrence-free survival rates were 91.2% (95% CI 75.1% to 97.1%) and 60.2% (95% CI 42.9% to 73.8%), respectively (HR=0.19, 95% CI 0.05 to 0.67, p=0.01). No death occurred during follow-up and no bleeding recurrence needed surgery.

Four adverse events (one major with systemic emboli) occurred during hospitalisation, all in the BAE strategy (11.8% vs 0%; difference 11.8%, 95% CI 0.9 to 22.6, p=0.045); all eventually resolved.

Conclusion

In non-severe haemoptysis of mild abundance, BAE associated with medical therapy had a superior efficacy for preventing bleeding recurrences at 30 and 90 days, as compared with medical therapy alone. However, it was associated with a higher rate of adverse events.

Trial registration number

NCT01278199

Haemoptysis due to an atypical right bronchial artery branching from the left subclavian artery evaluated by four-dimensional CT and bronchial arteriography

Haemoptysis can be a life-threatening condition, and bronchial artery embolisation (BAE) is the most effective treatment. A 19-year-old man who had been followed up for neutrophil migration failure and bronchiectasis since birth was admitted to our department with repeated haemoptysis. Contrast-enhanced CT revealed hyperplasia and tortuosity of the bronchial artery; however, it could not reveal the origin and running by the axial views. Three-dimensional (3D) and four-dimensional (4D) CT revealed branching of the right bronchial artery from the left subclavian artery and a bronchial artery–pulmonary artery shunt. Bronchial angiography confirmed these findings. Based on these findings, BAE was successfully performed. 3D and 4D CT can be useful for determining the cause of haemoptysis. Furthermore, evaluating the anatomy of bronchial arteries prior to BAE may be useful for performing safer procedures.

Preemptive non-selective bronchial artery angioembolization to reduce recurrence rate of hemoptysis

Background

Massive hemoptysis which is presented in advanced lung diseases is a life-threatening condition. Bronchial artery embolization as a minimally invasive procedure is the treatment of choice either in first or recurrent hemoptysis. This study aimed to assess the early and late efficacy of bronchial angioembolization (BAE) without microcatheter.

Methods

In this prospective cohort study, all patients with hemoptysis who had undergone BAE from August 2018 to March 2019 were included. Angiographic patterns including bleeding sources, number of involved vessels, the underlying etiology, and recurrence rate were evaluated in a one-year follow up.

Results

153 patients were included with mean age of 55 ±16 years. 68% of them were male and 58% had life-threatening massive hemoptysis. Three distinct angiographic patterns were recognized. The culprit bleeding vessel was bronchial in 126 (92%), intercostal in 4 (3%), and both vessels in 7 (5%) of cases (p<0.05). One vessel involvement was seen in 56 patients; however it was observed in 69% of non-cystic fibrosis lobar bronchiectasis patients. In 1, 3 and 12 months follow up, recurrent hemoptysis was reported in 15 (11%), 4 (2.5%), and 24 (15.5%), respectively. In 52% of cases, no abnormal vessels were observed during aorta injection, but culprit bronchial or intercostal arteries were found in selective investigational angiography.

Conclusion

BAE was successful in the control of hemoptysis and resulted in a low rate of recurrence in different types of lung diseases. This could be due to the embolization of all pathological arteries found during angiography which might have prevented recurrent bleeding.

Aetiology, diagnosis and treatment of moderate-to-severe haemoptysis in a North American academic centre

Significant haemoptysis is a frightening event for patients and clinicians alike. There is a paucity of contemporary literature on the subject.

A retrospective analysis of hospitalisations for haemoptysis of more than 50 mL·day⁻¹ in a tertiary referral centre during a 5-year period was performed. Patient's characteristics, haemoptysis aetiology, management and outcome were individually recorded. The aim of this study was to detail the causes of moderate (50–200 mL·day⁻¹) to severe (>200 mL·day⁻¹) haemoptysis along with the diagnostic measures and treatment options used in their management in a 21st century, tertiary-care North American centre.

A total of 165 hospitalisations for moderate-to-severe haemoptysis were included in the analysis. Lung cancer (30.3%) and bronchiectasis (27.9%) proved to be most frequent aetiologies. Computed tomography (CT) imaging and bronchoscopy were complementary in identifying the source of bleeding. Bronchial artery embolisation (BAE) was the most common treatment approach (61.8%) and resulted in initial bleeding control in 73.5% of cases. In-hospital mortality was 13.9%, varying from 3.3% in the moderate group to 24.7% in the severe group. Despite being the favoured approach in patients with more severe bleeding, initial BAE therapy was associated with a trend towards lower mortality compared to initial non-BAE therapy.

In summary, lung cancer and bronchiectasis were the main causes of moderate-to-severe haemoptysis in our population, CT and bronchoscopy are complementary in identifying the source of bleeding, bleeding volume is associated with outcomes and BAE is a key management tool.

In a contemporary North American population, lung cancer and bronchiectasis proved to be the leading causes of moderate-to-severe haemoptysis while CT and bronchoscopy appeared complementary in localising the source of bleedinghttps://bit.ly/2BFLvOT

Life-Threatening Hemoptysis

Life-threatening hemoptysis (LTH) is any amount of hemoptysis that causes significant hemodynamic decompensation or respiratory distress which may lead to death if left untreated. While the amount of hemoptysis that qualifies as massive hemoptysis has continued to be debated, any amount between 100 to 1,000 mL/day is considered significant. Up to 15% cases of hemoptysis are LTH and need urgent life-saving intervention. Understanding of pulmonary vascular anatomy is of paramount importance to manage LTH. The goal of treatment lies in airway protection, appropriate oxygenation, and prevention of exsanguination. Once the airway is stabilized, a quick diagnosis and control of bleeding site is targeted. This chapter highlights current practices and approach to LTH including medical management, bronchoscopic approach, and advanced therapies such as bronchial artery embolization and surgical resection. We review situations, such as bronchiectasis, vascular malformation, diffuse alveolar hemorrhage, and tracheostomy bleed and specific approach to management of these conditions in a systematic and evidence-based manner.

Management of life-threatening hemoptysis

It is estimated that 5-14% of patients presenting with hemoptysis will have life-threatening hemoptysis, with a reported mortality rate between 9 and 38%. This manuscript provides a comprehensive literature review on life-threatening hemoptysis, including the etiology and mechanisms, initial stabilization, and management of patients. There is no consensus on the optimal diagnostic approach to life-threatening hemoptysis, so we present a practical approach to utilizing chest radiography, computed tomography, and bronchoscopy, alone or in combination, to localize the bleeding site depending on patient stability. The role of angiography and embolization as well as bronchoscopic and surgical techniques for the management of life-threatening hemoptysis is reviewed. Through case presentation and flow diagram, an overview is provided on how to systematically evaluate and treat the bronchial arteries, which are responsible for hemoptysis in 90% of cases. Treatment options for recurrent hemoptysis and definitive management are discussed, highlighting the role of bronchial artery embolization for recurrent hemoptysis.

Modified silicone stent for difficult-to-treat massive hemoptysis: a pilot study of 14 cases

Background

Massive hemoptysis is a life-threatening event with limited therapeutic options. Bronchoscopic placement of stents may offer an alternative option for massive hemoptysis. However, traditional silicone stents have not been customized, making it difficult to tailor to individual patient’s needs for achieving optimal hemostasis. To investigate the efficacy and safety of the modified silicone stent in patients with difficult-to-treat massive hemoptysis.

Method

Between May 2016 and November 2018, we enrolled 14 patients who underwent bronchoscopic placement of the modified silicone stent, which was fabricated manually based on the Y-shaped silicone stent by tailoring and suturing on site. We recorded the technical success, clinical success, and complications. Patients were followed up for recording the recurrence of massive hemoptysis and complications.

Results

Placement of the modified silicone stent was successful in all 14 patients with a mean duration of 69.6 minutes (technical success rate: 100%). After stenting, no further massive hemorrhage episodes recurred in 12 patients (clinical success rate: 85.7%). Two cases suffered from recurrent hemoptysis in 4 and 6 days after stenting, respectively. The main complications were sputum plugging, granuloma proliferation and pulmonary infection such as pneumonia. There were no adverse events of stent migration and suture dehiscence. After a median follow-up of 5.8 (range, 0.3–21.3) months, three patients withdrew and seven patients succumbed. Only one patient died of uncontrolled pneumonia which was possibly related to stent placement.

Conclusions

The modified silicone stent is an effective and safe gate-keeping therapeutic option for difficult-to-treat massive hemoptysis.

Nebulized Vasopressin for the Control of Hematemesis and Hemoptysis in a Child With Recurrent, Refractory Stage III Burkitt Lymphoma

BACKGROUND

Bleeding occurs with some regularity at the end of life. Patients often endure fatigue, weakness, pain, dyspnea and anxiety. These symptoms are magnified in visually apparent bleeds. Management can be particularly challenging as we attempt to balance therapies with goals of care. Children are at risk for such complications and symptoms; providers must ensure comfort for both the patient and family.

CASE DESCRIPTION

A 7-year-old male with recurrent, refractory Burkitt lymphoma was frequently hospitalized for palliative chemotherapy and disease complications. On his final admission, he experienced gross hemoptysis and hematemesis: he was short of breath, fatigued and anxious due to his blood loss. His and his family's angst were heightened by "seeing" his bleed. Potential, especially invasive, treatments were limited by our goals to promote comfort, limit interventions, maintain alertness, poor intravenous access and a small bowel obstruction. Nebulized vasopressin, 10 units in 4ml of normal saline given over 10 minutes provided JC with needed relief. His bleeding remitted and he tolerated its administration.

CONCLUSION

There are many treatments for hemorrhage; however, given the challenges of goals of care, administration, side-effects and tolerability, further investigation into nebulized vasopressin as a potential therapy for hemoptysis and hematemesis at the end-of-life is warranted.

Chinese Expert Recommendation for Diagnosis and Treatment of Massive Hemoptysis

Massive hemoptysis is one of emergency and critical diseases of the respiratory system. The definition of massive hemoptysis has always been different in the literature, which often depends on the quantitative estimation of the amount of hemoptysis, such as the amount of hemoptysis being in the range of 300-600 mL within 24 h, or hemoptysis more than 3 times within 1 week. Each amount of hemoptysis that is greater than 100 mL can be considered as massive hemoptysis, but the amount of hemoptysis is difficult to accurately estimate. Therefore, massive hemoptysis can be defined as any life-threatening hemoptysis and any hemoptysis that may cause airway obstruction and asphyxia. Massive hemoptysis accounts for approximately 5% of all hemoptysis cases and usually indicates the presence of a potentially severe respiratory or systemic disease. The mortality rate of massive hemoptysis is about 6.5-38%. The cause of death is generally shock caused by airway obstruction or excessive bleeding, and asphyxia is the main cause of death. At present, due to insufficient understanding of massive hemoptysis, there are limited technical means in the etiological diagnosis and untimely or improper treatment, resulting in high mortality of massive hemoptysis. Therefore, the diagnosis and treatment of massive hemoptysis needs to be standardized.

Potential Factors Affected Safety and Efficacy of Transcatheter Plug Closure for Pediatric Hemoptysis with Anomalous Bronchial Arteries

OBJECTIVE

To evaluate the safety and efficacy of interventional care in pediatric hemoptysis for anomalous bronchial arteries (BAs) and to identify the potential factors resulting in hemoptysis recurrence.

METHODS

20 children complained of hemoptysis were diagnosed with anomalous BAs. All patients received transcatheter plug occlusion in Department of Cardiology, Children's Hospital of Chongqing Medical University. The safety and efficacy were evaluated according to clinical symptoms and images monitoring of enrolled subjects grouped as recurrence group and nonrecurrence group. The potential factors causing hemoptysis recurrence were reviewed and summarized.

RESULTS

No deaths were recorded in a follow-up. Otherwise, hemoptysis recurrence was found in 8 subjects for 14 times, accounting for about 40%. Compared with nonrecurrence group, it indicated a statistical significance in hemoglobin levels (P=0.049), mycoplasma pneumonia particle assays (MP-PA) titers (P=0.030), and number of anomalous BAs (P=0.020). Meanwhile, 50% recurrent scenarios were associated with a respiratory infection by microbiological assessment before transcatheter plug occlusion. The repeat occlusion was applied for unclosed BAs leading to visual recurrent hemoptysis, the average interval time of which was 5.4 ± 3.6 mon.

CONCLUSION

The data from this retrospective study have shown that transcatheter plug occlusion is a relatively safe procedure with a low mortality. The number of abnormal BAs has been identified as a highly significant predictor of recurrence, and the role of MP and other potential factors should be verified in a multicenter, larger sample size, and randomized controlled trial.

The Diagnosis and Treatment of Hemoptysis

BACKGROUND

Hemoptysis, i.e., the expectoration of blood from the lower airways, has an annual incidence of approximately 0.1% in ambulatory patients and 0.2% in inpatients. It is a potentially life-threatening medical emergency and carries a high mortality.

METHODS

This review article is based on pertinent publications retrieved by a selective search in PubMed.

RESULTS

Hemoptysis can be a sign of many different diseases. Its cause remains unknown in about half of all cases. Its more common recognized causes include infectious and inflammatory airway diseases (25.8%) and cancer (17.4%). Mild hemoptysis is self-limited in 90% of cases; massive hemoptysis carries a worse prognosis. In patients whose life is threatened by massive hemoptysis, adequate oxygenation must be achieved through the administration of oxygen, positioning of the patient with the bleeding side down (if known), and temporary intubation if necessary. A thorough diagnostic evaluation is needed to identify the underlying pathology, site of bleeding, and vascular anatomy, so that the appropriate treatment can be planned. The evaluation should include conventional chest x-rays in two planes, contrastenhanced multislice computerized tomography, and bronchoscopy. Hemostasis can be achieved at bronchoscopically accessible bleeding sites with interventionalbronchoscopic local treatment. Bronchial artery embolization is the first line of treatment for hemorrhage from the pulmonary periphery; it is performed to treat massive or recurrent hemoptysis or as a presurgical measure and provides successful hemostasis in 75-98% of cases. Surgery is indicated if bronchial artery embolization alone is not successful, or for special indications (traumatic or iatrogenic pulmonary/vascular injury, refractory asper gilloma).

CONCLUSION

The successful treatment of hemoptysis requires thorough diagnostic evaluation and close interdisciplinary collaboration among pulmonologists, radiologists, and thoracic surgeons.

Massive hemoptysis managed by rescue extracorporeal membrane oxygenation

Massive hemoptysis can have a rapid and potentially fatal clinical course. A 68-year-old woman presented with recurrent hemoptysis complicated by refractory hypoxemia and shock despite aggressive intervention. The use of veno-venous extracorporeal membrane oxygenation was a nontraditional intervention that ultimately proved to be lifesaving, but is by no means recommended for routine use in this setting.

Management of severe hemoptysis

INTRODUCTION

Though rare, severe hemoptysis (SH) is associated with a mortality rate exceeding 50% when not managed properly. Areas covered: This paper reviews the recent epidemiological data regarding SH, the role of multidetector computed tomography angiography (MDCTA), and fiberoptic bronchoscopy (FOB) in its management, as well as the value of current treatments. Expert commentary: MDCTA is becoming an essential modality, since it allows determining the location, etiology, and mechanism of the bleeding. FOB can be delayed, except when local control of bleeding is required. Emergency treatment relies on interventional radiology. Both bronchial and non-bronchial arteries should be explored during bronchial arteriography. Surgery must be considered in all operable patients if the cause of hemoptysis persists.

Surgery for hemoptysis in patients with benign lung disease

Background

Hemoptysis can be a life-threatening condition that requires urgent treatment. Surgery still plays an important role in managing this critical situation, although previous reports have reported high postoperative morbidity and mortality rates. We report our experience with surgical resection for hemoptysis caused by benign lung diseases.

Methods

We reviewed the retrospectively collected data from 94 patients undergoing pulmonary resection for various benign lung diseases with hemoptysis at a single institution from 2010 to 2016. Baseline characteristics, surgical factors, and postoperative outcomes (morbidity and mortality rates) were analyzed.

Results

The ratio of male to female patients was 1:1, and the mean age was 58.2±11.1 (range, 29-79) years. The etiology of hemoptysis included aspergilloma in 58 patients (61.7%), bronchiectasis in 10, tuberculosis in 7, necrotizing bronchiolitis in 6, and other inflammatory disease in 13. A total of 21 patients (22.3%) underwent emergency operation, and 73 (77.7%) had an elective operation. Pulmonary resection was performed by thoracotomy (n=53, 56.4%) and video-assisted thoracoscopic surgery (VATS) (n=41, 43.6%). Sublobar resection (n=50, 53.2%, segmentectomy in 19 and wedge resection in 31) was performed more often than lobectomy (n=35, 37.2%). Pneumonectomy was performed in 7 patients, and bilobectomy was performed in 2. Postoperative morbidity occurred in 23 patients (24.5%), with prolonged air leak being the most frequent complication (n=14, 14.9%). The in-hospital mortality rate was 3.2% (n=3). Complications were less frequent in patients undergoing an elective operation, VATS, and sublobar resection. Multivariate analysis showed that patients treated with VATS had a decreased risk of postoperative complications (odds ratio, 12.8; 95% confidence interval, 1.29-127.9; P=0.03).

Conclusions

Surgical resection for hemoptysis in patients with benign lung diseases is the mainstay of effective treatment with acceptable morbidity and mortality rates. If applicable, we recommend elective (planned) sublobar resection using VATS in order to improve postoperative outcomes.

Approach to Hemoptysis in the Modern Era

Hemoptysis is a frequent manifestation of a wide variety of diseases, with mild to life-threatening presentations. The diagnostic workup and the management of severe hemoptysis are often challenging. Advances in endoscopic techniques have led to different new therapeutic approaches. Cold saline, vasoconstrictive and antifibrinolytic agents, oxidized regenerated cellulose, biocompatible glue, laser photocoagulation, argon plasma coagulation, and endobronchial stents and valves are amongst the tools available to the bronchoscopist. In this article, we review the evidence regarding the definition, etiology, diagnostic modalities, and treatment of severe hemoptysis in the modern era with emphasis on bronchoscopic techniques.

Bronchial artery embolization: first-line option for managing massive hemoptysis

Background Today, treatment for hemoptysis is not limited to surgery, and among the various options, bronchial artery embolization is regarded as an effective approach. Methods In this retrospective study, 179 of 389 patients with massive hemoptysis were treated with bronchial artery embolization, without taking into account the underlying pathological lesions responsible (bronchiectasis in 41, aspergilloma in 29, lung cancer in 25, old tuberculosis in 23, pyothorax in 19, others in 23). Results Bronchial artery embolization failed in 12 cases. In the 167 successful cases, surgery was required in 16 and bronchial occlusion was performed in 4; 3 patients died due to recurrent massive hemoptysis. After bronchial artery embolization, thoracic surgery for reasons other than hemostasis was carried out in 15 patients. Bronchial artery embolization was performed in 31 patients with hemoptysis who had a history of chest surgery. Four patients underwent bronchial occlusion, and immediate hemostasis was achieved in all of them. Conclusions For treatment of hemoptysis, bronchial artery embolization is a safe and minimally invasive technique that can be performed repeatedly, and provides not only short-term but also prolonged effectiveness; thus it can be used as a first-line treatment irrespective of the underlying pathological lesion. Bronchial occlusion may be useful for emergency hemostasis, but it warrants careful follow-up with consideration of additional elective treatment such as bronchial artery embolization.

A systematic approach to the management of massive hemoptysis

Massive hemoptysis is regarded as a potentially lethal condition that requires immediate attention, and prompt action. Although minor hemoptysis is frequently encountered by most clinicians, massive hemoptysis in far less frequent and most physicians are not prepared to manage this time-sensitive clinical presentation in a systematic and timely fashion. Critical initial steps in management need to be implemented in an expedited fashion, such that patients may have a chance at a more definitive treatment. In this article, we review the definition, vascular anatomy, etiology, diagnostic evaluation, epidemiology and prognostic markers of massive hemoptysis. A systematic approach to management, stabilization and treatment options is followed. An algorithm is proposed for the management of massive hemoptysis and the importance of a multidisciplinary approach is emphasized.

MINIMALLY INVASIVE METHODS IN TREATMENT OF COMPLICATED FORMS OF CENTRAL LUNG CANCER

Despite certain achievements in lung cancer treatment, the essential number of patients is subjected to palliative and symptomatic treatment. Hemoptysis addition is the one of most heavy symptoms of unresectable lung cancer. No less heavy complication is an atelectasis and hypoventilation of a lobe or a whole lung, which clinical image is attended by respiratory failure phenomena or association of purulent-septic pneumonia. The combination of endoscopic hemostasis with roentgen endovascular embolization of bronchial arteries (REEBA) allows to increase patients’ live quality and to prolong it for some time. In the clinic REEBA has been done in 121 patients with unresectable forms of lung cancer. The causes of surgical treatment refusal were a widespread tumor process, age, and severity of associated pathology. Hemostasis was achieved in 112 patients. A relapse of pulmonary bleeding was observed in 11 patients, who underwent the repeated REEBA. Lethal outcome was observed in 5 cases. Hemostasis was ineffective in 9 patients. Thus, the experience of using REEBA and endoscopic hemostasis at complicated forms of unresectable lung cancer allows to increase the life quality and in further to realize chemoradial therapy that gives a possibility to prolong a patient’s life.

Role of Surgery in the Diagnosis and Management of Tuberculosis

Modern thoracic surgery can now offer management of tuberculosis and its complications in selected patients with greater efficacy and less morbidity than ever before. Significantly, newer minimally invasive thoracic surgical approaches potentially lower thresholds for surgical candidacy, allowing more tuberculosis patients to receive operative treatment. This review aims to provide an overview of the role that modern thoracic surgery can play in diagnosing and managing patients with tuberculosis and its sequelae.

Massive Hemoptysis

Hemoptysis, or coughing of blood, oftentimes triggers anxiety and fear for patients. The etiology of hemoptysis will determine the clinical course, which includes watchful waiting or intensive care admission. Any amount of hemoptysis that compromises the patient's respiratory status is considered massive hemoptysis and should be considered a medical emergency. In this article, we review introduction, definition, bronchial circulation anatomy, etiology, and management of massive hemoptysis.

Antifibrinolytic therapy to reduce haemoptysis from any cause

BACKGROUND

Haemoptysis is a common pathology around the world, occurring with more frequency in low-income countries. It has different etiologies, many of which have infectious characteristics. Antifibrinolytic agents are commonly used to manage bleeding from different sources, but their usefulness in pulmonology is unclear.

OBJECTIVES

To evaluate the effectiveness and safety of antifibrinolytic agents in reducing the volume and duration of haemoptysis in adult and paediatric patients.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library, EMBASE and LILACS for publications that describe randomized controlled trials (RCTs) of antifibrinolytic therapy in patients presenting with haemoptysis. We also performed an independent search in MEDLINE for relevant trials not yet included in CENTRAL or DARE. Searches are up to date to the 19th September 2016. We conducted electronic and manual searches of relevant national and international journals. We reviewed the reference lists of included studies to locate relevant randomized controlled trials (RCTs). An additional search was carried out to find unpublished RCTs.

SELECTION CRITERIA

We included RCTs designed to evaluate the effectiveness and safety of antifibrinolytic agents in reducing haemoptysis in adult and paediatric patients of both genders presenting with haemoptysis of any etiology and severity. The intervention of interest was the administration of antifibrinolytic agents compared with placebo or no treatment.

DATA COLLECTION AND ANALYSIS

All reviewers independently assessed methodological quality and extracted data tables pre-designed for this review.

MAIN RESULTS

The electronic literature search identified 1 original study that met the eligibility criteria. One unpublished study was also identified through manual searches. Therefore two randomized controlled trials met the inclusion criteria: Tscheikuna 2002 (via electronic searches) and Ruiz 1994 (via manual searches). Tscheikuna 2002, a double-blind RCT performed in Thailand, evaluated the effectiveness of tranexamic acid (TXA, an antifibrinolytic agent) administered orally in 46 hospital in- and outpatients with haemoptysis of various etiologies. Ruiz 1994, a double-blind RCT performed in Peru, evaluated the effectiveness of intravenous TXA in 24 hospitalised patients presenting with haemoptysis secondary to tuberculosis.Pooled together, results demonstrated a significant reduction in bleeding time between patients receiving TXA and patients receiving placebo with a weighted mean difference (WMD) of -19.47 (95% CI -26.90 to -12.03 hours), but with high heterogeneity (I² = 52%). TXA did not affect remission of haemoptysis evaluated at seven days after the start of treatment. Adverse effects caused by the drug's mechanism of action were not reported. There was no significant difference in the incidence of mild side effects between active and placebo groups (OR 3.13, 95% CI 0.80 to 12.24).

AUTHORS' CONCLUSIONS

There is insufficient evidence to judge whether antifibrinolytics should be used to treat haemoptysis from any cause, though limited evidence suggests they may reduce the duration of bleeding.

Management of Massive Hemoptysis: Analyses of 58 Patients

OBJECTIVES

The objective was to describe changing patterns of etiological factors and treatment modalities for massive hemoptysis.

MATERIAL AND METHODS

From January 2008-December 2012, the medical records of 58 massive hemoptysis patients were reviewed.

RESULTS

Fifty-eight patients, 44 were men (75.9%) and 14 were women (24.1%), with a mean age of 51.4 years (range= 19-84 years), were divided into three groups; surgical management (n= 37, 63.8%), conservative management (n= 14, 24.1%) and bronchial artery embolization (n= 6, 10.4%). One case (1.7%) had combined treatment modality; bronchial artery embolization was followed by surgical resection. Anatomical lung resections were the most preferred resection type in the surgical management group (n= 34, 91.9%). The most common etiological factor was bronchiectasis (n= 19, 32.8%); followed by bronchial cancer (n= 14, 24.1%). The duration of hospitalization in the surgical management group was 11.4 days (range= 4-24); whereas in the bronchial artery embolization group, hospitalization was only four days (range= 2-7) (p< 0.01). Prolonged air leak (n= 7; 18.9%) was the most common complication in the surgical management group.

CONCLUSION

We emphasize that bronchiectasis was leading cause of massive hemoptysis. Surgical treatment remains the definitive therapy in the management of massive hemoptysis with decreased mortality rates over decades; whereas bronchial artery embolization is an effective therapeutic tool.

Flexible bronchoscopy-induced massive bleeding: A 12-year multicentre retrospective cohort study

BACKGROUND AND OBJECTIVE

Although massive bleeding is the most life-threatening complication caused by flexible bronchoscopy, data on flexible bronchoscopy-induced massive bleeding are scarce, and the associated clinical characteristics and prognostic factors are unknown.

METHODS

This was a multicentre retrospective cohort study of all patients who underwent flexible bronchoscopy in 33 tertiary hospitals from January 2001 to June 2013. The clinical characteristics and outcomes were collected and analysed.

RESULTS

A total of 194 patients with massive bleeding were identified among 520 343 patients who underwent flexible bronchoscopy. The average blood loss reached up to 378 mL. The overall incidence and mortality were 0.037% and 0.004%, respectively, and the overall fatality was 10.8%. The risk of massive bleeding induced by therapeutic bronchoscopies was significantly higher than that induced by diagnostic bronchoscopies (incidence: 0.059% vs 0.031%, P < 0.001; mortality: 0.012% vs 0.003%, P < 0.001; fatality: 20% vs 8.4%, P = 0.068). Multivariate analysis showed that age ≥65 years, tracheal bleeding, blood loss ≥500 mL and occurrence of shock were independent factors predicting poor outcome, while emergency surgery was an independent protective factor. Re-bleeding occurred in six patients, resulting in three deaths within a month.

CONCLUSION

Flexible bronchoscopy-induced massive bleeding is rare but life-threatening. Age, bleeding location, bleeding volume, circulation condition and emergency surgery were independent prognostic factors.

Long-term outcomes of the bronchial artery embolization are diagnosis dependent

Background:

Bronchial artery embolization (BAE) is an established, safe, and effective procedure for the treatment of hemoptysis but long-term outcomes of the BAE have never been investigated before.

Objectives:

To retrospectively analyze long-term outcomes of the BAE.

Materials and Methods:

A retrospective chart analysis was done from the hospital central database for all patients undergoing the BAE over a consecutive 14-year period (January 2000-February 2014). A total of 58 patients were identified from the database. Eight patients were excluded due to the lack of follow-up. Data such as patient demographics, reason for hemoptysis, medical imaging results, bronchoscopy findings, recurrence rates, and morbidity/mortality rates after the BAE were collected.

Results:

Eighty three embolizations were performed in 50 patients. The median follow-up was of 2.2 years. Cystic fibrosis (CF) bronchiectasis was the most common etiology (21/50), followed by non-CF bronchiectasis (9/50). Cavitary lung disease occurred in 12/50 patients, an additional 4/50 had cancer (primary lung and metastatic), and one patient had antineutrophil cytoplasmic antibody (ANCA) vasculitis. In three patients the etiology was unknown. Postprocedural complications occurred in 5/83 (6%) patients, two patients with two major complications - stroke (one) and paraplegia (one) - and three patients with minor complications - chest pain (two) and bronchial artery dissection (one). A total of 15/50 patients died during the follow-up. Three patients died of hemoptysis, and the remaining deaths were unrelated to the procedure or hemoptysis. Twenty four patients had recurrent hemoptysis. A Kaplan-Meier analysis revealed an excellent long-term survival that was 85% at 10 years.

Conclusions:

The BAE is a safe and effective procedure with excellent overall long-term survival.

Diagnosis and Treatment of Hemoptysis

Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located.

Emergency transcatheter arterial embolization for massive hemoptysis due to pulmonary tuberculosis and tuberculosis sequelae

To explore the strategy and curative effect of emergency transcatheter arterial embolization (ETAE) in patients with massive hemoptysis due to pulmonary tuberculosis and tuberculosis sequelae. A total of 148 patients with massive hemoptysis due to pulmonary tuberculosis underwent emergency arteriography. After the bleeding artery was located, patients were given embolotherapy using gelfoam strips, coils, and polyvinyl alcohol particles. The arteriography manifestations and therapeutic outcomes in all patients were retrospectively analyzed. ETAE was performed successfully in 143 patients after location of the bleeding arteries. The bleeding arteries could not be located in another five patients, and embolotherapy, therefore, could not be performed. Among these five patients, three underwent surgical resection and two died of complications of tuberculosis/fungal ball coinfection. During a 2-year follow-up period, there were 15 cases of recurrent hemoptysis after initial embolotherapy. Among these, four cases were resolved by re-embolization, 11 patients still had massive hemoptysis after re-embolization who underwent surgical resection and resolved the hemoptysis eventually. Successful hemostasis was achieved by ETAE in 132 patients (89.19%; 132/148). No severe complications occurred after embolotherapy. ETAE is a safe and effective treatment for massive hemoptysis due to pulmonary tuberculosis. The key to successful treatment is thorough and complete embolization of the bleeding arteries. In the event of failure of embolotherapy, surgical resection should be used to resolve the bleeding.

Radiological Evaluation and Endovascular Treatment of Hemoptysis

Hemoptysis can be a life-threatening condition that warrants urgent investigation and intervention. Common causes include bronchiectasis, chronic obstructive pulmonary disease, tuberculosis, and malignancy. Computed tomography angiography is an accurate imaging modality for assessment of hemoptysis. The bronchial arteries are the source of bleeding in most cases of hemoptysis, and bronchial artery embolization is the treatment of choice. The aim of this article is to summarize the pathophysiology, causes, initial management, and diagnostic approach of hemoptysis. Endovascular treatment of hemoptysis, technique, embolic materials, outcomes, complications, and follow-up of patients are discussed.

Radiological findings and outcomes of bronchial artery embolization in cryptogenic hemoptysis

Management of cryptogenic massive hemoptysis is difficult, and conservative treatment may be inadequate to stop the hemorrhage. Surgery is not a reasonable option because there is no underlying identifiable pathology. This study aimed to investigate the radiologic findings and bronchial artery embolization outcomes in cryptogenic hemoptysis, and to compare the results with non-cryptogenic hemoptysis. We evaluated 26 patients with cryptogenic hemoptysis and 152 patients with non-cryptogenic hemoptysis. A comparison of the bronchial artery abnormalities between the cryptogenic and non-cryptogenic hemoptysis groups showed that only extravasation was more statistically significant in the cryptogenic hemoptysis group than in the non-cryptogenic hemoptysis group, while the other bronchial artery abnormalities, such as bronchial artery dilatation, hypervascularity, and bronchial-to-pulmonary shunting, showed no significant difference between groups. Involvement of the non-bronchial systemic artery was significantly greater in the non-cryptogenic hemoptysis group than in the cryptogenic hemoptysis group. While 69.2% of patients with cryptogenic hemoptysis also had hypervascularity in the contralateral bronchial arteries and/or ipsilateral bronchial artery branches other than the bleeding lobar branches, this finding was not detected in non-cryptogenic hemoptysis. Embolization was performed on all patients using polyvinyl alcohol particles of 355-500 µm. Hemoptysis ceased in all patients immediately after embolization. While recurrence of hemoptysis showed no statistically significant difference between the cryptogenic and non-cryptogenic hemoptysis groups, it was mild in cryptogenic hemoptysis in contrast to mostly severe in non-cryptogenic hemoptysis. Transarterial embolization is a safe and effective technique to manage cryptogenic hemoptysis.

Prevention of lung-to-lung aspiration during emergency thoracic surgery: an experimental study

BACKGROUND

Lung separation is essential for an emergency thoracic surgery for massive hemoptysis. When using a double lumen tube (DLT), a commonly adopted lung separation device during thoracic surgery, a water-tight seal of endobronchial cuff is crucial to prevent lung-to-lung aspiration of blood. In this study, we investigated the fluid sealing characteristics of the endobronchial cuff of a DLT and examined the effect of gel lubrication on the fluid leakage beyond the endobronchial cuff of DLT.

METHODS

An artificial tracheobronchial tree was intubated with a DLT. In the first phase of the study, the intra-cuff pressure of endobronchial cuff of DLT was set to 25, 50, or 100 cmH2O (n = 7, each), and the non-dependent bronchus was filled with 5 ml of water. Fluid leakage to the dependent bronchus beyond the endobronchial cuff was collected for 6 h. The time until leakage was first detected and the time until 100% leakage occurred were measured. In the second phase, the endobronchial cuff was coated with either saline (group C, n = 10) or lubricant gel (group GEL, n = 10), and the same parameters were measured.

RESULTS

In the first phase of the study, the times to first leakage and 100% leakage at an intra-cuff pressure of 25 cmH2O were 21.0 (7.0 - 59.0) sec and 3.0 (2.0 - 4.0) min, respectively. Higher intra-cuff (50 and 100 cmH2O) resulted in longer time for the first leakage and 100% leakage, but the duration was not long enough for clinical purpose. In the second phase, all the DLTs in group C showed 100% fluid leakage during the 6-hour period. In contrast, in group GEL, fluid leakage beyond the endobronchial cuff was detected only in 50% of the DLTs and none of the DLT showed 100% fluid leakage during the study. Among the DLTs which exhibited fluid leakage, the time to first leakage was 252.0 (171.0-305.0) min and the leakage volume at the end of the study period was 0.3〔0.0-1.8〕ml.

CONCLUSIONS

Endobronchial cuff of DLT cannot prevent fluid leakage beyond the endobronchial cuff, but lubricant gel coating on the endobronchial cuff can effectively reduce the lung-to-lung aspiration.

Pulmonary resection in the treatment of life-threatening hemoptysis

PURPOSE

Massive hemoptysis is a life threatening situation with high mortality rates. Surgery is effective, however generally an avoided treatment. We report our experience with patients undergoing lung resection for life-threatening hemoptysis.

METHODS

Records of all surgically treated patients for hemoptysis between June 2009 and June 2012 were reviewed and analyzed retrospectively.

RESULTS

Anatomical resection was performed on 31 (15.3%) patients out of 203 patients referred to our intensive care unit for life-threatening hemoptysis. 25 (80.6%) were male and six (19.4%) were female; with mean age of 46.4 ± 13.7 (21-77). Pneumonectomy was performed in four (12.9%), lobectomy in 24 (77.4%), segmentectomy in two (6.5%) and bilobectomy in one case. Postoperative complications developed in eight (25.8%), and mortality was observed in two (6.5%) patients. Etiology was bronchiectasis in 13 (42.0%), tuberculosis in eight (25.8%), carcinoma in four (12.9%), aspergilloma in four (12.9%), hydatid cyst in one (3.2%) and lung abscess in one (3.2%) of the cases.

CONCLUSIONS

Although lung resection in the treatment of massive hemoptysis is accompanied with high morbidity and mortality rates, surgery is the only permanent curative modality. Acceptable results can be achived in the company of a multidisciplinary approach, through avoidance of pneumonectomy and urgent surgery.

The management of near-fatal hemoptysis with left secondary carinal y stent

Massive hemoptysis can be a life threatening condition and needs urgent treatment in lung cancer. In the fiberoptic bronchoscopy of a fifty-two-year-old who was admitted with hemoptysis, left upper lobe upper division orifice was seen totally obstructed with a submucosal infiltration. One hour after the mucosal biopsies, massive hemoptysis occurred. Urgent rigid bronchoscopy was performed. The left main bronchus was occluded by sterile gauze. After cleaning of the coagulum patient was intubated and charged to intensive care unit. The next day, rigid bronchoscopy was repeated and the bleeding was observed to continue from the left upper lobe. Removing the gauze, 14 × 10 × 10 mm silicon Y stent was inserted in the left main bronchus after adjustments were made. Bleeding was stopped after insertion of the stent and patient could be extubated. In this case a successful control of hemoptysis was sustained after insertion of a customized silicon stent was presented.

A Very Unusual Cause of Hemoptysis

The use of Lucite balls or spheres played a role in the management of tuberculosis during the first decade of the 20th century. Several complications have been reported with the use of this surgical technique, but are rarely seen nowadays. The availability of effective oral regimens has forced to abandon this approach. Calcification of these spheres within the lung cavity produced a series of late complications result of the migration of these foreign bodies to adjacent structures, causing erosion of blood vessels and nerves. Herein, we present a case where the aforementioned complication caused significant bleeding with hemodynamic instability. The source of the profuse hemoptysis was identified and was resolved with the combined use of noninvasive approaches such as bronchoscopy and angiographic embolization.

Bronchoscopic findings and bleeding control predict survival in patients with solid malignancies presenting with mild hemoptysis

BACKGROUND

Regardless of its volume, hemoptysis is a concerning symptom. Mild hemoptysis and its significance in patients with solid malignancies has not been studied.

METHODS

We conducted a retrospective chart review of patients with solid malignancies who presented for evaluation of mild hemoptysis. In this population, we studied the impact of bronchoscopic findings and endobronchial therapies on overall survival and bleeding recurrence. Patients were categorized into four groups on the basis of the presence or absence of active bleeding and endobronchial disease at the time of initial bronchoscopy: active bleeding with endobronchial lesion (AB/EBL), active bleeding without endobronchial lesion (AB/no-EBL), absence of active bleeding but with endobronchial lesion (no-AB/EBL), and absence of active bleeding and endobronchial lesion (no-AB/no-EBL).

MEASUREMENTS AND MAIN RESULTS

Ninety-five of the 112 patients with solid malignancies and mild hemoptysis underwent bronchoscopies. There was a significantly lower median survival time for patients with bronchoscopic findings of active bleeding and endobronchial lesion compared with patients with no active bleeding and/or no endobronchial lesion (3.48 mo; 95% confidence interval [CI], 2.14-6.05). On a multivariate analysis, factors independently associated with improved survival were higher hemoglobin values (hazard ratio [HR], 0.78; 95% CI, 0.67-0.91) and cessation of hemoptysis without recurrence at 48 hours (HR, 0.43; 95% CI, 0.22-0.84). Variables independently associated with worse survival were disease stage (HR, 10.8; 95% CI, 2.53-46.08) and AB/EBL (HR, 3.20; 95% CI, 1.74-5.89).

CONCLUSIONS

In patients with solid malignancies presenting with mild hemoptysis, bronchoscopic findings of AB/EBL are associated with decreased survival. Hemoptysis control without recurrence at 48 hours after endobronchial intervention may improve survival.

Moderate hemoptysis: recurrent hemoptysis and mortality according to bronchial artery embolization

INTRODUCTION

The studies on hemoptysis have focused mainly on hemoptysis causes and massive or life-threatening hemoptysis. And there is a limited data that non-massive hemoptysis, especially moderate hemoptysis.

OBJECTIVES

We analyzed the prognosis and severity of bleeding on flexible bronchoscopy (FB) between moderate and massive hemoptysis.

METHODS

We reviewed total 852 subjects (59.9 ± 16.0 years) identified with hemoptysis. Reviewed database included severity of subjective hemoptysis, bleeding on FB, comorbid conditions, time from admission to bronchial artery embolization (BAE), recurrent hemoptysis and mortality.

RESULTS

In subjective hemoptysis, recurrent hemoptysis occurred in mild 8.0%, moderate 40.7%, massive hemoptysis 33.8%, and mortality was 4.7%, 13.4% and 13.5%. Especially, no statistical difference was shown in recurrent hemoptysis [hazard ratio (HR) = 0.795; 95% confidence interval (CI) 0.562-1.125, P = 0.196] and mortality (HR = 1.054; 95% CI 0.596-1.864, P = 0.856) between moderate and massive hemoptysis. In moderate hemoptysis patients, oozing or active bleeding on FB took up 83.3%. In this review, recurrent hemoptysis was more in oozing bleeding than active bleeding (HR = 1.781; 95% CI 1.214-2.431, P = 0.002), but mortality was similar (HR = 1.611; 95% CI 0.930-2.790, P = 0.089). Recurrent hemoptysis significantly decreased in the group with BAE performed within 24 h (HR = 0.308; 95% CI 0.149-0.637, P = 0.001) in moderate hemoptysis. Also, recurrent hemoptysis and mortality were significantly increased in the patients with smoking (≥40 pack-years), oozing or active bleeding on FB, and hypertension.

CONCLUSION

Moderate hemoptysis has shown similar prognosis of recurrent hemoptysis and mortality to massive hemoptysis. Therefore, the more aggressive FB and BAE should be considered in moderate hemoptysis.

Surgery of massive hemoptysis in pulmonary tuberculosis: immediate and long-term outcomes

BACKGROUND

To determine the current role of surgery and the risks and operative outcomes in patients with massive hemoptysis caused by pulmonary tuberculosis.

METHODS

A retrospective review of patients treated in the Department of Thoracic Surgery, Shanghai Pulmonary Disease Hospital between January 2001 and December 2010 was undertaken. The inclusion criteria were massive hemoptysis defined as expectoration of at least 200 mL of blood on each occasion or more than 600 mL in 24 hours; anatomic major pulmonary resection including lobectomy, bilobectomy, and pneumonectomy; histologic or bacteriologic pulmonary tuberculosis.

RESULTS

Sixty-eight men (76.4%) and 21 women (23.6%) aged 41.3 ± 11.7 years met the criteria. The cumulative amount of bleeding on admission was 558 ± 272 mL. A total of 36 patients (40.4%) underwent an emergency operation and 53 (59.6%) had a delayed operation. The operative morbidity rate was 31.5% (28 of 89) and mortality was 2.2% (2 of 89). Only 2 (2.2%) of the 89 patients had a recurrent episode of hemoptysis. Multivariate analysis showed that patients who received antituberculous therapy before surgery (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.04-0.38; P = .0003) had a decreased risk of developing postoperative complications and that patients who underwent an emergency operation (OR, 3.9; 95% CI, 1.29-11.5; P = .0154) had an increased risk.

CONCLUSIONS

In the present study, the immediate and long-term outcomes after surgery for patients with massive hemoptysis caused by pulmonary tuberculosis were fairly satisfactory. The morbidity and mortality were also acceptable. However, delayed elective surgery is preferred and emergency surgery should be reserved for patients with persistent life-threatening hemoptysis despite a multidisciplinary intervention.

Thoracic emergencies

This article discusses thoracic emergencies, including the anatomy, pathophysiology, clinical presentation, examination, diagnosis, technique, management, and treatment of acute upper airway obstruction, massive hemoptysis, spontaneous pneumothorax, and pulmonary empyema.