The Diagnosis and Treatment of Hemoptysis

Pediatric hemoptysis: diagnostic and interventional challenges

Hemoptysis in the pediatric population, while infrequent, poses significant challenges for both the family and healthcare practitioners. The severity of hemoptysis dictates management decisions. Most cases being mild and self-limiting are treated conservatively. However, "life-threatening hemoptysis" may occur, and is defined as any degree of blood loss that endangers the airway and is arbitrarily considered to be > 8 ml/kg in 24 h in children. It requires prompt airway management and resuscitation followed by a tailored approach consisting of bronchoscopy, computed tomography (CT), interventional radiology, and/or surgery depending on the patient 's clinical status and cardiopulmonary comorbidities. Bronchial arteries are hypertrophied in myriad conditions and account for 90-95% cases of hemoptysis due to their systemic pressure levels; the rest being contributed by pulmonary artery pathologies. Despite similar pathogenic mechanisms, the etiologies of pediatric hemoptysis differ from those in adults, with acute lower respiratory tract infections being the predominant cause. Imaging plays a crucial role in identifying the source and cause of hemorrhage. Multidetector computed tomography (MDCT) has emerged as a prime modality in the diagnostic evaluation of hemoptysis and provides a roadmap for potential interventional procedures. This article discusses the etiopathogenesis of hemoptysis along with a brief mention of the diagnostic modalities. It provides a structured reporting format and uses it to illustrate the imaging features in hemoptysis, with emphasis on CT angiography. The key findings in the lung parenchyma, airways, bronchial and non-bronchial systemic collaterals, and pulmonary arteries are elaborated upon. It further addresses the nuances of interventional management, particularly emphasizing the applications of bronchial artery embolization and pulmonary artery embolization in the pediatric population. The article also underscores the potential complications and factors influencing recurrence rates.

Bronchial artery embolization versus conservative treatment for hemoptysis: a systematic review and meta-analysis

BACKGROUND

Bronchial artery embolization (BAE) is currently an important treatment for hemoptysis. However, there is no consensus in the efficacy and safety of BAE compared to conservative treatment for hemoptysis, which limits the widespread use of BAE in hemoptysis. The objective was to assess the clinical benefit of BAE versus conservative treatment in patients with hemoptysis.

METHODS

A systematic search was conducted on the PubMed, Embase, ScienceDirect, CochraneLibrary, and ClinicalTrials up to March 2023. Both randomized controlled trials (RCTs) and cohort studies reporting rates of recurrent hemoptysis, clinical success, mortality, and complication by BAE and conservative treatment alone for hemoptysis were included. Data were pooled and compared by the use of odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Twelve studies (three RCTs, nine cohorts) involving 1231 patients met the eligibility criteria. Patients treated with BAE had lower recurrence rates of hemoptysis (26.5% vs. 34.6%; OR 0.37, 95% CI 0.14-0.98), higher clinical success rates (92.2% vs. 80.9%; OR 2.77, 95% CI 1.66-4.61), and lower hemoptysis-related mortality (0.8% vs. 3.2%; OR 0.20, 95% CI 0.05-0.84) compared with conservative treatment alone. There was no significant difference in all-cause mortality between the two groups. In terms of security, the incidence of major complications and minor complications in patients undergoing BAE treatment was 0.2% (1/422) and 15.6%, respectively.

CONCLUSIONS

BAE was more effective than conservative treatment alone in controlling hemoptysis, reducing recurrence, and decreasing hemoptysis-related mortality, with an almost negligible risk of major complications.

Analysis of angiographic findings and short-term recurrence factors in patients presenting with hemoptysis

OBJECTIVES

The abnormal anatomical alterations of blood vessels during DSA angiography in patients with hematological disorders were retrospectively examined, and the influencing factors of short-term (≤ 6 months) recurrent hemoptysis were statistically analyzed, and the consistency between admission diagnosis and intraoperative diagnosis was evaluated.

METHODS

The intraoperative angiography data of patients who underwent selective bronchial artery embolization for hemoptysis in our hospital from January 2022 to December 2022 were reviewed. They were divided into the observation group and the control group based on whether there was recurrent hemoptysis. The Logistic regression model and forest map were employed to analyze the factors influencing the recurrence rate.

RESULTS

A total of 104 patients were encompassed in this study (12 cases of tuberculosis, 35 cases of infection, 4 cases of lung cancer, 8 cases of bronchiectasis, 22 cases of arteriovenous fistula, 16 cases of aneurysm, and 7 cases of pulmonary hypertension). The coincidence rate of preoperative and intraoperative diagnoses was 73.1%. Pulmonary arteriovenous fistula and aneurysm were the predominant types of diseases that were misdiagnosed. The short-term recurrence rate was 16.3%, mainly attributed to the reopening of responsible vessels related to embolization, angiography leakage, and leaky embolization of specific types of vessels. The recurrence rate of only patients with arteriovenous fistula and aneurysm accounted for 47% of the total recurrence rate. The right bronchial artery, right internal thoracic artery, right thyroid neck trunk, and age were the independent factors influencing the recurrence of hemoptysis (p < 0.05).

CONCLUSIONS

The main reason for angiographic leakage and embolization leakage in cases of hemoptysis is the lack of understanding of the anatomic variations of the vessels responsible. Careful examination of the specific types and locations of the vessels is the principal approach to reducing secondary operations.

Bronchial artery embolization using small particles is safe and effective: a single center 12-year experience

BACKGROUND

Bronchial artery embolization (BAE) using particles is an established treatment for hemoptysis. The use of polyvinyl alcohol (PVA) with a particle size of 300 µm or larger is thought to reduce the risk of non-target embolization but may result in more proximal vessel occlusion than is ideal, resulting in a high rate of early recurrent hemorrhage.

OBJECTIVE

This study evaluates the safety and efficacy of BAE using PVA particles with a size of less than 300 µm.

METHODS

All patients who underwent BAE between 2010 and 2022 at a tertiary center were included. Demographic data, etiology and volume of hemoptysis, technical and clinical success, procedure-related complications, and follow-up information were collected from patients' electronic records. 150-250 µm PVA particles were used to commence embolization in all patients with the subsequent use of larger-sized particles in some individuals. The Kaplan-Meier method was used to estimate recurrence and survival rates.

RESULTS

One hundred forty-four patients underwent 189 embolization procedures between 2010 and 2022 and were followed up for a median of 35 months [IQR 19-89]. 150 µm to 250 µm PVA particles were used as the sole embolic agent in 137 cases. Hemoptysis recurred within 30 days in 7%. The median time to repeat intervention was 144 days [IQR 42-441]. Seventeen out of 144 patients had a pulmonary artery branch pseudoaneurysm. The rate of major complications was 1% with no instances of stroke or spinal artery ischemia. Thirty-day mortality was 2% (4/189).

CONCLUSION

BAE using 150-250 µm PVA particles is safe and effective with few complications and low rates of early hemoptysis recurrence.

CLINICAL RELEVANCE STATEMENT

BAE using small particles is likely to improve outcomes, particularly the rate of early recurrence, in patients with hemoptysis, without an increase in procedural complications.

KEY POINTS

BAE is a safe and effective treatment for patients with hemoptysis. Using small PVA particles in BAE has few complications and low rates of early recurrence. Pulmonary artery pseudoaneurysms should be actively sought in those with hemoptysis undergoing BAE.

Foreign Body in the Tracheobronchial Tree as a Cause of Hemoptysis in an Adult Without Risk Factors for Aspiration: A Case Report

Although aspiration of a foreign body into the trachea and bronchi can occur in all age groups, it is more common in infants and young children. Foreign bodies in the tracheobronchial tree are uncommon in adults and mainly present in patients with dysphagia and an altered level of consciousness. The identification of foreign bodies in the tracheobronchial tree is frequently overlooked or delayed, leading patients to present later with chronic symptoms and potential complications. These complications may include persistent coughing, wheezing, obstructive pneumonitis, bronchiectasis, and abscess formation secondary to recurrent pulmonary infections. This article aims to present the case of a 27-year-old patient without risk factors for aspiration who has experienced recurrent self-limiting hemoptysis episodes for five years. Bronchoscopy revealed a foreign body at the entrance to the middle lobe bronchus. The presence of a foreign body in the tracheobronchial tree should be considered in any patient with recurrent hemoptysis. Bronchoscopy leads to accurate diagnosis, treatment, and prevention of complications.

Pulmonary apoplexy following severe mitral valve stenosis: A case report

Hemoptysis is a common clinical symptom in emergency patients. It is characterized by the discharge of bloody sputum, which originates from the lower respiratory tract. In the majority of cases, this event is self-limiting, and only in less than 5% of cases, it is massive. Mitral valve stenosis is an uncommon cause of hemoptysis, with a prevalence of 4.2%. In rare cases of this condition, massive and sudden hemoptysis occurs, which is called pulmonary apoplexy. Here, a 35-year-old woman with a history of mitral valve stenosis is introduced who was referred to the hospital with a complaint of massive hemoptysis and sudden shortness of breath. According to the history of mitral valve stenosis, the patient was diagnosed with pulmonary apoplexy. After treatment, both the imaging findings and the patient's symptoms resolved within a short period of time. Even though pulmonary apoplexy is often severe, it can still respond well to conservative treatments and may indicate a need for immediate attention to the stenosis of the mitral valve.

Successful Endovascular Management of Recurrent Hemoptysis due to Multiple Rasmussen Aneurysms in a Case of Pulmonary Tuberculosis: A Rare Case Scenario

Background

Hemoptysis is defined as coughing out of blood. Pulmonary tuberculosis is the most common cause of hemoptysis in tuberculosis-endemic countries like India. Rasmussen aneurysm is a pseudoaneurysm arising from the pulmonary artery adjacent to or within a tuberculous cavity. Chest radiographs, chest computed tomography angiography (CTA), and digital subtraction angiography (DSA) are the imaging tools for evaluating a case of hemoptysis.

Case

A 32-year-old man with a history of pulmonary tuberculosis presented with complaints of recurrent hemoptysis. On imaging evaluation, multiple pulmonary artery pseudoaneurysms were seen in the left lung. The patient was shifted to the DSA lab and the pseudoaneurysms were subsequently treated by endovascular coil embolization. Hemoptysis resolved following the procedure and the patient was again started on anti-tubercular therapy.

Conclusion

Endovascular coiling is minimally invasive, safe, and effective management of multiple Rasmussen aneurysms for preventing possible torrential blood loss and unfortunate death.

Massive hemoptysis in pregnancy treated by ECMO combined with electronic bronchoscopy: A case report

Background

Massive hemoptysis during pregnancy is very rare. Dieulafoy's disease is one of the causes of massive hemoptysis. There are few reports of ECMO use to treat massive hemoptysis during pregnancy.

Findings

We report for the first time a patient with Dieulafoy's disease diagnosed at 29 weeks of pregnancy. The patient's hemoptysis occurred rapidly with large volumes. The bleeding amount reached 500 ml within half an hour, with the development of asphyxia and respiratory and cardiac arrest due to a blood clot blocking the airway. After successful cardiopulmonary resuscitation, the ventilator could not maintain effective ventilation. Emergency establishment of VV-ECMO was performed to maintain oxygen, and hemostasis was successfully achieved by performing bronchial artery embolization twice. We successfully cleaned blood clots in the airway four times by freezing and using a foreign body retrieval basket with an electronic bronchoscope. At the same time, small and smooth nodular lesions were found under bronchoscopy, and blood vessels with a diameter of 1.5 mm were found under Doppler mode with an ultrasonic bronchoscope, which was consistent with a diagnosis of Dieulafoy's disease. VV-ECMO was successfully stopped on the 3rd day of the disease course, tracheal intubation was successfully removed on the 5th day of the disease course, and the patient was discharged with no complications on the 16th day of the disease course.

Long term management of people with post-tuberculosis lung disease

Post-tuberculosis lung disease (PTLD) is emerging as a significant area of global interest. As the number of patients surviving tuberculosis (TB) increases, the subsequent long-term repercussions have drawn increased attention due to their profound clinical and socioeconomic impacts. A primary obstacle to its comprehensive study has been its marked heterogeneity. The disease presents a spectrum of clinical manifestations which encompass tracheobronchial stenosis, bronchiectasis, granulomas with fibrosis, cavitation with associated aspergillosis, chronic pleural diseases, and small airway diseases-all persistent consequences of PTLD. The spectrum of symptoms a patient may experience varies based on the severity of the initial infection and the efficacy of the treatment received. As a result, the long-term management of PTLD necessitates a detailed and specific approach, addressing each manifestation individually-a tailored strategy. In the immediate aftermath (0-12 months after anti-TB chemotherapy), there should be an emphasis on monitoring for relapse, tracheobronchial stenosis, and smoking cessation. Subsequent management should focus on addressing hemoptysis, managing infection including aspergillosis, and TB-associated chronic obstructive pulmonary disease or restrictive lung function. There remains a vast expanse of knowledge to be discovered in PTLD. This review emphasizes the pressing need for comprehensive, consolidated guidelines for management of patients with PTLD.

Papillary Thyroid Carcinoma Presenting with Chronic Cough and Hemoptysis in Primary Care: A Case Report

BACKGROUND The article discusses an unusual case of papillary thyroid carcinoma in which chronic cough and hemoptysis were the predominant symptoms. While the more common causes of hemoptysis are pulmonary in origin, extrapulmonary etiologies have been reported, including thyroid carcinoma. The clinical presentation of thyroid malignancy in this case mimics many other common disorders, such as pulmonary tuberculosis, bronchogenic carcinoma, bronchiectasis, and chronic obstructive pulmonary disease. Hence, making it challenging to suspect early when patients present to primary care. CASE REPORT A 54-year-old woman presented with a chronic cough and hemoptysis in our Primary Care Medicine Clinic. While initial assessments in the primary care medicine clinic yielded no remarkable findings, a subsequent high-resolution computed tomography scan of the thorax uncovered a thyroid lesion. Subsequent evaluation in the hospital setting included an ultrasound examination, revealing multiple thyroid nodules, and fine needle aspiration that confirmed papillary thyroid carcinoma. She underwent total thyroidectomy with central and left lateral neck dissection, complicated by left vocal cord palsy. She received 2 cycles of periodic radioactive iodine therapy and injection laryngoplasty postoperatively. There was no evidence of iodin avid disease and recurrence of hemoptysis after surgery. CONCLUSIONS This case report emphasizes the significance of considering papillary thyroid carcinoma when assessing hemoptysis in the primary care setting, as early detection and treatment of it would result in a better outcome.

An Infrequently Encountered Cause of Hemoptysis

Mitral stenosis (MS) is not a common entity in modern-day medicine, especially in developed countries, as the most common etiology is still rheumatic fever. MS can present mainly with a wide range of cardiac symptoms. However, infrequently, MS can cause extra-cardiac symptoms as well. We present a case report of a patient with severe bioprosthetic mitral valve stenosis with intermittent hemoptysis and cardiogenic shock. We aim to report this case to remind clinicians about this uncommon but significant cause of hemoptysis. This case report also emphasizes the importance of utilizing a team approach while treating patients with severe MS, especially if they have serious complications that could be life-threatening. We also aim to add to the current literature by reporting this case.

An overview on the principles of management of haemoptysis

Haemoptysis is a frequently encountered presentation in thoracic surgery practice. Most of the patients present with chronic haemoptysis while 5% of them will present with life-threatening acute haemoptysis. Emergency surgery used to be the first-line management in acute life-threatening haemoptysis which resulted in significant morbidity and mortality. With advancements in interventional procedures, most of these acute presentations are now being managed conservatively by interventionists. In a country like India with a high incidence of tuberculosis and other infectious diseases of the lungs, haemoptysis is even more common. While interventional procedures help to tide over the crisis and earn valuable time to stabilise a haemorrhaging patient, surgical resection is the definitive management most of the time. This review will endeavour to establish the definition, aetiology, emergency, and definitive management of a patient who presents with haemoptysis.

[An outline of pulmonary hemorrhage - A pulmonologists perspective]

Hemoptysis resembles a clinical emergency and necessitates a fast and well-coordinated diagnostic and therapeutic approach. While up to 50% of the underlying causes remain unidentified, the majority of cases in the western world can be attributed to respiratory infections and pulmonary neoplasm. While 10% of the patients present with massive, life-threatening hemoptysis, which require a timely airway protection in order to secure a sustained pulmonary gas-exchange, the vast majority presents with non-critical pulmonary bleeding events. Most critical pulmonary bleeding events arise from the bronchial circulation. An early chest imaging is key for identifying the bleeding cause and localization. While chest x-rays are widely implemented in the clinical work-flow and rapidly applicable, computed tomography and computed tomography angiography exhibit the highest diagnostic yield. Bronchoscopy can add diagnostic information especially in pathologies of the central airways, while offering multiple therapeutic options to maintain pulmonary gas exchange. The initial therapeutic regimen comprises early supportive care, but treatment of the underlying etiology is of prognostic relevance and avoids recurrent bleeding events. Bronchial arterial embolization usually is the therapy of choice in patients with massive hemoptysis, while definitive surgery is reserved for patients with refractory bleeding and complex pathologies.

Pseudomonas aeruginosa isolation is an important predictor for recurrent hemoptysis after bronchial artery embolization in patients with idiopathic bronchiectasis: a multicenter cohort study

BACKGROUND

Nearly half of bronchiectasis patients receiving bronchial artery embolization (BAE) still have recurrent hemoptysis, which may be life-threatening. Worse still, the underlying risk factors of recurrence remain unknown.

METHODS

A retrospective cohort was conducted of patients with idiopathic bronchiectasis who received BAE from 2015 to 2019 at eight centers. Patients were followed up for at least 24 months post BAE. Based on the outcomes of recurrent hemoptysis and recurrent severe hemoptysis, a Cox regression model was used to identify risk factors for recurrence.

RESULTS

A total of 588 individuals were included. The median follow-up period was 34.0 months (interquartile range: 24.3-53.3 months). The 1-month, 1-year, 2-year, and 5-year cumulative recurrent hemoptysis-free rates were 87.2%, 67.5%, 57.6%, and 49.4%, respectively. The following factors were relative to recurrent hemoptysis: 24-h sputum volume (hazard ratio [HR] = 1.99 [95% confidence interval [95% CI]: 1.25-3.15, p = 0.015]), isolation of Pseudomonas aeruginosa (HR = 1.50 [95% CI: 1.13-2.00, p = 0.003]), extensive bronchiectasis (HR = 2.00 [95% CI: 1.29-3.09, p = 0.002]), and aberrant bronchial arteries (AbBAs) (HR = 1.45 [95% CI: 1.09-1.93, p = 0.014]). The area under the receiver operating characteristic curve of the nomogram was 0.728 [95% CI: 0.688-0.769].

CONCLUSIONS

Isolation of Pseudomonas aeruginosa is an important independent predictor of recurrent hemoptysis. The clearance of Pseudomonas aeruginosa might effectively reduce the hemoptysis recurrence rate.

[Haemoptysis]

Haemoptysis describes the expectoration of blood originating from the tracheobronchial tree and lung. Its presentation varies from mild to massive haemoptysis, the latter entailing the risk of asphyxia and thus requiring rapid intervention that spans multiple specialties.

Association between High Blood Pressure in the Emergency Department and Cryptogenic Hemoptysis

Hemoptysis is a common cause of emergency department (ED) visits. There is little data about the role of systemic hypertension as a cause of hemoptysis. The aim of this study was to evaluate the association between systemic blood pressure and the unknown etiology of hemoptysis. This retrospective study included consecutive patients who visited the ED owing to hemoptysis and underwent a chest computed tomography between January 2011 and June 2021. Details of the initial blood pressure at the ED visit were compared between two groups with identified and unidentified causes of hemoptysis. In total, 1105 adult patients were included. The etiology of hemoptysis was identified in 1042 patients (94.3%) and remained unidentified in 63 patients (5.7%). The percentage of patients with severe hypertension was significantly higher in patients with unidentified causes of hemoptysis than in those with identified causes (35% vs. 11%, p < 0.001). In multivariate analysis, age, ever-smoker, and initial systolic blood pressure were significantly associated with hemoptysis of unidentified causes. Although further studies are needed, our findings suggest a possible association between high blood pressure and cryptogenic hemoptysis.

CIRSE Standards of Practice on Bronchial Artery Embolisation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing bronchial artery embolisation to effectively treat haemoptysis. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Severe Pulmonary Bleeding after Assist Device Implantation: Incidence, Risk Factors and Prognostic Impact

Background: Continuous flow left ventricular assist devices (CF-LVAD) improve survival in patients with advanced heart failure but confer risk of bleeding complications. Whereas pathophysiology and risk factors for many bleeding complications are well investigated, the literature lacks reports about pulmonary bleeding. Therefore, it was the aim of the present study to assess incidence, risk factors, and clinical relevance of pulmonary bleeding episodes after LVAD implantation. Methods: We retrospectively analyzed our institutional database of 125 consecutive patients who underwent LVAD implantation between 2008 and 2017. Demographic and clinical variables related to bleeding were collected. The primary endpoint was incidence of severe pulmonary bleeding (SPB). Results: Nine out of 125 patients suffered from SPB during the postoperative course (7.2%) 11 days after surgery in the median. None of them had a known history of lung disease or bleeding disorder. History of prior myocardial infarction (0% vWD. 42.2%, p = 0.012) and ischemic cardiomyopathy (25.0% vs. 50.0%, p = 0.046) were less frequent in the SBP group. Concomitant aortic valve replacement was more common in the group with SPB (33.3% versus 7.0%, p = 0.034). Surgical (blood loss 9950 vs. 3800 mL, p = 0.012) as well as ear-nose-throat (ENT) bleedings (33% vs. 4.6%, p = 0.015) were observed more frequently in patients with SPB. SPB was associated with a complicated postoperative course with a higher incidence of acute kidney failure (100% versus 36.7%, p = 0.001) and delirium (44.4% versus 14.8%, p = 0.045); a higher need for red blood cell (26 packs versus 7, p < 0.001), fresh frozen plasma (18 units versus 6, p = 0.002), and platelet transfusion (8 pools versus 1, p = 0.001); longer ventilation time (1206 versus 171 h, p = 0.001); longer ICU-stay (58 versus 13 days, p = 0.002); and higher hospital mortality (66.7% vs. 29%, p = 0.029). Conclusion: SPB is a rare but serious complication after LVAD implantation and is significantly associated with higher morbidity and mortality. The pathophysiology and potential risk factors are unknown but may include coagulation disorders and frequent suctioning or empiric bronchoscopy causing airway irritation.

Yunnan Baiyao Adjuvant Treatment for Patients with Hemoptysis: A Systematic Review and Meta-Analysis

Background

Yunnan Baiyao (YNBY) is a traditional Chinese medicine used to treat bleeding. We evaluated the efficacy of YNBY plus conventional pharmaceutical treatment (CPT) versus CPT alone in patients with hemoptysis.

Methods

A total of eight electronic databases were searched. The outcomes in the included studies were effective rate, hemoptysis volume, duration of hemoptysis and hospitalization, number of cases requiring endotracheal intubation, and adverse events (AEs). The studies were used to calculate risk ratios (RRs) or mean differences (MDs) with corresponding 95% confidence intervals. Risk of bias for included trials was assessed using the Cochrane risk of bias tool.

Results

Thirteen RCTs were analyzed consisting of a total of 1379 patients. Treatment with YNBY + CPT had a greater effective rate than CPT alone (RR: 1.18; 95% CI: 1.13 to 1.23; P < 0.001; I² = 0%), a lower hemoptysis volume (MD: −107.37; 95% CI: −121.69 to −93.06; P < 0.001; I² = 0%), a shorter duration of hemoptysis (MD: −2.70; 95% CI: −2.96 to 2.43; P < 0.001; I² = 0%) and hospitalization (MD: −2.38; 95% CI: −2.93 to −1.83; P < 0.001; I² = 9%), and a reduction in the incidence of AEs (RR: 0.34; 95% CI: 0.23 to 0.51; P < 0.001; I² = 0%). YNBY + CPT treatment provided no significant difference in reducing the number of cases requiring endotracheal intubation compared to CPT alone (RR: 0.49; 95% CI: 0.15 to 1.60; P=0.24; I² = 0%).

Conclusion

YNBY plus CPT showed better efficacy than CPT for patients with hemoptysis. Our study provides medical evidence for the efficacy and safety of YNBY for hemoptysis.

Haemoptysis in Pulmonary Arterial Hypertension Associated with Congenital Heart Disease: Insights on Pathophysiology, Diagnosis and Management

Haemoptysis represents one of the most severe major bleeding manifestations in the clinical course of pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD). Accumulating evidence indicates that dysfunction of the pulmonary vascular bed in the setting of PAH predisposes patients to increased hemorrhagic diathesis, resulting in mild to massive and life-threatening episodes of haemoptysis. Despite major advances in PAH targeted treatment strategies, haemoptysis is still correlated with substantial morbidity and impaired quality of life, requiring a multidisciplinary approach by adult CHD experts in tertiary centres. Technological innovations in the field of diagnostic and interventional radiology enabled the application of bronchial artery embolization (BAE), a valuable tool to efficiently control haemoptysis in modern clinical practice. However, bleeding recurrences are still prevalent, implying that the optimum management of haemoptysis and its implications remain obscure. Moreover, regarding the use of oral anticoagulation in patients with haemoptysis, current guidelines do not provide a clear therapeutic strategy due to the lack of evidence. This review aims to discuss the main pathophysiological mechanisms of haemoptysis in PAH-CHD, present the clinical spectrum and the available diagnostic tools, summarize current therapeutic challenges, and propose directions for future research in this group of patients.

Management of life-threatening hemoptysis in the ICU

Life-threatening hemoptysis is commonly encountered in the ICU and its management can be challenging even for experienced clinicians. Depending on the etiology and severity, one can tailor the treatment modality and therapeutic intervention(s). The grading of severity of hemoptysis varies greatly in the literature; however, unlike hemorrhage in other scenarios, small amounts of blood can significantly impair oxygenation and ventilation leading to cardiovascular collapse. Importantly, the initial evaluation and management should focus on airway and hemodynamic stabilization along with maintenance of oxygenation and ventilation. In this review, we discuss commonly encountered etiologies, vascular anatomy, diagnostic evaluation, and therapeutic interventions. We examine the evolving trends in etiologies of life-threating hemoptysis over the years. The role of flexible and rigid bronchoscopy as both a diagnostic and therapeutic modality is explored, as well as the use and indications of several bronchoscopic techniques, such as topical hemostatic agents, endobronchial tamponade, and tranexamic acid (TXA). In addition, we assess the use of multi-row detector computed tomography as the initial rapid diagnostic method of choice and its use in planning for definitive treatment. The efficacy and long-term results of bronchial artery embolization (BAE) are evaluated, as well as indications for surgical intervention. Furthermore, the importance of a multidisciplinary approach is emphasized. The necessary interplay between intensivists, consultative services, and radiologists is described in detail and an algorithmic management strategy incorporating the above is outlined. Given the complexity in management of life-threatening hemoptysis, this paper aims to summarize the available diagnostic and therapeutic methods and provide a standardized approach for the management of patients with this often difficult to treat condition.

Hemoptysis associated with percutaneous transthoracic needle biopsy: Development of critical events checklist and procedure outcomes

BACKGROUND

A percutaneous transthoracic needle biopsy (PTNB) is performed to obtain tissue for a pathologic diagnosis. A PTNB is necessary prior to the initiation of many cancer treatments. There is a risk of hemoptysis, the expectoration of blood, with the possibility for adverse, life-threatening outcomes. A critical event checklist is a cognitive aid used in an emergency to ensure critical steps are followed. To date, there are no known checklists published for management of PTNB-related, life-threatening hemoptysis. The purpose of this report is to describe the development and implementation of a critical event checklist and the adoption of the checklist into hemoptysis management.

METHODS

In March 2017, a process improvement team convened to evaluate the hemoptysis response using the Plan-Do-Study-Act (PDSA) methodology. The checklist was evaluated and updated through September 2019. The team educated Interventional Radiology (IR) clinicians on the new checklist and conducted simulations on its use. A retrospective chart review was performed on hemoptysis events between the ten-year period of October 1, 2008 and September 30, 2018 to evaluate the adoption of the checklist into practice.

RESULTS

There were 231 hemoptysis events occurring in 229 patients (2 with repeat biopsies). Prior to implementing the protocol and checklist, there were 166 (71.9%) hemoptysis events. After implementation there were 65 (28.1%) events. The median amount of documented blood expectorated with hemoptysis was 100 mL (IQR 20.0-300.0). Twenty-six patients were admitted after PTNB for reasons related to the hemoptysis event (11.3%). During the procedure, four (1.7%) patients with hemoptysis suffered a cardiac arrest. Prior to implementation of the protocol and critical events checklist, nurses positioned patients in the lateral decubitus (LD) position in 40 out of 162 (24.7%) cases. After implementation of the critical events checklist, nurses positioned patients in the LD position 42 out of 65 cases (64.6%) (OR=5.57(95% CI 2.99-10.367), p<0.001).

DISCUSSION

Interventional Radiology nurses successfully adopted the checklist into management of hemoptysis events. The reported incidence of hemoptysis suggests a need for IR teams to prepare for and simulate hemoptysis events. Future research is needed to evaluate the change in patient outcomes before and after critical events checklist implementation.

Feasibility and outcomes of bronchial artery embolization in patients with non-massive hemoptysis

Purpose

To evaluate the safety, efficacy, and long-term outcome of bronchial artery embolization (BAE) in the treatment of non-massive hemoptysis and the prognostic factors associated with recurrent bleeding.

Materials and methods

From March 2005 to September 2014, BAE was performed in 233 patients with non-massive hemoptysis. All patients had a history of persistent or recurrent hemoptysis despite conservative medical treatment. We assessed the technical and clinical success, recurrence, prognostic factors related to recurrent bleeding, recurrence-free survival rate, additional treatment, and major complications in all the patients.

Results

Technical success was achieved in 224 patients (96.1%), and clinical success was obtained in 219 (94.0%) of the 233 patients. In addition, 64 patients (27.5%) presented hemoptysis recurrence with median time of 197 days after embolization. Tuberculosis sequelae and presence of aberrant bronchial artery or non-bronchial systemic collaterals were significantly related to recurrent bleeding (p < 0.05). The use of Histoacryl-based embolic materials significantly reduced the recurrent bleeding rate (p < 0.05). Patient who had a tuberculosis sequelae showed a significantly lower recurrence-free survival rate (p = 0.013). Presence of aberrant bronchial artery or non-bronchial systemic collaterals showed a statistically significant correlation with recurrence-free survival rate (p = 0.021). No patients had major complications during follow-up.

Conclusions

BAE is a safe and effective treatment to manage non-massive hemoptysis. The procedure may offer a better long-term control of recurrent hemoptysis and quality of life than conservative therapy alone.

A Nomogram to Predict Recurrence After Bronchial Artery Embolization for Hemoptysis Due to Bronchiectasis

OBJECTIVE

To develop and validate a nomogram for predicting recurrent hemoptysis after successful bronchial arterial embolization (BAE) in patients with bronchiectasis.

MATERIALS AND METHODS

From January 2015 to December 2019, a total of 251 patients were enrolled in this study. A nomogram was developed with the predictors of recurrent events, which were identified by univariate and multivariate Cox regression analyses. We evaluated nomogram discrimination by area under the receiver operating characteristic curve, calibration by the calibration curve, and clinical usefulness potential by decision curve analysis.

RESULTS

The one-month, 1-year, 2-year, 3-year, and 5-year cumulative recurrence-free rates of patients were 98.4%, 90.5%, 82.8%, 77.7%, and 74.4%, respectively. Three predictive factors, namely sex, lung destruction, and systemic arterial-pulmonary circulation shunts, were applied to develop the nomogram. The model maintained good discrimination (area under the curve, 0.72; 95% confidence interval, 0.62-0.81), low prediction error (integrated Brier score, 0.129), and certain net benefits in terms of clinical usefulness.

CONCLUSIONS

The proposed nomogram showed favorable predictive efficacy for hemoptysis recurrence after BAE in patients with bronchiectasis. Improved long-term outcomes are expected with close follow-up, a healthy lifestyle, and pulmonary rehabilitation for patients at risk of recurrence according to the model.

Outcomes of bronchial artery embolization for the management of hemoptysis

INTRODUCTION

  Hemoptysis is an alarming symptom that requires immediate investigation and management. Bronchial artery embolization (BAE) is a minimally invasive procedure that has become the treatment of choice of recurrent and massive hemoptysis.

AIM

To assess the efficacy and safety of BAE for management of recurrent and/or massive hemoptysis.

METHODS

A retrospective analysis was carried out of the medical records of 46 patients who were hospitalized in our department of pneumology in Mohamed Taher Maamouri hospital for hemoptysis and who underwent bronchial arteriography (BA) for the purpose of transarterial embolization.

RESULTS

The most frequent causes of hemoptysis included idiopathic bronchiectasis (32.6%), pulmonary tumors (26%) and tuberculosis (8.6%) Embolization was successfully performed in 97.5% of cases. Immediate cessation of haemoptysis was achieved in 95%. Recurrence of haemoptysis was noted in 12% of cases. No major complication involving the vital or the functional prognosis, related to BAE was noted.   Conclusions: Our study confirms the safety and the efficacy of the BAE for management of massive and/or recurrent hemoptysis.

Bronchial Artery Embolization, an Increasingly Used Method for Hemoptysis; Treatment and Avoidance

Objectives

Hemoptysis is an alarming symptom. It may cause some severe life-threatening complications. Hypertrophic and fragile bronchial artery causes hemoptysis and occurs mostly in bronchiectasis, sarcoidosis, active or sequelae tuberculosis, aspergilloma, lung cancer or cystic fibrosis. Bronchial artery embolization is one of the angiographic methods used in diagnosis and treatment for years performed by radiologists. Hemoptysis is used mostly in patients with hemoptysis. Using this method, surgical management with high mortality and morbidity rates can be avoided or better conditions for surgery can be provided via stopping hemorrhage before surgery. We aim to share the experiences of our hospital about patients who underwent bronchial artery embolization and compare our results with the literature.

Methods

Thirty-nine patients (29 male, 10 female) underwent angiography-aiming embolization. Pathologies were hemoptysis in 37 patients, Castleman disease in two patients. Embolization was performed in 33 patients; 31 for hemoptysis, two for Castleman disease. Bilateral embolization was performed in six patients.

Results

Computed tomography (CT) was helpful in diagnosing the side of bleeding in 91.8% of the patients with hemoptysis. Bronchoscopy was diagnostic in 53% of patients. Polyvinyl alcohol (n=27) was mostly used for embolization. Hemoptysis recurred in six patients (19.3%). All were managed successfully, of four with re-embolization. One major complication, transient blindness, was observed.

Conclusion

Bronchial artery embolization is minimally invasive, more tolerable compared to surgery can be managed with high success and lower complication rates, especially hemoptysis and in some other situations. It provides time for evaluating the underlying disease and delaying surgery for elective conditions. That is why this method has been used increasingly.

The Cause of Massive Hemoptysis After Thoracic Endovascular Aortic Repair May Not Always Be an Aortobronchial Fistula: Report of a Case

Hemoptysis after thoracic endovascular/open aortic repair is relatively rare but a well-known complication, and normally diagnosed with aortobronchial fistula (ABF). Here, we present a patient who suffered from recurrent massive hemoptyses even after multiple thoracic endovascular aortic repairs (TEVARs), where hemoptysis was ultimately controlled by pneumonectomy. In this case, the bleeding source was not the aorta but the lung parenchyma itself, indicating the importance of raising awareness that the cause of massive hemoptysis after TEVAR may not always be an ABF.

Palliative care in pulmonary medicine

Palliative care was initially developed for patients with advanced cancer. The concept has evolved and now encompasses any life-threatening chronic disease. Studies carried out to compare end-of-life symptoms have shown that although symptoms such as pain and dyspnea are as prevalent in patients with lung disease as in patients with cancer, the former receive less palliative treatment than do the latter. There is a need to refute the idea that palliative care should be adopted only when curative treatment is no longer possible. Palliative care should be provided in conjunction with curative treatment at the time of diagnosis, by means of a joint decision-making process; that is, the patient and the physician should work together to plan the therapy, seeking to improve quality of life while reducing physical, psychological, and spiritual suffering.

Massive hemoptysis secondary to Behçet's aneurysm controlled with endobronchial balloon lung isolation: Case report and review of literature

Behçet's disease (BD) is a multisystem disorder with various clinical presentations. Herein, we present a lethal complication associated with pulmonary artery aneurysm due to BD, resulting in massive hemoptysis that was controlled using endobronchial balloon lung isolation.

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

Background

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

Method

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

Results

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

Conclusions

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

Outcomes and Complications of Bronchial Angioembolization in Patients with Massive Hemoptysis

BACKGROUND

Massive hemoptysis is a potentially life threatening medical condition and one major problem for both patients and physicians. Choosing the appropriate treatment for the patients is crucial in order to decrease the complications and increase the success rate. Hence, in this study the outcomes and complications of bronchial angioembolization (BAE) were determined in patients with massive hemoptysis.

MATERIALS AND METHODS

In this prospective cohort, 189 consecutive patients with moderate and severe hemoptysis who had referred to two large cardiovascular centers were enrolled. The Chest X Ray, CT Scan, Fiberoptic Bronchoscopy, Selective and Nonselective Bronchial Angiography were performed in patients. The outcomes with 20-month follow-up were compared.

RESULTS

The immediate success rate was 97.3%. In 79.7% there were no complications. Temporary chest pain, subintimal dissection, temporary dysphagia, and pancreatitis were seen in 12.3, 2.4, 5.1, and 0.5%, respectively, without any major complication. The in-hospital mortality rate was 1.1% and mortality during 20-month follow-up was 9.6%, and recurrence rate was 28.3% on total.

CONCLUSION

Our case series showed that BAE is a safe and effective method in treating patients with hemoptysis. Compared to surgery, the procedure is faster and less invasive and might be used both as first line or bridging therapy. Importantly, no major complications have been detected.

[Acute emergencies in oncology]

The spectrum of dermato-oncological emergencies is multifaceted. They are particularly observed in cases with malignant melanoma due to the large number of patients and prolonged survival rates that are associated with new therapies for advanced disease. Dermato-oncological patients present to the hospital with symptoms like nausea and emesis, unexpected neurological deficits, various gastrointestinal problems, and even acute abdomen, acute breathlessness, or hemoptysis. Furthermore, emergencies can be caused by hematological problems like anemia and leukopenia. In addition to standardized care for medical emergencies, there are many other problems caused by metastases and/or therapeutic side effects that need interdisciplinary skills to optimize procedures and deliberate on surgical interventions, radiotherapy, and medical therapeutic choices with regard to the overall situation of the patient. The article deals with a spectrum of acute organ-specific emergencies, including recommendations for medical treatment and considerations for therapeutic decisions. Recommendations for supportive care in patients who are severely ill are summarized. In addition to stage-adapted pain therapy, supportive measures such as nutritional supplementation, the use of dronabinol in cases of loss of appetite, and antipruritic therapies are outlined. This article provides a succinct summary of the most frequently observed dermato-oncological emergencies with references to the respective detailed literature of associated medical societies and guidelines.

Approach to Hemoptysis in the Modern Era

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