Impact of multidetector CT-angiography on the emergency management of severe hemoptysis

[Severe hemoptysis in the onco-hematology patient]

In France, even though it occurs only exceptionally in cases of hemopathy, severe hemoptysis in cancer is the leading cause of hemoptysis. Without adequate treatment, in-hospital mortality exceeds 60%, even reaching 100% at 6 months. The management of severe hemoptysis should be discussed with the oncologist. Aside from situations of threatening hemoptysis, in which bronchoscopy should be performed immediately, CT angiography is an essential means of localizing the bleeding and determining the causes and the vascular mechanisms involved. In more than 90% of cases, hemoptysis is linked to systemic bronchial or non-bronchial hypervascularization, whereas in fewer than 5%, it is associated with pulmonary arterial origin or, exceptionally, with damage to the alveolar-capillary barrier. The most severely ill patients must be treated in intensive care in centers equipped with interventional radiology, thoracic surgery and, ideally, with interventional bronchoscopy. Interventional radiology is the first-line symptomatic treatment. In over 80% of cases, bronchial arteriography with embolization allows immediate control. Emergency surgery should be avoided, as it is associated with significant mortality. Appropriate and adequate care reduces hospital mortality to 30%, enabling patients to benefit from the most recent, survival-prolonging treatments.

Hemoptysis: From Diagnosis to Treatment

Management of hemoptysis begins with an angio-CT to identify the location, the bleeding vessel, mapping of systemic arteries and the cause of the hemoptysis. Endovascular treatment is the first-line therapy, in 90% of cases by embolization of the systemic arteries and in 10% of cases by occlusion of the pulmonary arteries.

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.

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

Value of multidetector computed tomography angiography before bronchial artery embolization in hemoptysis management and early recurrence prediction: a prospective study

Background

Multidetector computed tomography (MDCT) angiography is a useful examination to detect the source of the bleeding in patients with hemoptysis. The aim of the study was to prospectively evaluate the role and clinical efficacy of MDCT angiography before bronchial artery embolization (BAE) for the management of hemoptysis, and to investigate the predictors of early recurrence.

Methods

It is a double-center study which included 57 hemoptysis patients undergoing MDCT angiography prior to BAE from August 2019 to July 2020. A prospective analysis of culprit arteries detected by MDCT angiography allowed an evaluation of the role of this technique. A follow-up was done to assess the efficacy of BAE with preprocedural MDCT angiography and to explore the risk factors of early recurrent hemoptysis.

Results

The accuracy of MDCT angiography in the identification of culprit arteries was as high as 97.5%. The average number of total culprit arteries per patient was 2.75 ± 1.73. Among which, the average numbers of culprit ectopic bronchial arteries (BAs) and non-bronchial systemic arteries (NBSAs) per patient were 0.21 ± 0.41 and 1.04 ± 1.57, respectively. The immediate clinical success rate, total hemoptysis recurrence rate, and early hemoptysis recurrence rate of BAE following MDCT angiography were 94.7, 18.5, 16.7%, respectively. Aspergilloma (HR = 6.63, 95% CI: 1.31–33.60, p = 0.022) was associated with an increase in the risk of early recurrence.

Conclusions

MDCT angiography should be performed before BAE for the management of hemoptysis. Aspergilloma was an independent predictor for early recurrence.

[Management of massive hemoptysis secondary to pulmonary hydatidosis: Special features]

INTRODUCTION

Massive hemoptysis is a rare but serious presentation of pulmonary hydatid cysts. The literature reporting this clinical phenomenon is limited to sporadic cases.

MATERIAL AND METHODS

We undertook a retrospective study considering patients who had undergone lung surgery because of hydatid cyst from January 2000 o December 2015 and examined features associated with massive hemoptysis.

RESULTS

Among 270 patients operated on for lung hydatidosis, 13 (4.8%) had experienced massive hemoptysis. This sub group had an average age of 24±12 years (13-60 years) and a sex ratio of 0.85. Preoperative embolization was attempted in 5 patients but failed in all cases. All patients with massive hemoptysis were operated on emergency. The origin of bleeding was determined and controlled in all cases (from a vein or an artery from the pulmonary circulation). Pulmonary re-expansion was satisfactory after obliteration of the residual cavity and no pulmonary resection was necessary. The postoperative course was uneventful in 11 patients. Prolonged air-leak beyond 7 days was noted in two patients but settled subsequently with simple follow-up. Average postoperative follow-up was 32 months (8-63 months). One patient (who had hydatid vomit with massive hemoptysis) developed controlateral hydatid recurrence that was also successfully operated on. No recurrence of hemoptysis was noted during the follow-up period for all patients.

CONCLUSION

Massive haemoptysis secondary to pulmonary hydatidosis may be life-threatening. Surgery of hydatid cysts associated with direct vascular control of eroded vessels is sufficient to control hemoptysis.

Bronchopulmonary arteriovenous malformation presenting as cryptogenic hemoptysis in a patient with bicuspid aortic valve

We report the case of a 44-year-old male patient with bicuspid aortic valve, presenting with hemoptysis. Catheter angiography revealed an abnormal communication between bronchial and pulmonary artery, which remained undetected on computed tomography angiography. Angioembolization was done using polyvinyl alcohol and gelfoam particles. This is the first case in literature describing bronchial arteriovenous malformation associated with bicuspid aortic valve.

Value of CT-Angiography in the Emergency Management of Severe Hemoptysis

Objective To depict imaging anatomy of bronchial artery (BA) using multidetector CT-angiography (MDCTA) and evaluate the value of MDCTA for management of hemoptysis patients requiring admission to emergency room. Methods We retrospectively studied the clinical and radiological data of patients with severe hemoptysis (≥100 ml of expectorated blood in a 24-hour period) requiring admission to emergency room from Jan 1, 2013 to Dec 31, 2015. Patients' images of MDCTA, treatment modalities, and outcome were discussed. Results A total of 108 patients underwent MDCTA scans. Etiology of hemoptysis was mainly bronchiectasis (44%), tuberculosis sequelae (26%) and tumor (18%). MDCTA visualized 197 traceable BAs and also suggested the involvement of 35 nonbronchial systemic arteries. The mean diameter of BAs, measured at the level of the bronchial bifurcation in the mediastinum, was 2.8±1.2 mm. The mean diameter of BAs, for 52 patients who only received conservative treatment, was 2.9±1.1 mm, and was not significantly larger than that of BAs for 56 patients who underwent bronchial artery embolization (BAE) for continued bleeding which did not resolve after conservative treatment (2.7±1.1 mm, P = 0.94). The technical success rate of embolization was 95% (53/56). Clinical success rate during follow-up was achieved in 50 (94%) of 53 patients who had undergone embolization. Conclusions MDCTA provides useful information for identifying the anatomical characteristics of bleeding-related BAs and nonbronchial systemic arteries for the management of patients with severe hemoptysis. However, MDCTA could not determine the individuals who need BAE through measuring diameter of BAs.

Bronchoscopy to assess patients with hemoptysis: which is the optimal timing?

Background

Bronchoscopy plays a key role to diagnose the etiology, to localize the site, and to identify the sources of the bleeding in patients with hemoptysis, but the ideal timing of an endoscopic examination is still unclear.

Methods

We performed a secondary analysis of an observational and multicenter study, aimed at evaluating the epidemiology of hemoptysis in Italy and the diagnostic yield of the most frequently prescribed examinations. The aim of the study was to evaluate whether an early bronchoscopy (i.e., performed during active bleeding/≤48 h after hemoptysis stopped) helps localize bleeding (i.e., site, lobe, lung) and increase diagnostic yield in comparison with a delayed examination.

Results

Four hundred eighty-six consecutive adult patients (69.2% males; median [IQR] age: 67 [53–76] years) with hemoptysis requiring an etiological diagnosis and undergoing bronchoscopy were recruited.

Bleeding focus could be located more frequently in case of moderate-severe bleedings than in cases of mild hemoptysis (site: 70/154, 45.4%, VS. 73/330, 22.1%; p-value < 0.0001; lobe: 95/155, 61.3%, VS. 95/331, 28.7%; p-value < 0.0001; lung: 101/155, 65.1%, VS. 111/331, 33.5%; p-value < 0.0001). Early bronchoscopy showed a higher detection rate of bleeding source in comparison with delayed examination (site: 76/214, 35.5%, VS. 67/272, 24.6%; p-value = 0.01; lobe: 98/214, 45.8%, VS. 92/272, 33.8%; p-value = 0.007; lung: 110/214, 51.4%, VS. 102/272, 37.5%; p-value = 0.002). Early bronchoscopy did not provide any advantages in terms of increased diagnostic yield, in the total cohort (113/214, 52.8%, VS. 123/272, 45.2%; p-value = 0.10) and in the severity subtypes (mild: 56/128, 43.8%, VS. 88/203, 43.4%; p-value = 0.94; moderate-severe: 57/86, 66.2%, VS. 35/69, 50.7%; p-value = 0.051).

Conclusions

Early bronchoscopy helps detect bleeding sources, particularly in cases of moderate-severe hemoptysis, without increasing diagnostic accuracy.

Trial registration

ClinicalTrials.gov (identifier: NCT02045394).

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.

Cone beam computed tomography improves the detection of injured vessels and involved vascular territories in patients with bleeding of uncertain origin

OBJECTIVE

The purpose of this preliminary retrospective study was to analyse if cone beam CT (CBCT) is able to identify more bleeding sites and corresponding feeding arteries in patients with haemorrhage of uncertain origin.

METHODS

In 18 vascular territories (16 patients), pre-interventional CT angiography (CTA) and selective angiograms resulted in discordant information regarding the suspected bleeding site and hence received CBCT. Image data of CTA and selective angiograms in comparison to CBCT were independently reviewed by two interventional radiologists. Image quality, diagnostic confidence, number of bleeding sites and involved vascular territories were investigated. Additionally, the correlation between number of bleeding sites and involved vascular territories with a  clinical gold-standard (super-selective angiographic findings and definitive clinical outcomes) was analysed.

RESULTS

Overall, subjective image quality did not significantly differ between investigated imaging modalities. However, CBCT significantly improved diagnostic confidence in both readers in detecting bleeding vessel (s) (p = 0.0024/0.0005; Reader 1/Reader2). High correlation coefficients regarding the number of bleeding sites (r = 0.9163/0.7692) in contrast to the number of involved vascular territories (r = 0.2888/0.0105) were observed for CTA in comparison to clinical gold-standard. In this context, CBCT demonstrated a very strong correlation for both parameters, the number of bleeding vessels (r = 0.9720/0.9721) and the number involved vascular territories (r = 0.9441/0.9441).

CONCLUSION

In complex cases of suspected haemorrhage, CBCT images can aid the interventionalist in detecting bleeding sites as well as narrowing down the number of involved vascular territories and thereby identifying feeding arteries of the bleeding source. Advances in knowledge: (1) CBCT showed no improvement in image quality. However, in complex bleeding cases CBCT information might aid in treatment planning. (2) CBCT improves visualization of bleeding vessels and involved feeding arteries. (3) Particularly, less experienced interventionalists might benefit from the three-dimensional information gathered by CBCT.

Robot-assisted ligation of bronchial artery could be an alternative to embolization

A 37-year-old patient presented with a self-limiting episode of moderate haemoptysis. Contrast-enhanced chest computed tomography showed a tortuous and dilated right bronchial artery arising from the descending aorta at the level of T6. Therapeutic angiography was attempted, but in the presence of spinal artery arising from the bronchial artery in question, selective embolization was contraindicated due to risk of spinal cord ischaemia. After a multidisciplinary meeting, it was decided to attempt surgery to ligate this pathological artery. We performed minimally invasive robot-assisted ligation of this pathological artery. The postoperative course was uneventful with good clinical and radiological outcome at 3-month follow-up. A minimally invasive approach provides a real alternative to embolization and could be a therapeutic option.

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.

Electrocardiography-Gated Computed Tomography of the Bronchial Arteries With Iterative Image Reconstruction: Clinical Evaluation and Image Quality

BACKGROUND

The aim of this study was to apply electrocardiography (ECG)-gated prospective-triggered multidetector row computed tomography angiography with iterative model reconstruction (IMR) to optimize imaging of the bronchial arteries in patients with the chief complaint of hemoptysis.

METHODS

This was a prospective observational study. Between August 2015 and June 2016, we enrolled 31 consecutive patients with the chief complaint of hemoptysis who were scheduled to undergo computed tomography of the bronchial artery. Patients were randomly divided into 3 groups: group A, with filtered back-projection reconstruction; group B, with iDose reconstruction; and group C, with ECG-gated prospective-triggered multidetector row computed tomography angiography with IMR. Image quality, visibility, and traceability were compared.

RESULTS

Image quality, including signal-to-noise and contrast-to-noise ratios, visibility, and traceability, was best in group C.

CONCLUSIONS

With the help of IMR and ECG-synchronized prospective-triggered technology, the bronchial artery anatomy can be accurately depicted in patients with massive hemoptysis.

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.