1
|
Pirotte M, Pirotte A, Koyfman A, Long B. High risk and low incidence diseases: Massive hemoptysis. Am J Emerg Med 2024; 85:179-185. [PMID: 39278024 DOI: 10.1016/j.ajem.2024.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 08/25/2024] [Accepted: 09/03/2024] [Indexed: 09/17/2024] Open
Abstract
BACKGROUND Massive hemoptysis (MH) is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of massive hemoptysis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION MH is a rare but deadly condition. It is defined clinically as any bleeding from the tracheobronchial tree that compromises respiratory or circulatory function. The bronchial artery system is the primary source in the majority of cases of MH. The most common cause is tuberculosis worldwide, but bronchiectasis, bronchogenic carcinoma, and mycetoma are more common causes in the U.S. Patients with MH require rapid assessment and management, as decompensation can be rapid. Patients with altered mental status, inability to clear their sections, respiratory distress, or hemodynamic compromise require emergent airway intervention. The imaging modality of choice is computed tomography angiography with pulmonary arterial phase contrast. A reasonable order or sequence of management includes initial stabilization; assessment for the need for airway intervention; reversal of any coagulopathy; advanced imaging; and emergent consultation of pulmonary, cardiothoracic surgery, and interventional radiology. Ongoing resuscitation including blood products may be required in some patients with MH until definitive hemostasis is achieved. CONCLUSIONS An understanding of MH can assist emergency clinicians in diagnosing and managing this dangerous disease. Providing a prompt evaluation, obtaining intravenous access, pursuing advanced imaging, providing reversal of coagulopathy, supporting hemodynamics, and appropriate consultation are key interventions in MH.
Collapse
Affiliation(s)
- Matthew Pirotte
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew Pirotte
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| |
Collapse
|
2
|
Maksimoski M, McCauley M, Osoba M, Pirotte M, Liddy W. Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality. Ann Otol Rhinol Laryngol 2024; 133:729-734. [PMID: 38801210 DOI: 10.1177/00034894241254697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
OBJECTIVES The use of nebulized tranexamic acid (TXA) in massive pulmonary hemorrhage is well-described. Published utilization in post-tonsillectomy bleeding (PTB) is limited to a single case. This study examines whether TXA resulted in change of operative intervention necessity and narcotic utilization. METHODS This was a retrospective cohort study at a single, urban academic medical center in the United States. Chart review was conducted of all patients who presented to the hospital for post-tonsillectomy bleed (PTB) between 3/1/2018 and 7/1/2020. Demographic data, intervention modality, need for control under general anesthesia, and opioid use were collected and analyzed. RESULTS Twenty-one patients underwent a total of 23 visits for PTB over the study period. Control of hemorrhage without need for operating room intervention for PTB was 100% (6/6) for patients receiving TXA nebulizer and 53% (9/17) for those receiving other treatment modalities. Opioid usage in hospital and on discharge was also lower in patients receiving TXA nebulizers. All results were statistically significant. CONCLUSIONS Our study supports nebulized TXA as an effective, non-invasive mode of hemostasis in patients presenting to the emergency department for post-tonsillectomy hemorrhage. Nebulized TXA may prevent the need for general anesthesia and operative intervention. Otolaryngologists should consider addition of this novel treatment appropriation of TXA to their management options for postoperative tonsillar hemorrhage.
Collapse
Affiliation(s)
- Matthew Maksimoski
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| | - Matthew McCauley
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - Muyinat Osoba
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| | - Matthew Pirotte
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - Whitney Liddy
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University, Chicago, IL, USA
| |
Collapse
|
3
|
Moynihan KM, Ryerson LM, Le J, Nicol K, Watt K, Gadepalli SK, Alexander PMA, Muszynski JA, Gehred A, Lyman E, Steiner ME. Antifibrinolytic and Adjunct Hemostatic Agents: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference. Pediatr Crit Care Med 2024; 25:e44-e52. [PMID: 38959359 PMCID: PMC11216380 DOI: 10.1097/pcc.0000000000003491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
OBJECTIVES To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference. DATA SOURCES A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021. STUDY SELECTION Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs). DATA EXTRACTION Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form. MEASUREMENTS AND MAIN RESULTS Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented. CONCLUSIONS Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.
Collapse
Affiliation(s)
- Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Faculty of Medicine and Health, Children's Hospital at Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
- Department of Pediatric Cardiac Intensive Care, Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta Hospital, Edmonton, AB, Canada
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Ohio State University College of Medicine, Columbus, OH
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minnesota, MN
| | - Lindsay M Ryerson
- Department of Pediatric Cardiac Intensive Care, Stollery Children's Hospital, Edmonton, AB, Canada
- Department of Pediatrics, University of Alberta Hospital, Edmonton, AB, Canada
| | - Jennifer Le
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children's Hospital, Columbus, OH
| | - Kevin Watt
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Samir K Gadepalli
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
- Ohio State University College of Medicine, Columbus, OH
| | - Alison Gehred
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Elizabeth Lyman
- Grant Morrow III MD Medical Library, Nationwide Children's Hospital Columbus, Columbus, OH
| | - Marie E Steiner
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minnesota, MN
| |
Collapse
|
4
|
Hurley C, McArthur J, Gossett JM, Hall EA, Barker PJ, Hijano DR, Hines MR, Kang G, Rains J, Srinivasan S, Suliman A, Qudeimat A, Ghafoor S. Intrapulmonary administration of recombinant activated factor VII in pediatric, adolescent, and young adult oncology and hematopoietic cell transplant patients with pulmonary hemorrhage. Front Oncol 2024; 14:1375697. [PMID: 38680864 PMCID: PMC11055461 DOI: 10.3389/fonc.2024.1375697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/26/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction Diffuse alveolar hemorrhage (DAH) is a devastating disease process with 50-100% mortality in oncology and hematopoietic cell transplant (HCT) recipients. High concentrations of tissue factors have been demonstrated in the alveolar wall in acute respiratory distress syndrome and DAH, along with elevated levels of tissue factor pathway inhibitors. Activated recombinant factor VII (rFVIIa) activates the tissue factor pathway, successfully overcoming the tissue factor pathway inhibitor (TFPI) inhibition of activation of Factor X. Intrapulmonary administration (IP) of rFVIIa in DAH is described in small case series with successful hemostasis and minimal complications. Methods We completed a single center retrospective descriptive study of treatment with rFVIIa and outcomes in pediatric oncology and HCT patients with pulmonary hemorrhage at a quaternary hematology/oncology hospital between 2011 and 2019. We aimed to assess the safety and survival of patients with pulmonary hemorrhage who received of IP rFVIIa. Results We identified 31 patients with pulmonary hemorrhage requiring ICU care. Thirteen patients received intrapulmonary rFVIIa, while eighteen patients did not. Overall, 13 of 31 patients (41.9%) survived ICU discharge. ICU survival (n=6) amongst those in the IP rFVIIa group was 46.2% compared to 38.9% (n=7) in those who did not receive IP therapy (p=0.69). Hospital survival was 46.2% in the IP group and 27.8% in the non-IP group (p=0.45). There were no adverse events noted from use of IP FVIIa. Conclusions Intrapulmonary rFVIIa can be safely administered in pediatric oncology patients with pulmonary hemorrhage and should be considered a viable treatment option for these patients.
Collapse
Affiliation(s)
- Caitlin Hurley
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jeffrey M. Gossett
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Elizabeth A. Hall
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Patricia J. Barker
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Diego R. Hijano
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Pediatrics, University of Tennessee Health and Science Center, Memphis, TN, United States
| | - Melissa R. Hines
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Guolian Kang
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jason Rains
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Saumini Srinivasan
- Department of Pediatrics, Division of Pulmonary Medicine, University of Tennessee Health and Science Center, Memphis, TN, United States
| | - Ali Suliman
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Amr Qudeimat
- Department of Bone Marrow Transplant and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Saad Ghafoor
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| |
Collapse
|
5
|
Lou L, Wang S. The application of tranexamic acid in respiratory intervention complicated with bleeding. Ther Adv Respir Dis 2024; 18:17534666241281669. [PMID: 39301736 DOI: 10.1177/17534666241281669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024] Open
Abstract
Tranexamic acid (TA) is a well-established antifibrinolytic agent utilized across various medical scenarios to manage bleeding, including surgical, traumatic, postpartum, and upper gastrointestinal bleeding. Despite its widespread application, the systematic evaluation of TA's efficacy in achieving hemostasis during interventional pulmonary procedures remains limited. This review aims to address this gap by examining the utility and effectiveness of TA in promoting hemostasis during pulmonary interventions, encompassing procedures such as bronchial artery embolization, percutaneous lung biopsy, bronchoscopy, and pleural procedures. By synthesizing existing evidence, this review seeks to provide valuable insights into the potential role of TA in mitigating hemorrhage following interventional pulmonary procedures, thereby informing clinical practice and guiding future research endeavors.
Collapse
Affiliation(s)
- Lingyun Lou
- Department of Pulmonary and Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua, Zhejiang, China
| | - Saibin Wang
- Department of Pulmonary and Critical Care Medicine, Jinhua Municipal Central Hospital, No. 365, East Renmin Road, Jinhua, Zhejiang 321000, China
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang 312000, China
| |
Collapse
|
6
|
Alkazemi A, Kovacevic M, Dube K, Lauffenburger JC, Smith A, Malinowski S, Weinhouse GL. Effectiveness of Nebulized Tranexamic Acid in Patients with Moderate-to-Massive Hemoptysis at a Tertiary Academic Medical Center. J Aerosol Med Pulm Drug Deliv 2023; 36:309-315. [PMID: 37962861 DOI: 10.1089/jamp.2022.0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
Introduction: The management of severe hemoptysis mainly consists of invasive interventional procedures, including angiographic bronchial artery embolization, various endobronchial interventions, and sometimes surgery. However, there are limited effective noninvasive medical therapies available. The objective of this analysis was to evaluate the effectiveness and safety of nebulized tranexamic acid (TXA) administration compared with conventional management in patients with hemoptysis. Methods: This Institutional Review Board-approved, single-center, retrospective matched cohort study was performed from January 1, 2018 to March 31, 2021. Electronic health record data were used to identify all adult inpatients with hemoptysis (International Classification of Diseases, Tenth Revision, code R04.2). All patients who received ≥1 dose of nebulized TXA were matched with up to five controls based on available severity criteria (hemoptysis severity, need for mechanical ventilation, and sequential organ failure assessment score at the time of hemoptysis diagnosis) with coarsened exact matching. The primary outcome was the need for invasive interventions for the management of hemoptysis. Secondary outcomes included time to hemoptysis resolution, duration of mechanical ventilation, hemoptysis recurrence, and hospital length of stay. Results: A total of 14 patients were treated with nebulized TXA; they were matched with 58 controls. Patients were 59.7% male, had a median age of 65.5 years, with airway disease (36.1%) being the major etiology of hemoptysis. There was no difference in the number of patients who required an invasive intervention between the TXA (35.7%) versus control group (56.9%), p = 0.344. Additionally, no difference was found in the time to hemoptysis resolution (p = 0.050), duration on mechanical ventilation (p = 0.128), hemoptysis recurrence (p = 1.000), or hospital length of stay (p = 0.139). Conclusions: In patients with hemoptysis, nebulized TXA may be considered as a noninvasive option for the management of hemoptysis. However, a larger analysis is warranted to determine the impact of nebulized TXA on invasive interventions for management.
Collapse
Affiliation(s)
- Afrah Alkazemi
- Department of Pharmacy Practice, College of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Mary Kovacevic
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kevin Dube
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Adam Smith
- Department of Respiratory Therapy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stephen Malinowski
- Department of Respiratory Therapy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gerald L Weinhouse
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Karlafti E, Tsavdaris D, Kotzakioulafi E, Kougias L, Tagarakis G, Kaiafa G, Netta S, Savopoulos C, Michalopoulos A, Paramythiotis D. Which Is the Best Way to Treat Massive Hemoptysis? A Systematic Review and Meta-Analysis of Observational Studies. J Pers Med 2023; 13:1649. [PMID: 38138876 PMCID: PMC10744930 DOI: 10.3390/jpm13121649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION Hemoptysis is one of the most common symptoms of respiratory system diseases. Common causes include bronchiectasis, tumors, tuberculosis, aspergilloma, and cystic fibrosis. The severity of hemoptysis varies from mild to moderate to massive hemoptysis and can easily lead to hemodynamic instability and death from suffocation or shock. Nevertheless, the most threatening hemoptysis that is presented to the emergency department and requires hospitalization is the massive one. In these cases, today, the most common way to manage hemoptysis is bronchial artery embolization (BAE). METHODS A systematic literature search was conducted in PubMed and Scopus from January 2017 (with the aim of selecting the newest possible reports in the literature) until May 2023 for studies reporting massive hemoptysis. All studies that included technical and clinical success rates of hemoptysis management, as well as rebleeding and mortality rates, were included. A proportional meta-analysis was conducted using a random-effects model. RESULTS Of the 30 studies included in this systematic review, 26 used bronchial artery embolization as a means of treating hemoptysis, with very high levels of both technical and clinical success (greater than 73.7% and 84.2%, respectively). However, in cases where it was not possible to use bronchial artery embolization, alternative methods were used, such as dual-vessel intervention (80% technical success rate and 66.7% clinical success rate), customized endobronchial silicone blockers (92.3% technical success rate and 92.3% clinical success rate), antifibrinolytic agents (50% clinical success rate), and percutaneous transthoracic embolization (93.1% technical success rate and 88.9% clinical success rate), which all had high success rates apart from antifibrinolytic agents. Of the 2467 patients included in these studies, 341 experienced rebleeding during the follow-up period, while 354 other complications occurred, including chest discomfort, fever, dysphagia, and paresis. A total of 89 patients died after an episode of massive hemoptysis or during the follow-up period. The results of the meta-analysis showed a pooled technical success of bronchial artery embolization equal to 97.22% and a pooled clinical success equal to 92.46%. The pooled recurrence was calculated to be 21.46%, while the mortality was 3.5%. These results confirm the ability of bronchial artery embolization in the treatment of massive hemoptysis but also emphasize the high rate of recurrence following the intervention, as well as the risk of death. CONCLUSION In conclusion, massive hemoptysis can be treated with great clinical and technical success using bronchial artery embolization, reducing mortality. Mortality has now been reduced to a small percentage of cases.
Collapse
Affiliation(s)
- Eleni Karlafti
- Emergency Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
- 1st Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (G.K.); (C.S.)
| | - Dimitrios Tsavdaris
- 1st Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.T.); (S.N.); (A.M.); (D.P.)
| | - Evangelia Kotzakioulafi
- 1st Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (G.K.); (C.S.)
| | - Leonidas Kougias
- Department of Radiology, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Georgios Tagarakis
- Department of Cardiothoracic Surgery, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Georgia Kaiafa
- 1st Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (G.K.); (C.S.)
| | - Smaro Netta
- 1st Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.T.); (S.N.); (A.M.); (D.P.)
| | - Christos Savopoulos
- 1st Propaedeutic Department of Internal Medicine, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (E.K.); (G.K.); (C.S.)
| | - Antonios Michalopoulos
- 1st Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.T.); (S.N.); (A.M.); (D.P.)
| | - Daniel Paramythiotis
- 1st Propaedeutic Surgery Department, University General Hospital of Thessaloniki AHEPA, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (D.T.); (S.N.); (A.M.); (D.P.)
| |
Collapse
|
8
|
Lynch Y, Vande Vusse LK. Diffuse Alveolar Hemorrhage in Hematopoietic Cell Transplantation. J Intensive Care Med 2023:8850666231207331. [PMID: 37872657 DOI: 10.1177/08850666231207331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Diffuse alveolar hemorrhage (DAH) is a morbid syndrome that occurs after autologous and allogeneic hematopoietic cell transplantation in children and adults. DAH manifests most often in the first few weeks following transplantation. It presents with pneumonia-like symptoms and acute respiratory failure, often requiring high levels of oxygen supplementation or mechanical ventilatory support. Hemoptysis is variably present. Chest radiographs typically feature widespread alveolar filling, sometimes with peripheral sparing and pleural effusions. The diagnosis is suspected when serial bronchoalveolar lavages return increasingly bloody fluid. DAH is differentiated from infectious causes of alveolar hemorrhage when extensive microbiological testing reveals no pulmonary pathogens. The cause is poorly understood, though preclinical and clinical studies implicate pretransplant conditioning regimens, particularly those using high doses of total-body-irradiation, acute graft-versus-host disease (GVHD), medications used to prevent GVHD, and other factors. Treatment consists of supportive care, systemic corticosteroids, platelet transfusions, and sometimes includes antifibrinolytic drugs and topical procoagulant factors. Therapeutic blockade of tumor necrosis factor-α showed promise in observational studies, but its benefit for DAH remains uncertain after small clinical trials. Even with these treatments, mortality from progression and relapse is high. Future investigational therapies could target the vascular endothelial cell biology theorized to contribute to alveolar bleeding and pathways that contribute to susceptibility, inflammation, cellular resilience, and tissue repair. This review will help clinicians navigate through the limited evidence to diagnose and treat DAH, counsel patients and families, and plan for future research.
Collapse
Affiliation(s)
- Ylinne Lynch
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Lisa K Vande Vusse
- Division of Pulmonary, Critical Care & Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
9
|
Singer ED, Faiz SA, Qdaisat A, Abdeldaem K, Dagher J, Chaftari P, Yeung SCJ. Hemoptysis in Cancer Patients. Cancers (Basel) 2023; 15:4765. [PMID: 37835458 PMCID: PMC10571539 DOI: 10.3390/cancers15194765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/22/2023] [Accepted: 09/24/2023] [Indexed: 10/15/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Emad D. Singer
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (E.D.S.); (A.Q.); (K.A.)
- Department of Abdominal Imaging, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Saadia A. Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (E.D.S.); (A.Q.); (K.A.)
| | - Karim Abdeldaem
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (E.D.S.); (A.Q.); (K.A.)
| | - Jim Dagher
- Faculty of Medicine, Saint Joseph University of Beirut, Beirut 1100, Lebanon
| | - Patrick Chaftari
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (E.D.S.); (A.Q.); (K.A.)
| | - Sai-Ching J. Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (E.D.S.); (A.Q.); (K.A.)
| |
Collapse
|
10
|
Kalchiem-Dekel O, Tran BC, Glick DR, Ha NT, Iacono A, Pickering EM, Shah NG, Sperry MG, Sachdeva A, Reed RM. Prophylactic epinephrine attenuates severe bleeding in lung transplantation patients undergoing transbronchial lung biopsy: Results of the PROPHET randomized trial. J Heart Lung Transplant 2023; 42:1205-1213. [PMID: 37140517 DOI: 10.1016/j.healun.2023.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/03/2023] [Accepted: 03/08/2023] [Indexed: 03/15/2023] Open
Abstract
BACKGROUND Severe hemorrhage is an uncommon yet potentially life-threatening complication of transbronchial lung biopsy. Lung transplantation recipients undergo multiple bronchoscopies with biopsy and are considered to be at an increased risk for bleeding from transbronchial biopsy, independent of traditional risk factors. We aimed to evaluate the efficacy and safety of endobronchial administration of prophylactic topical epinephrine in attenuating transbronchial biopsy-related hemorrhage in lung transplant recipients. METHODS The Prophylactic Epinephrine for the Prevention of Transbronchial Lung Biopsy-related Bleeding in Lung Transplant Recipients study was a 2-center, randomized, double blind, placebo-controlled clinical trial. Participants undergoing transbronchial lung biopsy were randomized to receive 1:10,000-diluted topical epinephrine vs saline placebo administered prophylactically into the target segmental airway. Bleeding was graded based on a clinical severity scale. The primary efficacy outcome was incidence of severe or very severe hemorrhage. The primary safety outcome was a composite of 3-hours all-cause mortality and an acute cardiovascular event. RESULTS A total of 66 lung transplantation recipients underwent 100 bronchoscopies during the study period. The primary outcome of severe or very severe hemorrhage occurred in 4 cases (8%) in the prophylactic epinephrine group and in 13 cases (24%) in the control group (p = 0.04). The composite primary safety outcome did not occur in any of the study groups. CONCLUSIONS In lung transplantation recipients undergoing transbronchial lung biopsy, prophylactic administration of 1:10,000-diluted topical epinephrine into the target segmental airway before biopsy attenuates the incidence of significant endobronchial hemorrhage without conveying a significant cardiovascular risk. (ClinicalTrials.gov identifier: NCT03126968).
Collapse
Affiliation(s)
- Or Kalchiem-Dekel
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bich-Chieu Tran
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Danielle R Glick
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ngoc-Tram Ha
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aldo Iacono
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Edward M Pickering
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nirav G Shah
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mark G Sperry
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
| |
Collapse
|
11
|
Gopinath B, Mishra PR, Aggarwal P, Nayaka R, Naik SR, Kappagantu V, Shrimal P, Ramaswami A, Bhoi S, Jamshed N, Sinha TP, Ekka M, Kumar A. Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial. Chest 2023; 163:1176-1184. [PMID: 36410494 DOI: 10.1016/j.chest.2022.11.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Tranexamic acid (TA) is used to control bleeding in patients with hemoptysis. However, the effectiveness of the different routes of TA administration has not been studied. RESEARCH QUESTION Does the nebulized route of TA administration reduce the amount of hemoptysis compared with the IV route in patients presenting to the ED with hemoptysis? STUDY DESIGN AND METHODS This was a pragmatic, open-label, randomized, parallel, single-center, pilot trial of nebulized TA (500 mg tid) vs IV TA (500 mg tid) in adult patients presenting to the ED with active hemoptysis. The primary outcome was cessation of bleeding at 30 min. Secondary outcomes included amount of hemoptysis at 6, 12, and 24 h; interventional procedures; and side effects of TA. Patients who were hemodynamically unstable or requiring immediate interventional procedure or mechanical ventilation were excluded from the study. RESULTS Of the 55 patients in each arm, hemoptysis cessation at 30 min following TA administration was significantly higher in the nebulization arm (n = 40) compared with the IV arm (n = 28): χ2 (1, n = 110) = 5.55; P = .0019. Also, hemoptysis amount was reduced significantly in the nebulization arm at all time periods of observation (P value at 30 min = .011, at 6 h = .002, 12 h = .0008, and at 24 h = .005). Fewer patients in the nebulization arm required bronchial artery embolization (13 vs 21; P = .024) and thereby had higher discharge rates from the ED (67.92% vs 39.02%; P = .005). Two patients in the nebulization arm had asymptomatic bronchoconstriction that resolved after short-acting beta-agonist nebulization. No patient discharged from the ED underwent any interventional procedure or revisited the ED with rebleed during the 72 h follow-up period. INTERPRETATION Nebulized TA may be more efficacious than IV TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared with IV TA in patients with mild hemoptysis. CLINICAL TRIAL REGISTRATION Clinical Trials Registry-India; No.: CTRI/2019/05/019337; URL: http://ctri.nic.in/Clinicaltrials/advancesearchmain.php.
Collapse
Affiliation(s)
- Bharath Gopinath
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prakash Ranjan Mishra
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India.
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Nayaka
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shivdas Rajaram Naik
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vignan Kappagantu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prawal Shrimal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshaya Ramaswami
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tej Prakash Sinha
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Meera Ekka
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Kumar
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
12
|
Badovinac S, Glodić G, Sabol I, Džubur F, Makek MJ, Baričević D, Koršić M, Popović F, Srdić D, Samaržija M. Tranexamic Acid vs Adrenaline for Controlling Iatrogenic Bleeding During Flexible Bronchoscopy: A Double-Blind Randomized Controlled Trial. Chest 2022; 163:985-993. [PMID: 36273651 DOI: 10.1016/j.chest.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The most commonly used topical hemostatic agents during flexible bronchoscopy (FB) are cold saline and adrenaline. Data on use of other agents such as tranexamic acid (TXA) for this purpose are limited. RESEARCH QUESTION Is TXA effective and safe in controlling iatrogenic bleeding during FB compared with adrenaline? STUDY DESIGN AND METHODS We conducted a cluster-randomized, double-blind, single-center trial in a tertiary teaching hospital. Patients were randomized in weekly clusters to receive up to three applications of TXA (100 mg, 2 mL) or adrenaline (0.2 mg, 2 mL, 1:10000) after hemostasis failure after three applications of cold saline (4 ° C, 5 mL). Crossover was allowed (for up to three further applications) before proceeding with other interventions. Bleeding severity was graded by the bronchoscopist using a visual analog scale (VAS; 1 = very mild, 10 = severe). RESULTS A total of 2,033 FBs were performed and 130 patients were randomized successfully to adrenaline (n = 65) or TXA (n = 65), whereas 12 patients had to be excluded for protocol violations (two patients from the adrenaline arm and 10 patients from TXA arm). Bleeding was stopped in 83.1% of patients (54/65) in both groups (P = 1). The severity of bleeding and number of applications needed for bleeding control were similar in both groups (adrenaline: mean VAS score, 4.9 ± 1.3 [n = 1.8 ± 0.8]; TXA: mean VAS score, 5.3 ± 1.4 [n = 1.8 ± 0.8]). Both adrenaline and TXA were more successful in controlling moderate bleeding (86.7% and 88.7%, respectively) than severe bleeding (40% and 58.3%, respectively; P = .008 and P = .012, respectively) and required more applications for severe bleeding (3.0 ± 0 and 2.4 ± 0.5, respectively) than moderate bleeding (1.7 ± 0.8 and 1.7 ± 0.8, respectively) control (P = .006 and P = .002, respectively). We observed no drug-related adverse events in either group. INTERPRETATION We found no significant difference between adrenaline and TXA for controlling noncatastrophic iatrogenic endobronchial bleeding after cold saline failure, adding to the body of evidence that TXA can be used safely and effectively during FB. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04771923; URL: www. CLINICALTRIALS gov.
Collapse
Affiliation(s)
- Sonja Badovinac
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Goran Glodić
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia.
| | - Ivan Sabol
- Ruđer Bošković Institute, Zagreb, Croatia
| | - Feđa Džubur
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia
| | - Mateja Janković Makek
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia
| | - Denis Baričević
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marta Koršić
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Filip Popović
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Dražena Srdić
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miroslav Samaržija
- Clinic for Lung Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia
| |
Collapse
|
13
|
Patel S, Angelidis IK, Malsin ES, Smith S, Pawale A, Budd AN. Inhaled Tranexamic Acid for the Management of Hemoptysis in a Patient With Right and Left Ventricular Assist Devices: A Case Report. A A Pract 2022; 16:e01604. [PMID: 35917204 DOI: 10.1213/xaa.0000000000001604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The use of mechanical circulatory support (MCS) devices continues to expand in cases of refractory cardiogenic shock. Bleeding is one of the most common complications associated with MCS, and management can be challenging due to need for systemic anticoagulation. Significant hemoptysis can be a devastating complication. We describe a case of a patient supported by a right ventricular assist device with an oxygenator and a left ventricular assist device who developed pulmonary hemorrhage that was successfully treated with nebulized tranexamic acid (TXA). Following a 5-day treatment course, bleeding resolved, no adverse side effects were noted, and systemic anticoagulation was resumed.
Collapse
Affiliation(s)
- Shamik Patel
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Anesthesiology, Northwestern Medicine, Chicago, Illinois
| | - Ioannis K Angelidis
- Department of Anesthesiology
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Elizabeth S Malsin
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
| | - Sean Smith
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
| | - Amit Pawale
- Department of Cardiac Surgery, Washington University, St. Louis, Missouri
| | - Ashley N Budd
- From the Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Anesthesiology, Northwestern Medicine, Chicago, Illinois
| |
Collapse
|
14
|
Tranexamic acid – A narrative review for the emergency medicine clinician. Am J Emerg Med 2022; 56:33-44. [DOI: 10.1016/j.ajem.2022.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/07/2022] [Accepted: 03/14/2022] [Indexed: 02/06/2023] Open
|
15
|
Seth I, Bhagavata Srinivasan SP, Bulloch G, Yi DS, Frankel A, Hsu K, Passam F, Garsia R, Corte TJ. Diffuse alveolar haemorrhage as a rare complication of antiphospholipid syndrome. Respirol Case Rep 2022; 10:e0948. [PMID: 35414937 PMCID: PMC8980908 DOI: 10.1002/rcr2.948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/01/2022] [Accepted: 03/25/2022] [Indexed: 12/24/2022] Open
Abstract
Diffuse alveolar haemorrhage (DAH) is a rare complication of antiphospholipid syndrome. With a mortality rate of 46%, early diagnosis and management remain an ongoing challenge. Case reports are limited, and management guidelines are not yet definitive. In this case report, we present a 43-year-old male with DAH who required high-dose oral steroids, intravenous methylprednisolone cyclophosphamide and rituximab over 18 months to control life-threatening episodes of pulmonary bleeding.
Collapse
Affiliation(s)
- Ishith Seth
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | | | - Gabriella Bulloch
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | - Dong Seok Yi
- Wagga Wagga Base HospitalMurrumbidgee Local Health DistrictWagga WaggaNew South WalesAustralia
| | - Anthony Frankel
- Bankstown Lidcombe HospitalSouth Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Kelvin Hsu
- Bankstown Lidcombe HospitalSouth Western Sydney Local Health DistrictSydneyNew South WalesAustralia
- South Western Sydney Clinical SchoolUniversity of New South WalesSydneyNew South WalesAustralia
| | - Freda Passam
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Roger Garsia
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| | - Tamera J. Corte
- Royal Prince Alfred HospitalSydney Local Health DistrictSydneyNew South WalesAustralia
- Sydney Medical SchoolUniversity of SydneySydneyNew South WalesAustralia
| |
Collapse
|
16
|
Calero Rodriguez A, de Grauw J. Spontaneous pulmonary haemorrhage in a standing sedated horse. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Abraham Calero Rodriguez
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
| | - Janny de Grauw
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
| |
Collapse
|
17
|
Dermendjieva M, Gopalsami A, Glennon N, Torbati S. Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature. Clin Pract Cases Emerg Med 2021; 5:1-7. [PMID: 34437029 PMCID: PMC8373187 DOI: 10.5811/cpcem.2021.5.52549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/24/2021] [Accepted: 05/28/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Post-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient. CASE SERIES Eight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED. CONCLUSION Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention. Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site.
Collapse
Affiliation(s)
- Mira Dermendjieva
- Cedars Sinai Medical Center, Department of Pharmacy Los Angeles, California
| | - Anand Gopalsami
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Nicole Glennon
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Sam Torbati
- Cedars Sinai Medical Center, Department of Emergency Medicine, Los Angeles, California
| |
Collapse
|
18
|
Atchinson PRA, Hatton CJ, Roginski MA, Backer ED, Long B, Lentz SA. The emergency department evaluation and management of massive hemoptysis. Am J Emerg Med 2021; 50:148-155. [PMID: 34365064 DOI: 10.1016/j.ajem.2021.07.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/09/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment. OBJECTIVE The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician. DISCUSSION Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology. CONCLUSION Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.
Collapse
Affiliation(s)
- Patricia Ruth A Atchinson
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Colman J Hatton
- Dartmouth-Hitchcock Medical Center, Section of Critical Care Medicine, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Matthew A Roginski
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Elliot D Backer
- Dartmouth-Hitchcock Medical Center, Section of Critical Care Medicine, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America
| | - Skyler A Lentz
- Division of Emergency Medicine and Pulmonary Disease and Critical Care Medicine, The University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
| |
Collapse
|
19
|
Tret’yakov AY, Radenska-Lopovok SG, Novikov PI, Tret’yakova VA, Zakharchenko SP. Pulmonary embolism and diffuse alveolar bleeding: combination options and therapy features. TERAPEVT ARKH 2021; 93:311-319. [DOI: 10.26442/00403660.2021.03.200657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/08/2021] [Indexed: 11/22/2022]
Abstract
The analysis of the mechanisms of the formation of a rare clinical combination of pulmonary embolism (PE) and diffuse alveolar hemorrhage (DAH), which are complications of systemic vasculitis associated with antibodies to the cytoplasm of neutrophils (primarily granulomatosis with polyangiitis), systemic lupus erythematosus and secondary antiphlogistic syndrome primary antiphospholipid syndrome and Goodpastures syndrome. Taking into account the chronological sequence of the occurrence of PE and DAH, 3 variants of the onset of these potentially fatal additions to the underlying disease were considered: the anticipatory DAH development of PE, delayed from DAH PE and joint (within 24 hours) formation of PE and DAH. A review of single descriptions of such a combination of complications of granulomatosis with polyangiitis is carried out, criteria are indicated, a working classification of severity is given and, taking this into account, a modern program of therapy for DAH as an independent event and in combination with PE.
Collapse
|
20
|
Park JA. Treatment of Diffuse Alveolar Hemorrhage: Controlling Inflammation and Obtaining Rapid and Effective Hemostasis. Int J Mol Sci 2021; 22:E793. [PMID: 33466873 PMCID: PMC7830514 DOI: 10.3390/ijms22020793] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
Diffuse alveolar hemorrhage (DAH) is a life-threatening pulmonary complication in patients with hematologic malignancies or systemic autoimmune disorders. Pathologic findings show pulmonary capillaritis, bland hemorrhage, diffuse alveolar damage, and hemosiderin-laden macrophages, but in the majority of cases, pathogenesis remains unclear. Despite the severity and high mortality, the current treatment options for DAH remain empirical. Systemic treatment to control inflammatory activity including high-dose corticosteroids, cyclophosphamide, and rituximab and supportive care have been applied, but largely unsuccessful in critical cases. Activated recombinant factor VII (FVIIa) can achieve rapid local hemostasis and has been administered either systemically or intrapulmonary for the treatment of DAH. However, there is no randomized controlled study to evaluate the efficacy and safety, and the use of FVIIa for DAH remains open to debate. This review discusses the pathogenesis, diverse etiologies causing DAH, diagnosis, and treatments focusing on hemostasis using FVIIa. In addition, the risks and benefits of the off-label use of FVIIa in pediatric patients will be discussed in detail.
Collapse
Affiliation(s)
- Jeong A Park
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| |
Collapse
|
21
|
Goel MK, Kumar A, Maitra G, Singh B, Ahlawat S, Jain P, Garg N, Verma RK. Safety and diagnostic yield of transbronchial lung cryobiopsy by flexible bronchoscopy using laryngeal mask airway in diffuse and localized peripheral lung diseases: A single-center retrospective analysis of 326 cases. Lung India 2021; 38:109-116. [PMID: 33687002 PMCID: PMC8098897 DOI: 10.4103/lungindia.lungindia_220_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Intubation with either an endotracheal tube or a rigid bronchoscope is generally preferred to provide airway protection as well as to manage unpredictable complications during transbronchial lung cryobiopsy (TBLC). The laryngeal mask airway has been described as a safe and convenient tool for airway control during bronchoscopy. Aims and Objectives In this study, we evaluated the safety and outcome of using a laryngeal mask airway (LMA) as a conduit for performing TBLC by flexible video bronchoscopy (FB). Methods We retrospectively analyzed the database of the patients who underwent TBLC between November 2015 and September 2019. The procedure was performed using FB through LMA under general anesthesia. Prophylactic occlusion balloon was routinely used starting January 2017 onwards. Radial endobronchial ultrasound (R-EBUS) guidance was used for TBLC in the localized lung lesions when deemed necessary. Multidisciplinary consensus diagnostic yield was determined and periprocedural complications were recorded. Results A total of 326 patients were analysed. The overall diagnostic yield was 81.60% (266/326) which included a positive yield of 82.98% (161/194) in patients with diffuse lung disease and 79.54% (105/132) in patients with localized disease. Serious bleeding complication occurred in 3 (0.92%) cases. Pneumothorax was encountered in 8 (2.45%) cases. A total of 9 (2.76%) cases had at least 1 major complication. Conclusion This study demonstrates that the use of LMA during TBLC by flexible bronchoscopy allows for a convenient port of entry, adequate airway support and effective endoscopic management of intrabronchial haemorrhage especially with the use of occlusion balloon.
Collapse
Affiliation(s)
- Manoj Kumar Goel
- Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Ajay Kumar
- Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Gargi Maitra
- Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Balkar Singh
- Department of Anesthesiology, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Sunita Ahlawat
- Department of Pathology, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Priti Jain
- Department of Pathology, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Neeraj Garg
- Department of Pathology, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - R K Verma
- Department of Radiology, Fortis Memorial Research Institute, Gurugram, Haryana, India
| |
Collapse
|
22
|
Jacob G, Aharon A, Brenner B. COVID-19-Associated Hyper-Fibrinolysis: Mechanism and Implementations. Front Physiol 2020; 11:596057. [PMID: 33391014 PMCID: PMC7772395 DOI: 10.3389/fphys.2020.596057] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/24/2020] [Indexed: 01/08/2023] Open
Abstract
The emerging novel coronavirus disease (COVID-19), which is caused by the SARS-CoV-2 presents with high infectivity, morbidity and mortality. It presenting a need for immediate understanding of its pathogenicity. Inflammation and coagulation systems are over-activated in COVID-19. SARS-CoV-2 damages endothelial cell and pneumocyte, resulting in hemostatic disorder and ARDS. An influential biomarkers of poor outcome in COVID-19 are high circulating cytokines and D-dimer level. This latter is due to hyper-fibrinolysis and hyper-coagulation. Plasmin is a key player in fibrinolysis and is involved in the cleavage of many viruses envelop proteins, including SARS-CoV. This function is similar to that of TMPRSS2, which underpins the entry of viruses into the host cell. In addition, plasmin is involved in the pathophysiology of ARDS in SARS and promotes secretion of cytokine, such as IL-6 and TNF, from activated macrophages. Here, we suggest an out-of-the-box treatment for alleviating fibrinolysis and the ARDS of COVID-19 patients. This proposed treatment is concomitant administration of an anti-fibrinolytic drug and the anticoagulant.
Collapse
Affiliation(s)
- Giris Jacob
- Medicine F and Recanati Research Center, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematologic Research Laboratory, Hematologic Department, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Aharon
- Hematologic Research Laboratory, Hematologic Department, Tel Aviv Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Benjamin Brenner
- Coagulation Research Laboratory Unit, Department of Hematology, Rambam Medical Center, Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
23
|
Kuint R, Levy L, Cohen Goichman P, Huszti E, Abu Rmeileh A, Shriki O, Abutbul A, Fridlender ZG, Berkman N. Prophylactic use of tranexamic acid for prevention of bleeding during transbronchial lung biopsies - A randomized, double-blind, placebo-controlled trial. Respir Med 2020; 173:106162. [PMID: 32979620 DOI: 10.1016/j.rmed.2020.106162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Although massive bleeding following transbronchial lung biopsies (TBLB) is rare, even minor hemorrhage may prolong the procedure and result in inadequate sampling. Tranexamic acid (TXA) is an antifibrinolytic agent, which reduces bleeding in numerous scenarios, however, its prophylactic use in mitigating post-TBLB bleeding has not been investigated. We conducted a prospective, randomized, double-blind, placebo-controlled trial to determine whether topical infusion of TXA prior to TBLB would reduce bleeding, shorten procedure duration and increase the number of biopsies obtained. METHODS We blindly randomized patients undergoing TBLB to receive topical TXA or placebo in the lobar bronchus prior to biopsies. Vital signs, procedure length, fluid balance (as a measure of the amount of bleeding), operator's assessment of bleeding, and number of biopsies obtained were measured. Data was analyzed using the two-tailed Student's T-Test, Chi-square or Mann-Whitney tests as appropriate. RESULTS Fifty patients were randomized, 26 to the TXA arm. The bleeding in the TXA group was significantly lower (P = 0.0037), with more specimens being obtained (placebo 7 (6, 9) (median and interquartile range) vs. TXA 9 (8, 10), P = 0.023) and no difference in procedure length (placebo 30 min (29.3, 34.3) vs. TXA 30 (24.8, 36), P = 0.90). There were no clinically significant adverse events in any of the groups up to one month of follow up. CONCLUSION Endobronchial installation of TXA prior to obtaining TBLB results in less bleeding and allows more biopsies to be obtained with no additional adverse events. The prophylactic use of TXA during TBLB may be considered as standard.
Collapse
Affiliation(s)
- Rottem Kuint
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
| | - Liran Levy
- Institute of Pulmonary Medicine, Chaim Sheba Medical Center, The Sackler School of Medicine, Tel Aviv, Israel
| | - Polina Cohen Goichman
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ayman Abu Rmeileh
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ora Shriki
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avraham Abutbul
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Zvi G Fridlender
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Neville Berkman
- Institute of Pulmonary Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
24
|
Fan K, McArthur J, Morrison RR, Ghafoor S. Diffuse Alveolar Hemorrhage After Pediatric Hematopoietic Stem Cell Transplantation. Front Oncol 2020; 10:1757. [PMID: 33014865 PMCID: PMC7509147 DOI: 10.3389/fonc.2020.01757] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/05/2020] [Indexed: 12/21/2022] Open
Abstract
Pulmonary complications are common following hematopoietic cell transplantation (HCT) and contribute significantly to its morbidity and mortality. Diffuse alveolar hemorrhage is a devastating non-infectious complication that occurs in up to 5% of patients post-HCT. Historically, it carries a high mortality burden of 60–100%. The etiology remains ill-defined but is thought to be due to lung injury from conditioning regimens, total body irradiation, occult infections, and other comorbidities such as graft vs. host disease, thrombotic microangiopathy, and subsequent cytokine release and inflammation. Clinically, patients present with hypoxemia, dyspnea, and diffuse opacities consistent with an alveolar disease process on chest radiography. Diagnosis is most commonly confirmed with bronchoscopy findings of progressively bloodier bronchoalveolar lavage or the presence of hemosiderin-laden macrophages on microscopy. Treatment with glucocorticoids is common though dosing and duration of therapy remains variable. Other agents, such as aminocaproic acid, tranexamic acid, and activated recombinant factor VIIa have also been tried with mixed results. We present a review of diffuse alveolar hemorrhage with a focus on its pathogenesis and treatment options.
Collapse
Affiliation(s)
- Kimberly Fan
- Division of Pediatric Critical Care, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jennifer McArthur
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - R Ray Morrison
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| | - Saad Ghafoor
- Division of Critical Care, St. Jude Children's Research Center, Memphis, TN, United States
| |
Collapse
|
25
|
Abstract
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.
Collapse
|
26
|
Alabdrabalnabi F, Alshahrani M, Ismail N. Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med 2020; 13:45. [PMID: 32819268 PMCID: PMC7439666 DOI: 10.1186/s12245-020-00304-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 08/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hemoptysis is a clinical condition encountered in the emergency department (ED) and must be managed and investigated urgently to maintain the patient's hemostasis. The management of hemoptysis depends on treating the underlying cause. Tranexamic acid (TXA) is an anti-fibrinolytic drug used to systemically control bleeding. There are a few studies available that investigate the use of nebulized tranexamic acid for hemoptysis with contradictory results. Our paper demonstrates three cases where patients presented with significant hemoptysis and had significant improvement in symptoms following the administration of nebulized tranexamic acid. The overall need for blood transfusion was reduced. RESULTS Three patients presented to the emergency room for evaluation of hemoptysis. All three patients had different underlying pathologies resulting in their hemoptysis and were monitored in the ICU. Initial conventional medical therapies including the correction of coagulopathy and discontinuing offending agents were utilized for treatment. After persistent symptoms, nebulized TXA at a dose of 500 mg three times a day was administered. The patients were all discharged from the hospital with improvement in their symptoms. CONCLUSION Tranexamic acid may be considered in the treatment of hemoptysis regardless of the underlying cause. This may be utilized pending further workup and investigation into the underlying source of the bleeding.
Collapse
Affiliation(s)
- Fatimah Alabdrabalnabi
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
| | - Mohammed Alshahrani
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
| | - Nadia Ismail
- Imam Abdulrahman Bin Faisal University and King Fahad University hospital, Dammam, Saudi Arabia
| |
Collapse
|
27
|
Lee J, Rhee CK, Kim SC, Kim YK, Kim HJ, Lee S, Cho SG, Lee JW. Use of intrapulmonary administration of thrombin in hematological malignancy patients with alveolar haemorrhage: A case series. Medicine (Baltimore) 2020; 99:e20284. [PMID: 32443373 PMCID: PMC7253869 DOI: 10.1097/md.0000000000020284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Alveolar hemorrhage (AH) is characterized by the acute onset of alveolar bleeding and hypoxemia and can be fatal. Thrombin has been widely used to achieve coagulation and hemostasis. However, the efficacy of thrombin in patients with AH is unclear. Thus, this study aimed to evaluate the efficacy of thrombin administration in patients with hematological malignancy and AH. PATIENT CONCERNS AND DIAGNOSES This retrospective study included 15 hematological malignancy patients (8 men and 7 women; mean age 47.7 ± 17.3 years) with AH who were administered intrapulmonary thrombin between March 2013 and July 2018. INTERVENTIONS AND OUTCOMES All patients received bovine-origin thrombin (1000 IU/ml, Reyon Pharmaceutical Co., Ltd., Seoul, Korea) via a fiberoptic bronchoscope. A maximum of 15 ml of thrombin was injected via the working channel to control bleeding. The ability of thrombin to control bleeding was assessed. Additionally, the change in the PaO2/FiO2 (PF) ratio after intrapulmonary thrombin administration was evaluated. Intrapulmonary thrombin was administered a minimum of 3 days after starting mechanical ventilation in all patients, and it immediately controlled the active bleeding in 13 of 15 patients (86.7%). However, AH relapse was noted in 3 of the 13 patients (23.1%). The PF ratio improved in 10 of 15 patients (66.6%), and the mean PF ratio was significantly higher after thrombin administration than before administration (P = .03). No adverse thromboembolic complications or systemic adverse events were observed. CONCLUSION Thrombin administration was effective in controlling bleeding in hematological malignancy patients with AH. Intrapulmonary thrombin administration might be a good therapeutic option for treating AH.
Collapse
Affiliation(s)
- Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Seok Chan Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Young Kyoon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine
| | - Hee Je Kim
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Lee
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok-Goo Cho
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Wook Lee
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
28
|
Sood R, Mancinetti M, Betticher D, Cantin B, Ebneter A. Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review. Ann Med Surg (Lond) 2020; 50:14-23. [PMID: 31908774 PMCID: PMC6940657 DOI: 10.1016/j.amsu.2019.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed. METHODS Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients. RESULTS Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary. CONCLUSION Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.
Collapse
Affiliation(s)
- R. Sood
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
| | - M. Mancinetti
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
- Medical Education Unit, University of Fribourg, Avenue de l'Europe 20, 1700, Fribourg, Switzerland
| | - D. Betticher
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
| | - B. Cantin
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
- Palliative Care Department, Fribourg Hospital, Avenue Jean-Paul II 12, 1752, Villars-sur-Glâne, Switzerland
| | - A. Ebneter
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
| |
Collapse
|
29
|
Inhaled Tranexamic Acid As a Novel Treatment for Pulmonary Hemorrhage in Critically Ill Pediatric Patients: An Observational Study. Crit Care Explor 2020; 2:e0075. [PMID: 32166295 PMCID: PMC7063899 DOI: 10.1097/cce.0000000000000075] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objectives: To describe the use of inhaled or endotracheally instilled tranexamic acid in critically ill pediatric patients for the treatment of pulmonary hemorrhage, which can be severe, life-threatening, and include potentially high-risk management procedures. Design: Retrospective observational study from 2011-2018 with patients followed until hospital discharge. Setting: Free-standing children’s hospital with an annual ICU volume of more than 3,500 yearly admissions. Patients: Pediatric patients, ages 0 to 18 years, admitted to an ICU and who received at least one dose of inhaled or endotracheally instilled tranexamic acid were included. Interventions: Inhaled or endotracheally instilled tranexamic acid. Measurements and Main Results: This study described the efficacy and adverse effects of patients who received inhaled or endotracheally instilled tranexamic acid. A total of 19 patients met inclusion criteria; median age was 72 months (11–187 mo), most patients were female (11, 58%), and almost half our patients (8, 42%) had congenital heart disease. Nine of 19 encounters (47%) had diffuse alveolar hemorrhage, four (21%) had pulmonary hemorrhage related to major aortopulmonary collateral arteries, two (11%) had mucosal airway bleeding, two (11%) were iatrogenic, one had a pulmonary embolism, and one patient did not have their etiology of pulmonary hemorrhage determined. Cessation of pulmonary hemorrhage was achieved in 18 of 19 patients (95%) with inhaled tranexamic acid with no major adverse events recorded. Conclusions and Relevance: We demonstrate that inhaled tranexamic acid may be safely used to treat pulmonary hemorrhage from varied etiologies in critically ill pediatric patients. Prospective studies are required in this vulnerable population to determine optimal dosing and delivery strategies, as well as to define any differential effect according to etiology.
Collapse
|
30
|
Nebulized Tranexamic Acid for the Use of Epistaxis: A Case Report. J Emerg Med 2019; 58:110-112. [PMID: 31818611 DOI: 10.1016/j.jemermed.2019.10.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/14/2019] [Accepted: 10/27/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Tranexamic acid is an antifibrinolytic agent and functions as a competitive inhibitor of plasminogen activation, promoting hemostasis. Topical application of tranexamic acid for the control of epistaxis has been described in the literature, mainly through administration with gauze and packing. There is limited evidence for the use of tranexamic acid via alternative routes of administration such as nebulization. CASE REPORT We describe a patient who presented to the emergency department with epistaxis who was treated with nebulized tranexamic acid. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case provides an alternative treatment modality using nebulizing tranexamic acid to help manage epistaxis in patients that cannot be managed with topical antifibrinolytic therapy administered by other means.
Collapse
|
31
|
Simon RP, Oromendia C, Sanso LM, Ramos LG, Rajwani K. Bronchoscopic delivery of aminocaproic acid as a treatment for pulmonary bleeding: A case series. Pulm Pharmacol Ther 2019; 60:101871. [PMID: 31783097 DOI: 10.1016/j.pupt.2019.101871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/21/2019] [Accepted: 11/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Bronchoscopy is an essential therapeutic modality in the treatment of pulmonary bleeding. Although numerous endoscopic treatments exist, topical ε-aminocaproic acid has not been described in the literature. This study documents the use of this novel treatment for pulmonary bleeding and compares it to available evidence for tranexamic acid, a similar anti-fibrinolytic agent. DESIGN Case-series study. SETTING ICU and general inpatient floors of a tertiary medical center. PATIENTS Forty-six patients receiving endobronchial ε-aminocaproic acid for the treatment or prevention of pulmonary bleeding. MEASUREMENTS AND MAIN RESULTS Of the 46 patients included in the study, 41.6% and 13% presented with non-massive and massive hemoptysis, respectively. In patients with active pulmonary bleeding, endobronchial application of ε-aminocaproic acid and accompanying therapies resulted in cessation of bleeding in 94.7% of cases. A total of six patients received ε-aminocaproic acid monotherapy; in three patients with active bleeding, 100% achieved hemostasis after treatment. Of the 36 patients successfully treated for active pulmonary bleeding, 27.8% had recurrent bleeding within 30 days. Thirty-day adverse events were as follows: death (10 patients), deep vein thrombosis (2 patients), renal failure (2 patients), and stroke (2 patients). CONCLUSIONS Endobronchial administration of ε-aminocaproic acid during bronchoscopy may be a safe and efficacious option in the treatment and prevention of pulmonary bleeding. Further studies are necessary to better define ε-aminocaproic acid's safety profile, optimal routes of administration, and comparative effectiveness to tranexamic acid.
Collapse
Affiliation(s)
- Russell P Simon
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA.
| | - Clara Oromendia
- Division of Biostatistics and Epidemiology, Weill Cornell Medicine, New York, NY, USA
| | - Lourdes M Sanso
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Liz G Ramos
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Kapil Rajwani
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
32
|
Dhanani JA, Roberts J, Reade MC. Nebulized Tranexamic Acid Therapy for Hemoptysis Associated with Submassive Pulmonary Embolism. J Aerosol Med Pulm Drug Deliv 2019; 33:12-14. [PMID: 31161941 DOI: 10.1089/jamp.2019.1534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hemoptysis and pulmonary embolism (PE) are life-threatening pulmonary emergencies that, when present together, create a therapeutic conundrum. We present an illustrative case of a 65-year-old man with unprovoked submassive PE and moderate hemoptysis due to pulmonary infarction. Hemoptysis precluded systemic anticoagulation. Failing a conservative management strategy, we administered nebulized tranexamic acid. After four doses of nebulized tranexamic acid 500 mg, 6 hours apart, hemoptysis had ceased. Systemic anticoagulation with intravenous heparin was then successfully commenced 12 hours after the last episode of hemoptysis. The patient was weaned off high-flow nasal oxygen therapy over the course of the next 5 days with no hemoptysis recurrence. Noting the absence of trial evidence, but good pharmacological rationale and our positive experience, we suggest tranexamic acid is a useful noninvasive treatment option for the management of such conditions. Consent for this publication was obtained from the patient.
Collapse
Affiliation(s)
- Jayesh A Dhanani
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia
| | - Jason Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Centre for Translational Anti-Infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Michael C Reade
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia.,Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Australia.,Joint Health Command, Australian Defence Force, Canberra, Australia
| |
Collapse
|
33
|
Spiliopoulos S, Festas G, Theodosis A, Palialexis K, Reppas L, Konstantos C, Brountzos E. Incidence and endovascular treatment of severe spontaneous non-cerebral bleeding: a single-institution experience. Eur Radiol 2019; 29:3296-3307. [PMID: 30519935 DOI: 10.1007/s00330-018-5869-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/16/2018] [Accepted: 10/29/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the incidence and endovascular treatment of severe spontaneous non-cerebral hemorrhage (SSNCH) in a high-volume, tertiary university hospital. METHODS All patients diagnosed with SSNCH between January 2016 and June 2017 were retrospectively analyzed. Endovascular treatment (group EVT) was offered only in patients demonstrating active bleeding at CT angiography (CTA). In cases without active bleeding at CTA, conservative management was decided (group CM). Outcome measures included the incidence of SSNCH, 6-month rebleeding, and survival rates in the two groups as well as EVT technical success and related complications. RESULTS Within the 18-month period, 44 SSNCH cases were identified, resulting in an annual incidence of 29.3 cases. In 37/44 cases (84.1%), bleeding was attributed to the antithrombotic therapy. In total, 19/44 patients underwent EVT (43.2%), and 25/44 patients (56.8%) were managed conservatively. Two patients who were initially treated conservatively finally underwent EVT due to rebleeding (7.4%). The technical success of EVT was 100%, while rebleeding occurred in 1 case (5.2%) following lumbar artery embolization and was successfully re-embolized. According to the Kaplan-Meier analysis, the 1-, 3-, and 6-month survival rates were 68.4%, 63.2%, and 42.1% for group EVT and 87.5%, 75.0%, and 58.3% for group CM, respectively. There were no EVT-related complications. CONCLUSIONS The annual incidence of SSNCH in our institution is substantial. EVT resulted in uncomplicated, high bleeding control rates. The mortality rate was similarly high following either EVT or conservative treatment and was mainly attributed to severe comorbidities. KEY POINTS • This study demonstrates that the incidence of severe spontaneous non-cerebral hemorrhage (SSNCH) in our institution is substantial. • Endovascular treatment was offered only in patients with clinical signs of ongoing hemorrhage and active bleeding at CT angiography and resulted in effective and uncomplicated, minimal invasive hemostasis, in a population with severe comorbidities. • This is the first study to evaluate the outcomes of both endovascular hemostasis and conservative management. Rebleeding following either conservative or endovascular treatment was minimal.
Collapse
Affiliation(s)
- Stavros Spiliopoulos
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Georgios Festas
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonios Theodosis
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Palialexis
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Lazaros Reppas
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Chysostomos Konstantos
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Elias Brountzos
- 2nd Department of Radiology, Division of Interventional Radiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
34
|
Response. Chest 2019; 155:876-877. [DOI: 10.1016/j.chest.2019.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022] Open
|
35
|
Kalchiem-Dekel O, Iacono A, Pickering EM, Sachdeva A, Shah NG, Sperry M, Tran BC, Reed RM. Prophylactic epinephrine for the prevention of transbronchial lung biopsy-related bleeding in lung transplant recipients (PROPHET) study: a protocol for a multicentre randomised, double-blind, placebo-controlled trial. BMJ Open 2019; 9:e024521. [PMID: 30904852 PMCID: PMC6475255 DOI: 10.1136/bmjopen-2018-024521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Transbronchial lung biopsy (TBLB) is frequently performed in single-lung and double-lung transplant recipients for evaluation of clinical and radiological findings as well as routine surveillance for acute cellular rejection. While rates of clinically significant TBLB-related haemorrhage are <1% for all comers, the incidence in lung transplant recipients is reported to be higher, presumably due to persistent allograft inflammation and alterations in allograft blood flow. While routinely performed by some bronchoscopists, the efficacy and safety profile of prophylactic administration of topical intrabronchial diluted epinephrine for the prevention of TBLB-related haemorrhage has not been explored in a prospective manner. METHODS AND ANALYSIS In this randomised, double-blind, placebo-controlled multicentre trial (PROPHET Study), single-lung and double-lung transplant adult recipients from participating institutions who are scheduled for bronchoscopy with TBLB for clinical indications will be identified. Potential participants who meet inclusion and exclusion criteria and sign an informed consent will be randomised to receive either diluted epinephrine or placebo prior to performance of TBLB. The degree of TBLB-related haemorrhage will be graded by the performing bronchoscopist as well as independent observers. The primary analysis will compare the rates of severe and very severe bleeding in participants treated with epinephrine or placebo. The study will also evaluate the safety profile of prophylactic topical epinephrine including the occurrence of serious cardiovascular and haemodynamic adverse events. Additional secondary outcomes to be explored include rates of non-severe TBLB-related haemorrhage, overall yield of the bronchoscopic procedure and non-serious cardiovascular and haemodynamic adverse effects. ETHICS AND DISSEMINATION The study procedures were reviewed and approved by institutional review boards in participating institutions. This study is being externally monitored, and a data and safety monitoring committee has been assembled to monitor patient safety and to evaluate the efficacy of the intervention. The results of this study will be published in peer-reviewed scientific journals and presented at relevant academic conferences. TRIAL REGISTRATION NUMBER NCT03126968; Pre-results.
Collapse
Affiliation(s)
- Or Kalchiem-Dekel
- Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Aldo Iacono
- Departments of Medicine and Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Edward M Pickering
- Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ashutosh Sachdeva
- Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nirav G Shah
- Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mark Sperry
- Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bich-Chieu Tran
- Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Robert M Reed
- Department of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
36
|
Hensch LA, Hui SKR, Teruya J. Coagulation and Bleeding Management in Pediatric Extracorporeal Membrane Oxygenation: Clinical Scenarios and Review. Front Med (Lausanne) 2019; 5:361. [PMID: 30693282 PMCID: PMC6340094 DOI: 10.3389/fmed.2018.00361] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/17/2018] [Indexed: 12/23/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving procedure that requires careful coagulation management. Indications for ECMO continue to expand, leading to more complicated patients treated by ECMO teams. At our pediatric institution, we utilize a Coagulation Team to guide anticoagulation, transfusion and hemostasis management in an effort to avoid the all-to-common complications of bleeding and thrombosis. This team formulates a coagulation plan in conjunction with a multidisciplinary ECMO team after careful review of all available laboratory data as well as the patient's clinical status. Here, we present our general strategies for ECMO management in various clinical scenarios and a review of the literature pertaining to coagulation management in the pediatric ECMO setting.
Collapse
Affiliation(s)
- Lisa A Hensch
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Houston, TX, United States.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Shiu-Ki Rocky Hui
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Houston, TX, United States.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| | - Jun Teruya
- Division of Transfusion Medicine & Coagulation, Texas Children's Hospital, Houston, TX, United States.,Department of Pathology & Immunology, Baylor College of Medicine, Houston, TX, United States
| |
Collapse
|
37
|
Wand O, Guber E, Guber A, Epstein Shochet G, Israeli-Shani L, Shitrit D. Inhaled Tranexamic Acid for Hemoptysis Treatment. Chest 2018; 154:1379-1384. [DOI: 10.1016/j.chest.2018.09.026] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/29/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022] Open
|
38
|
Ittrich H, Bockhorn M, Klose H, Simon M. The Diagnosis and Treatment of Hemoptysis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018. [PMID: 28625277 DOI: 10.3238/arztebl.2017.0371] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Harald Ittrich
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, Center for Radiology and Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg; Department of General, Visceral and Thoracic Surgery, Center for Surgical Sciences, University Medical Center Hamburg-Eppendorf, Hamburg; Department of Pulmonology, II. Medical Clinic, University Medical Center Hamburg-Eppendorf, Hamburg
| | | | | | | |
Collapse
|
39
|
Novel Bronchoscopic Management of Airway Bleeding With Absorbable Gelatin and Thrombin Slurry. J Bronchology Interv Pulmonol 2018; 25:204-211. [PMID: 29351111 DOI: 10.1097/lbr.0000000000000470] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Airway bleeding, either spontaneous or as a result of bronchoscopy, is associated with significant morbidity and mortality. Multiple bronchoscopic techniques are available to achieve complete hemostasis or as a bridge to definitive therapies. METHODS We report our experience on the feasibility of endobronchial instillation of an absorbable gelatin and thrombin slurry (GTS) for the treatment of spontaneous hemoptysis and procedure-related bleeding. RESULTS We identified 13 cases in which GTS was used for endobronchial hemostasis when standard bronchoscopic measures like cold saline, epinephrine, and in some cases balloon occlusion were not successful. GTS was delivered through the working channel of the bronchoscope in 10 cases and through the distal port of a bronchial blocker in the remaining 3 cases. Median age was 69 years (range, 52 to 79 y). Eight cases corresponded to spontaneous hemoptysis and 5 cases to diagnostic or therapeutic procedures. Bleeding was considered severe in 9 (70%) cases. All but 1 case were associated with malignancy. Hemostasis was achieved in 10 (77%) cases by using standard measures in addition to GTS. No patient adverse events at 30 days or damage to the equipment were identified. CONCLUSIONS Bronchoscopic instillation of an absorbable GTS is feasible and may be used in cases of spontaneous or procedure-related bleeding in addition to conventional measures. It can be delivered through the working channel of the bronchoscope or through the distal port available in some bronchial blockers. Controlled studies are necessary to determine the safety and efficacy of this novel technique.
Collapse
|
40
|
Abstract
Cancer continues to be a leading cause of death despite a broader understanding of its biology and the development of novel therapies. Nonetheless, with an increasing survival of this population, intensivists must be aware of the associated emergencies, both old and new. Oncologic emergencies can be seen as an initial presentation of the disease or precipitated by its treatment. In this review, we present key oncologic emergencies that may be encountered in daily practice, complications associated with innovative therapies, and treatment-related adverse events.
Collapse
Affiliation(s)
- Krishna Thandra
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zuhair Salah
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sanjay Chawla
- Critical Care Medicine Service, Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| |
Collapse
|
41
|
Berman S, Bucher J, Koyfman A, Long BJ. Emergent Complications of Rheumatoid Arthritis. J Emerg Med 2018; 55:647-658. [DOI: 10.1016/j.jemermed.2018.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/03/2018] [Accepted: 07/22/2018] [Indexed: 12/20/2022]
|
42
|
Abstract
INTRODUCTION Rigid bronchoscopy is an invaluable tool for the management of airway disorders and an essential skill for an interventional pulmonologist. Since its introduction in the late 19th century, it has remained an important technique for the management of central airway obstruction, foreign body aspiration and massive hemoptysis. Areas covered: This article will review the history, indications, contraindication, technique and complications of rigid bronchoscopy. We will also briefly discuss the methods of anesthesia and ventilation and finally our perspective on the future of rigid bronchoscopy. Expert commentary: Although the rise of flexible bronchoscopy in the 1960s led to a decline in the use of rigid bronchoscopy, the last two decades have witnessed resurgence in its popularity. We anticipate that it will remain an important tool used by interventional pulmonologists for decades to come. We suggest that interventional pulmonologists must have training and develop expertise in this technique.
Collapse
Affiliation(s)
- Hitesh Batra
- a Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine , Johns Hopkins Hospital , Baltimore , MD , USA
| | - Lonny Yarmus
- a Interventional Pulmonology, Division of Pulmonary and Critical Care Medicine , Johns Hopkins Hospital , Baltimore , MD , USA
| |
Collapse
|
43
|
Komura S, Rodriguez RM, Peabody CR. Hemoptysis? Try Inhaled Tranexamic Acid. J Emerg Med 2018; 54:e97-e99. [PMID: 29502864 DOI: 10.1016/j.jemermed.2018.01.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/03/2018] [Accepted: 01/19/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Tranexamic acid (TXA) is a synthetic anti-fibrinolytic agent used to prevent and treat various bleeding complications. In many studies, investigators have evaluated its utility and safety orally, intravenously, and topically, but few studies have described the potential benefits of nebulized TXA. CASE REPORT We present a case of massive hemoptysis treated with nebulized TXA in the emergency department (ED) that led to the cessation of bleeding and avoidance of endotracheal intubation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In massive hemoptysis, rapidly available nebulized TXA may be considered a therapeutic option, serving either as primary therapy or as a bridge until other definitive therapies can be arranged.
Collapse
Affiliation(s)
- Stephanie Komura
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Robert M Rodriguez
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California; Department of Emergency Medicine, University of California, San Francisco, California
| | - Christopher R Peabody
- Department of Emergency Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California; Department of Emergency Medicine, University of California, San Francisco, California
| |
Collapse
|
44
|
Zahed R, Mousavi Jazayeri MH, Naderi A, Naderpour Z, Saeedi M. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Acad Emerg Med 2018; 25:261-266. [PMID: 29125679 DOI: 10.1111/acem.13345] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 11/02/2017] [Accepted: 11/05/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We evaluated the efficacy of topical application of the injectable form of tranexamic acid (TXA) compared with anterior nasal packing (ANP) for the treatment of epistaxis in patients taking antiplatelet drugs (aspirin, clopidogrel, or both) who presented to the emergency department (ED). METHODS A randomized, parallel-group clinical trial was conducted at two EDs. A total of 124 participants were randomized to receive topical TXA (500 mg in 5 mL) or ANP, 62 patients per group. The primary outcome was the proportion of patients in each group whose bleeding had stopped at 10 minutes. Secondary outcomes were the rebleeding rate at 24 hours and 1 week, ED length of stay (LOS), and patient satisfaction. RESULTS Within 10 minutes of treatment, bleeding was stopped in 73% of the patients in the TXA group, compared with 29% in the ANP group (difference = 44%, 95% confidence interval, 26% to 57%; p < 0.001). Additionally, rebleeding was reported in 5 and 10% of patients during the first 24 hours in the TXA and the ANP groups, respectively. At 1 week, 5% of patients in the TXA group and 21% of patients in the ANP group had experienced recurrent bleeding (p = 0.007). Patients in the TXA group reported higher satisfaction scores (median [interquartile range {IQR}], 9 [8-9.25]) compared with the ANP group (median [IQR] = 4 [3-5]; p < 0.001). Discharge from the ED in <2 hours was achieved in 97% of patients in the TXA group versus 13% in the ANP group (p < 0.001). There were no adverse events reported in either group. CONCLUSIONS In our study population, epistaxis treatment with topical application of TXA resulted in faster bleeding cessation, less rebleeding at 1 week, shorter ED LOS, and higher patient satisfaction compared with ANP.
Collapse
Affiliation(s)
- Reza Zahed
- Department of Emergency Medicine Imam Khomeini Hospital Complex Faculty of Medicine Tehran University of Medical Sciences TehranIran
| | | | - Asieh Naderi
- Eye Research Center Farabi Eye Hospital Tehran University of Medical Sciences Tehran Iran
| | - Zeinab Naderpour
- Department of Internal Medicine Tehran University of Medical Sciences TehranIran
| | - Morteza Saeedi
- Emergency Medicine Research Center Department of Emergency Medicine Shariati Hospital Faculty of Medicine Tehran University of Medical Sciences TehranIran
| |
Collapse
|
45
|
Gagnon S, Quigley N, Dutau H, Delage A, Fortin M. Approach to Hemoptysis in the Modern Era. Can Respir J 2017; 2017:1565030. [PMID: 29430203 PMCID: PMC5752991 DOI: 10.1155/2017/1565030] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 11/14/2017] [Indexed: 11/26/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Sébastien Gagnon
- Institut Universitaire de Pneumologie et de Cardiologie de Québec, 2725 Ch Ste-Foy, Quebec City, QC, Canada G1V 4G5
| | - Nicholas Quigley
- Institut Universitaire de Pneumologie et de Cardiologie de Québec, 2725 Ch Ste-Foy, Quebec City, QC, Canada G1V 4G5
| | - Hervé Dutau
- Hôpital Nord Marseille, Assistance Publique des Hôpitaux de Marseille, 13915 Chemin des Bourrely, Marseille, France
| | - Antoine Delage
- Institut Universitaire de Pneumologie et de Cardiologie de Québec, 2725 Ch Ste-Foy, Quebec City, QC, Canada G1V 4G5
| | - Marc Fortin
- Institut Universitaire de Pneumologie et de Cardiologie de Québec, 2725 Ch Ste-Foy, Quebec City, QC, Canada G1V 4G5
| |
Collapse
|
46
|
Korraa EEDA, Madkour AM, Galal IH, Ibrahim El-Saidy IM. Bronchoscopic instillation of tranexamic acid to control bronchopulmonary bleeding. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2017. [DOI: 10.4103/ejb.ejb_27_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
47
|
Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. J Thorac Dis 2017; 9:S1069-S1086. [PMID: 29214066 DOI: 10.21037/jtd.2017.06.41] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
Collapse
Affiliation(s)
- Christopher Radchenko
- Department of Pulmonary and Critical Care Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Samira Shojaee
- Departments of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| |
Collapse
|
48
|
Bernasconi M, Koegelenberg CF, Koutsokera A, Ogna A, Casutt A, Nicod L, Lovis A. Iatrogenic bleeding during flexible bronchoscopy: risk factors, prophylactic measures and management. ERJ Open Res 2017; 3:00084-2016. [PMID: 28656131 PMCID: PMC5478796 DOI: 10.1183/23120541.00084-2016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 03/18/2017] [Indexed: 12/19/2022] Open
Abstract
Significant iatrogenic bleeding during flexible bronchoscopy is fortunately rare and usually self-limiting. Life-threatening bleeding, however, can occur, especially after conventional or cryoprobe-assisted transbronchial biopsy. The aim of this review is to provide the practising pulmonologist with a concise overview of the incidence, severity and risk factors for bleeding, to provide sensible advice on prophylactic measures and to suggest a plan of action in the case of significant bleeding. Bronchoscopy units should have a standardised approach and plan of action in the case of life-threatening haemorrhage. Wedging the bronchoscope in the bleeding segment, turning the patient in an anti-Trendelenburg position and onto the side in order for the bleeding lung to be in the dependent position, installing vasoconstrictors and using a tamponade balloon early are the recommended first-line strategies. Involving a resuscitation team should be considered early in the case of massive bleeding, desaturation and haemodynamic instability.
Collapse
Affiliation(s)
- Maurizio Bernasconi
- Division of Pulmonology, Dept of Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Coenraad F.N. Koegelenberg
- Division of Pulmonology, Dept of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Angela Koutsokera
- Division of Pulmonology, Dept of Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Adam Ogna
- Division of Pulmonology, Dept of Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Alessio Casutt
- Division of Pulmonology, Dept of Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Laurent Nicod
- Division of Pulmonology, Dept of Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Alban Lovis
- Division of Pulmonology, Dept of Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| |
Collapse
|
49
|
|
50
|
Giudice E, Crinò C, Lanzafame P, Viganò F, Macrì F, Di Pietro S. Acute Hypoxemic Respiratory Failure With Hemoptysis in a Dog Exposed to Copper Sulfate Powder. Top Companion Anim Med 2017; 32:36-40. [DOI: 10.1053/j.tcam.2017.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/10/2017] [Indexed: 11/11/2022]
|