Pulmonary resection in the treatment of life-threatening hemoptysis

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

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

Which Is the Best Way to Treat Massive Hemoptysis? A Systematic Review and Meta-Analysis of Observational Studies

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.

Rare but life-threatening cause of massive haemoptysis in an adolscent with tuberculosis: Rasmussen's aneurysm

Rasmussen's aneurysm is a rare yet fatal cause of massive haemoptysis in pulmonary tuberculosis. Early identification and timely intervention are of utmost importance to reduce the associated mortality. A girl in early adolescence presented with persistent fever and massive haemoptysis who required intubation and was subsequently confirmed to have tuberculosis. CT pulmonary angiogram showed the presence of pseudoaneurysms in the left upper and lower lobes. The haemoptysis resolved following the embolisation of the culprit's vessel. Residual lung destruction was evident on CT after a 12-month course of antituberculosis therapy. Rasmussen's aneurysm is a significant vascular complication of cavitary tuberculosis and needs to be considered in patients presenting with massive haemoptysis.

Rasmussen aneurysm: Case series of a rare complication of Pulmonary Tuberculosis

Rasmussen aneurysm refers specifically to a pseudoaneursysmal dilatation of a branch of the pulmonary artery adjacent or within a tuberculous cavity. The incidence of pulmonary vascular complication secondary to tuberculosis is very rare hence underdiagnosed by many clinicians. It can present with life threatening haemoptysis and CT angiography plays an important role in localizing the lesion and guiding treatment. On contrary the most common cause of massive haemoptysis is of bronchial artery origin. Early diagnosis and proper interventions are essential as it is associated with high mortality. Herein we report three cases of Rasmussen aneurysm in patients with haemoptysis. Only one patient underwent emergency trans-arterial embolization of the involved pulmonary artery.

Congenital Pulmonary Airway Malformation in an Adult Male Presenting With Hemoptysis

Congenital pulmonary airway malformations (CPAMs) are rarely encountered in the adult population. Although they are typically diagnosed in the prenatal period, some may not cause symptoms and go unnoticed until adulthood. Patients with CPAM are at risk of developing pneumonia, hemorrhage, pneumothorax, and malignancy. There is a paucity of evidence regarding the management and prognostication of adults with CPAM. Patients often need to undergo surgical resection to prevent further episodes of infection, bleeding, or malignant transformation. Here, we present the case of an adult male with a CPAM who presented with frank hemoptysis. Computed tomography scan and bronchoscopy localized the lesion to the lingula. The patient underwent elective surgical resection of the lesion by video-assisted thoracoscopy and did not suffer any adverse outcomes. Surgical resection is generally recommended and appears to be a safe and effective approach to treating patients with symptomatic CPAMs. Inhaled tranexamic acid and bronchial artery embolization are valuable interventions in our armamentarium for managing hemoptysis but should not replace a definite surgical intervention due to the risk of recurrence.

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.

Plombage for Hemoptysis Control in Pulmonary Aspergilloma: Safety and Effectiveness of Forgettable Surgery in High-Risk Patients

Objectives: To evaluate plombage surgery for hemoptysis control in pulmonary aspergilloma in high-risk patients.

Methods: This study was carried out on 75 pulmonary aspergilloma patients presenting with hemoptysis that underwent a plombage surgery for approximately 7 years (November 2011–September 2018) at Pham Ngoc Thach Hospital. They revisited the hospital 6 months after plombage surgery and considered plombage removal. The group whose plombage was removed was compared with that whose plombage was retained 6 and 24 months after surgery.

Results: Hemoptysis reduced significantly after surgery. Hemoptysis ceased in 91.67% of the patients and diminished in 8.33% of the patients 6 months after surgery. Similarly, hemoptysis ceased in 87.32% of the patients and diminished in 12.68% of the patients 24 months after surgery. Body mass index (BMI) index, Karnofsky score, and forced expiratory volume in one second (FEV1) increased. Plombage surgery was performed with operative time of 129.5 ± 36.6 min, blood loss during operation of 250.7 ± 163.1 mL, and the number of table tennis balls of 4.22 ± 2.02. No deaths related to plombage surgery were recorded. Plombage was removed in 29 cases because of patients’ requirements (89.8%), infection (6.8%), and pain (3.4%). There were no patient developing complications after the treatment and there were no statistically significant differences between the two groups.

Conclusions: Plombage surgery is safe and effective for hemoptysis control in pulmonary aspergilloma. To minimize the risk of long-term complications, surgeons should remove the plombage 6 months after the initial operation.

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

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

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

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

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

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

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Surgical treatment of hydatidothorax in children: A retrospective study of 19 patients

OBJECTIVE

The objective of this study was to describe the role of surgical management of ruptured hydatid cysts into the pleural cavity in children. A review of the management of patients with intrapleural rupture of pulmonary hydatid cysts in children at our center was performed.

MATERIALS AND METHODS

A retrospective chart review was performed on all children who developed intrapleural rupture of a hydatid cyst in the lung. Patients with intrapleural rupture from other locations (liver, mediastinum, diaphragm, kidney) were excluded.

RESULTS

In these 19 patients, there were 11 males and 8 females with a mean age of 9.4 years (range 7-16 years). Different clinical symptoms, biological, and imaging data allowed the diagnosis. The surgical approach consisted of a posterolateral thoracotomy and decortication in all patients. In addition, different procedures were needed for the pulmonary lesion according to the degree of lung destruction. Radical resections were required in four cases, including lobectomies (n = 1) and segmentectomies (n = 3). Conservative treatment was possible in 15 patients (simple capitonnage and bronchial fistula closure). Post-operative complications occurred in 2 cases (10.5%), including one pyothorax with a prolonged air leak and one wound infection. There were no postoperative deaths. There was no recurrence of thoracic hydatid disease in postoperative follow-up ranging from 1 to 3 years (mean: 2 years).

CONCLUSION

Intrapleural hydatid cyst rupture may be prevented by early treatment of simple forms to avoid increased morbidity.

LEVEL OF EVIDENCE

Level IV.

Hemoptysis from complex pulmonary aspergilloma treated by cavernostomy and thoracoplasty

BACKGROUND

In high-risk patients with complex pulmonary aspergilloma but unable for lung resection, cavernostomy and thoracoplasty could be performed. This study aimed to evaluate this surgery compared two compressing materials.

METHODS

A total of 63 in high-risk patients who suffered from hemoptysis due to complex pulmonary aspergilloma and underwent cavernostomy and thoracoplasty surgery from November 2011 to September 2018 at Pham Ngoc Thach hospital were evaluated prospectively studied. Patients were allocated to two groups: the table tennis ball group and tissue expander group. We evaluated at the time of before operation, 6 months and 24 months after operation.

RESULTS

Tuberculosis was the most common comorbidity diseases in both groups. Upper lobe occupied almost in location. Hemoptysis symptoms plunged from time to time. Statistically significant Karnofsky score was observed in both groups. Postoperative pulmonary functions (FVC and FEV1) have remained in both groups at all time points. The remarkable results were no deaths related to surgery and low complications both short and long-term. There was no statistical significance between two groups in operative time, blood loss during operation, ICU length-stay time. Four patients died because of co-morbidity in 24 months follow-up.

CONCLUSION

Cavernostomy and thoracoplasty was safe and effective surgery for the treatment of complex pulmonary aspergilloma with hemoptysis in high-risk patients. No mortality related to surgery and low complications were recorded. The was no inferiority when compared two compressing materials .

Management of hemoptysis in patients with lung cancer

Hemoptysis related to malignancy is common and accounts for nearly a quarter of all cases of hemoptysis in the US, and approximately 20% of patients with lung cancer will experience some degree of hemoptysis during their disease course. Both minor and massive hemoptysis come with diagnostic and treatment challenges and are associated with increased mortality. We will discuss the definition and epidemiology of hemoptysis related to malignancy, outline our approach to the initial evaluation and diagnostic workup, and extensively review the management of minor and massive hemoptysis. Specific emphasis will be on relevant signs and symptoms, imaging, and the role of bronchoscopy, and the differences in approach for minor hemoptysis compared to massive hemoptysis. While the role of surgical management is very limited in this patient population, the role of endobronchial and endovascular management will be discussed in detail.

Emergency management of massive haemoptysis

In this manuscript, we present a rare case of massive haemoptysis secondary to rupture of a pulmonary artery aneurysm, which was unusual for having occurred in the absence of tuberculosis or a vasculitis. We describe the emergency management of this that ultimately resulted in the patient's survival from both an anaesthetic and surgical perspective, as well as discuss the role of interventional radiology in this situation.

Management of severe hemoptysis

INTRODUCTION

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

Rasmussen's pseudoaneurysm- case report

Background

Pulmonary aneurysms and pseudoaneurysms have various etiologies; however, the term Rasmussen's pseudoaneurysm refers specifically to a focal dilatation of a branch of the pulmonary artery into adjacent tuberculous cavity. The incidence of such tuberculosis related pulmonary vascular complication is extremely rare, hence, under recognized by many physicians. Management of pulmonary pseudoaneurysms is challenging as they present by life-threatening hemoptysis. Furthermore, contrary to the most causes of massive hemoptysis their bleeding is of pulmonary rather than bronchial artery origin. Prompt diagnosis and early interventions are needed as a very high mortality rate is associated with this illness.

Case description

We are reporting on a case of a young male who was presented to our hospital with recurrent episodes of massive hemoptysis and was diagnosed to have pulmonary tuberculosis. Despite being actively treated, his hemoptysis persisted. We describe in this case the role of different diagnostic modalities and the available therapeutic options.

Conclusion

Rasmussen's psudoaneurysm is rare and potentially lethal pulmonary vascular complication of tuberculosis. It should be considered in the differential diagnosis of hemoptysis in patients known or suspected to have pulmonary tuberculosis. In such cases, multidetector computed tomography (MDCT) scanning is the investigation of choice to confirm the diagnosis and to localize the source of bleeding prior to the therapeutic interventions. Head to head comparison between interventional radiology procedures and surgery in treatment of pulmonary psudoaneurysms is lacking, thus, choice depend on the availability and local expertise.

Surgery for hemoptysis in patients with benign lung disease

Background

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

Methods

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

Results

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

Conclusions

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

Approach to Hemoptysis in the Modern Era

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

Is Anatomic Lung Resection Necessary in Surgical Treatment of Giant Lung Hydatid Cysts in Childhood?

PURPOSE

The aim of this study is to evaluate the results of parenchymal saving methods for giant lung hydatid cysts and to discuss the necessity of anatomic lung resection in childhood.

METHODS

The patients under the age of 16 years who were operated between January 2000 and January 2017 due to pulmonary hydatid cyst were evaluated retrospectively (n = 200). In all, 32 patients who had giant hydatid cyst were included in this study. Parenchymal saving methods (cystotomy-capitonnage) were preferred and decortication was also performed for pleural thickening if needed. No lung resections were applied.

RESULTS

Male patients were 53.1%. The mean age was 11.3 ± 3.2 years. The total number of giant cysts was 32. The average size of the cysts was 11 cm. Thirty seven point five percent of the cysts were perforated. Postoperative complication rate was 31.3%. No recurrence and mortality were seen during follow-up period.

CONCLUSION

Considering the high recovery capacity of lung tissue, a chance should be given to recover the existing infection, atelectasis, and parenchymal damage. Especially in areas where hydatid disease is endemic, children may be infected with the parasite again. For these reasons, we do not recommend resection with any indications.

A systematic approach to the management of massive hemoptysis

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

3D-CT anatomy for VATS segmentectomy

Segmentectomy has become a widely adopted surgical procedure, with recent reports describing the use of video-assisted thoracoscopic surgery (VATS) and robotic surgery. A major feature of segmentectomy is that it requires a three-dimensional (3D) understanding of the patient's pulmonary structure and a thorough preoperative analysis of the patient's individual anatomy. Here, we present our method for VATS segmentectomy based on 3D-computed tomography (3D-CT), with a review of the literature. We focus on techniques for 3D-CT reconstruction, analyses of the individual anatomy and anomalies, preoperative simulations of the procedure and surgical margin, and intraoperative navigation with 3D-CT images. We also reference the roles of members of our multi-disciplinary surgical team.

Endosonography of a Pulmonary Artery Obstruction in Echinococcosis

A 44-year-old woman with a history of pulmonary embolism and abdominal echinococcosis complained of sudden thoracic pain and shortness of breath. A D-dimer of 77.5 mg/l (reference ≤0.5 mg/l) was found. Chest CT scan revealed obstruction of the right lower and middle lobe pulmonary artery (PA). Anticoagulation therapy was initiated for the presumed diagnosis of recurrent pulmonary embolism. However, due to persistent symptoms of dyspnea, follow-up CT angiography of the chest was performed 3 months later. A persistent PA obstruction was found and the presumed diagnosis of embolism was questioned. Subsequently, endobronchial ultrasound (EBUS) imaging was performed to support an alternative diagnosis. EBUS imaging showed an inhomogeneous, sharply demarcated, intravascular lesion with round hypoechoic areas compatible with cysts. The diagnosis of embolism was rejected and treatment with albendazole was initiated for pulmonary echinococcosis. Echinococcosis is a parasitic disease and cystic spread in the PA is exceptional. The patient has remained stable for more than 4 years. In case of disease progression, including progressive PA obstruction or life-threatening hemoptysis, surgical resection will be considered.