[Management of massive hemoptysis: current role of interventional endoscopy]

Massive hemoptysis represent a very serious pathology and a vital threat for the patients. In spite of the availability of several therapeutical tools, the prognosis remains dark: mortality more than 60%. We expose here, the pathophysiological mechanisms of this severe complication and the main predisposing conditions and etiologies, to then approach the contribution of new endobronchial interventional treatments. The flexible endoscopy allowing only limited acts like the instillation of adrenalin and physiological solution at 4 degrees C, can in some cases contribute to probe or endobronchial catheter installation or intubation. The rigid bronchoscopy finds in massive hemoptysis a vast field of action and will make possible to better control the bleeding and to ensure the hemostasis: thermocoagulation, laser and cryotherapy aim at the same time stopping the haemorrhage and allow specific treatment. Their results are different according to the technique. The endovascular and surgical procedures have a complementary role.

Anesthetic management of a parturient undergoing cesarean section with a tracheal tumor and hemoptysis

Anesthetic management of a parturient with respiratory failure associated with hemoptysis, dyspnea, and orthopnea is difficult. An anesthesiologist should realize that the patient's major problem is not solved during the surgery. This circumstance is similar to a patient with associated cardiac disease scheduled for non-cardiac surgery. General anesthesia with endotracheal intubation can provide safe oxygenation for both the parturient and the fetus, but with possible unexpected massive hemoptysis and tumor seeding. Prolonged intubation may delay the patient's pulmonary treatment course. Laryngeal mask anesthesia can provide an airway, but must not be secured due to the risk of aspiration. The need of high doses of inhalation drugs may hinder uterine contractions. The addition of a muscle relaxant will change the patient's respiratory patterns and physiology. Regional anesthesia alone might not be tolerated. A decrease in cough strength, as well as dyspnea, orthopnea, and hyperventilation may be harmful to both the parturient and the fetus. However, we successfully managed this case using epidural anesthesia combined with assisted mask ventilation instead of spontaneous breathing usually provided by a simple mask in almost all American Society of Anesthesiology (ASA) class I-II parturients during cesarean section. The anesthetic level was maintained at T8 with 18 ml of 2% Xylocaine mixed with 2 ml of 7% sodium bicarbonate with 1:200,000 epinephrine epidurally and with the patient in a supine position with the head up at 30 degrees to prevent cephalic spreading and to ensure better pulmonary ventilation.

Lymphocytic interstitial lung disorder: an isolated entity

A 40 years female patient presented with recurrent haempoptysis since last five years and taking antituberculous as well as antidiabetic treatment. She was further investigated and found having lymphocytic interstitial lung disease without any other autoimmune disorder. She was treated by surgery with good response.

Mechanistic basis for the gas exchange threshold in Thoroughbred horses

The exercising Thoroughbred horse (TB) is capable of exceptional cardiopulmonary performance. However, because the ventilatory equivalent for O2 (VE/VO2) does not increase above the gas exchange threshold (Tge), hypercapnia and hypoxemia accompany intense exercise in the TB compared with humans, in whom VE/VO2 increases during supra-Tge work, which both removes the CO2 produced by the HCO buffering of lactic acid and prevents arterial partial pressure of CO2 (PaCO2) from rising. We used breath-by-breath techniques to analyze the relationship between CO2 output (VCO2) and VO2 [V-slope lactate threshold (LT) estimation] during an incremental test to fatigue (7 to approximately 15 m/s; 1 m x s(-1) x min(-1)) in six TB. Peak blood lactate increased to 29.2 +/- 1.9 mM/l. However, as neither VE/VO2 nor VE/VCO2 increased, PaCO2 increased to 56.6 +/- 2.3 Torr at peak VO2 (VO2 max). Despite the presence of a relative hypoventilation (i.e., no increase in VE/VO2 or VE/VCO2), a distinct Tge was evidenced at 62.6 +/- 2.7% VO2 max. Tge occurred at a significantly higher (P < 0.05) percentage of VO2 max than the lactate (45.1 +/- 5.0%) or pH (47.4 +/- 6.6%) but not the bicarbonate (65.3 +/- 6.6%) threshold. In addition, PaCO2 was elevated significantly only at a workload > Tge. Thus, in marked contrast to healthy humans, pronounced V-slope (increase VCO2/VO2) behavior occurs in TB concomitant with elevated PaCO2 and without evidence of a ventilatory threshold.

Diffuse alveolar hemorrhage syndromes

Diffuse alveolar hemorrhage (DAH) is a rare yet serious and frequently life-threatening complication of a variety of conditions. DAH may result from coagulation disorders, inhaled toxins, or infections. Most cases of DAH are caused by capillaritis associated with systemic autoimmune diseases such as antineutrophil cytoplasmic antibodies-associated vasculitis, anti-glomerular basement membrane disease, and systemic lupus erythematosus. Early recognition is crucial, because the prompt institution of supportive measures and immunosuppressive therapy is required for survival. Our understanding of DAH and its management is largely empiric and based on small case series and individual reports, many dating back more than one decade. To provide the practicing specialist with a rational diagnostic and management approach to the patient with DAH, this review summarizes the most recent publications and salient information derived from older publications.

Management of massive hemoptysis: a single institution experience

BACKGROUND

Massive hemoptysis is a life threatening condition. Several therapeutic strategies have been applied in the clinical setting, with variable results. We reviewed our recent experience on this subject.

MATERIAL AND METHODS

In a 5-year period, fifty-four patients (41 males, mean age 57.9 years) were treated for massive hemoptysis in our unit. The underlying pathology included bronchiectasis (n=31), active tuberculosis (n=9), pneumoconiosis (n=3), lung cancer (n=2) and pulmonary angiodysplasia (n=1). These patients often present with continuous bleeding with large volume of hemoptysis, or with recurrent episodes of bleeding. Bronchoscopic assessment and interventions were performed upon admission in all patients. Surgery was considered if the patient had acceptable pulmonary reserve and a bleeding source was clearly identified. If the patient was not considered fit for surgery, bronchial artery embolization was attempted.

RESULTS

Hemoptysis ceased with conservative management in 7 patients (13%) only. Twenty seven (50%) patients received surgical resection. The procedures included lobectomy (n=21), bilobectomy (n=4) and pneumonectomy (n=2). The in-hospital mortality after surgery was 15%. Postoperative morbidity occurred in 8 patients, including prolonged ventilatory support, bronchopleural fistulae, empyema and myocardial infarction. Twenty-one patients not suitable for surgery were treated with bronchial artery embolisation, which was successful in 17 patients without any complications.

CONCLUSION

The clinical outcome for massive hemoptysis reflects the generalized nature of a destructive disease process involving both lungs and a limited respiratory reserve. Surgery is associated with high risk of morbidity and mortality, and should be performed only in selected patients. Meanwhile, aggressive conservative therapy including bronchial artery embolization should be pursued.

Fever in acute pulmonary embolism

BACKGROUND

Although fever has been reported in several case series of acute pulmonary embolism (PE), the extent to which fever may be caused by PE, and not associated disease, has not been adequately sorted out. Clarification of the frequency and severity of fever in acute PE may assist in achieving an accurate clinical impression, and perhaps avoid an inadvertent exclusion of the diagnosis.

PURPOSE

The purpose of this investigation is to evaluate the extent to which fever is caused by acute PE.

METHODS

Patients participated in the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). Temperature was evaluated among patients with angiographically proven PE. A determination of whether other causes of fever were present was based on a retrospective analysis of discharge summaries, PIOPED summaries, and a computerized list of all discharge diagnoses.

RESULTS

Among patients with PE and no other source of fever, fever was present in 43 of 311 patients (14%). Fever in patients with pulmonary hemorrhage or infarction was not more frequent than among those with no pulmonary hemorrhage or infarction, 39 of 267 patients (15%) vs 4 of 44 patients (9%; not significant). Clinical evidence of deep venous thrombosis was often present in patients with PE and otherwise unexplained fever.

CONCLUSION

Low-grade fever is not uncommon in PE, and high fever, although rare, may occur. Fever need not be accompanied by pulmonary hemorrhage or infarction.

Fatal pulmonary haemorrhage during anaesthesia for bronchial artery embolization in cystic fibrosis

Three children with cystic fibrosis (CF) had significant pulmonary haemorrhage during anaesthetic induction prior to bronchial artery embolization (BAE). Haemorrhage was associated with rapid clinical deterioration and subsequent early death. We believe that the stresses associated with intermittent positive pressure ventilation (IPPV) were the most likely precipitant to rebleeding and that the inability to clear blood through coughing was also an important factor leading to deterioration. Intermittent positive pressure ventilation should be avoided when possible in children with CF with recent significant pulmonary haemorrhage.

[Duration of anamnesis in patients with hemoptysis]

The duration of anamnesis and its dependence on the amount of expectorated blood and on concomitant complaints was evaluated in 774 patients examined for hemoptysis in the Department of Respiratory Diseases and Tuberculosis, Faculty Hospital, Brno, with the aim to detect the factors hastening the visiting the physician by the patient. The longest anamnesis in average was in patients with COPD (123 days) and lung cancer (58 days). The patients coming too late to the physician originated mostly from these 2 groups as well--the anamnesis was longer than 2 months in 27% out of COPD patients and in 25% out of cancer patients. After including the influence of the amount of expectorated blood and of the concomitant complaints, the conclusion was reached that the bloody expectoration alone especially when streaks of blood only are present in sputum represent in many patients the motive not important enough for consulting the physician.

Massive hemoptysis from an endobronchial metastasis of thyroid papillary carcinoma

A 68-year-old female was admitted to our hospital with massive hemoptysis. She had undergone total thyroidectomy and postoperative radioisotope therapy for thyroid papillary carcinoma associated with multiple lung metastases one year before the present disorder. The right middle lobe was resected because of lethal airway bleeding from the lobe. Pathological examination showed an endobronchial metastasis 30 mm in size at the segmental bronchi. Other numerous small metastatic lesions exhibited two growth patterns: subepithelial endobronchial metastasis at the peripheral bronchi and visceral pleural metastasis. Endobronchial metastasis is an extreme type of lung metastasis of thyroid carcinoma, and can cause massive hemoptysis as the lesion increases in size.

[Menstruation-associated (catamenial) pneumothorax and catamenial hemoptysis]

We report on 2 patients with catamenial pneumothorax and one patient with catamenial hemoptysis. The pathogenesis of these diseases is not clear, and intrathoracic endometriosis is often assumed. Catamenial pneumothorax is rare and differs from primary spontaneous pneumothorax in its prevalence in the fourth decade and in mainly multiparous women, its recurrent and almost exclusively right-sided occurrence within 72 hours of the beginning of menstruation, and the generally small size of the pneumothorax. About 5% of women under 50 presenting with primary pneumothorax have catamenial pneumothorax. Prevention of recurrence is difficult, as the recurrence rate is high, treatment duration is potentially long, and residual thoracic pain during menstruation is sometimes seen. The combination of medication (Gn-RH analogues, danazol, possibly hormonal contraceptive drugs or progestagens) with efficient pleurodesis (e.g. thoracoscopic talc application preferentially performed during menstruation) seems so far to be the most efficient, although no controlled studies have yet been performed. Catamenial hemoptysis is very rare and hormonal treatment alone is frequently successful in the long term. In the event of relapse, resection of the implicated endometriotic or angiomatous lesion localized by computed tomography can be performed.

Goodpasture's syndrome superimposed on membranous nephropathy. A case report

We describe a patient with idiopathic membranous glomerulopathy who developed acute deterioration in renal function; this was associated with hemoptysis, severe hypertension, and anti-glomerular basement membrane (anti-GBM) antibody in the serum. Despite aggressive therapy with plasmapheresis, cyclophosphamide and prednisone, the patient progressed to end-stage renal failure and is on maintenance hemodialysis.

Hypofractionated irradiation for inoperable non-small cell lung cancer

A policy of palliative intent thoracic irradiation was prospectively evaluated in 38 consecutive patients referred for treatment of inoperable non-small cell lung cancer at a single institution. A target dose of 1700 cGy in two fractions 1 week apart was delivered. Characteristics of the treatment group revealed most (87%; 33/38) to be of good-excellent performance status with minimal weight loss before irradiation. Although three patients (8%) had initial metastatic disease, all had symptoms referable to the thorax with cough (71%), dyspnoea (55%), haemoptysis (39%), and chest wall pain (34%) being dominant. Following treatment, the relative risk of maintaining complete response with regard to each of these symptoms was 0.91, 0.40, 0.92 and 0.78, respectively. Overall 70% of patients maintained complete symptomatic response to time of death or last review. Uncorrected median survival was 35 weeks and was comparable to best international end-results for either palliative intent or curative intent radiation schedules. We conclude that the radiation regimen employed is safe, efficacious and eminently resource conscious. Recognition of patient groups who overwhelmingly derive no benefit from conventional fractionation schedules will streamline access to radiotherapy services of patients suitable for radical treatment.

Case report: extensive pulmonary and aortic thrombosis and ectasia

Progressive shortness of breath developed in an elderly woman with a 25-year history of recurrent superficial phlebitis and hemoptysis. Extensive mural thrombosis and ectasia of the large and medium-sized pulmonary arteries and aorta were revealed on echocardiography and computerized tomography. The patient died 2 months later. On autopsy, the gross morphologic findings were similar with those observed by imaging. Histologically, there was mild inflammation in the intima and media of the aorta and the large pulmonary arteries, consistent with nonspecific arteritis. The extensive thrombosis and ectasia of the pulmonary arteries and aorta differ from previously published cases and cannot be assigned to a known nosologic entity. Two alternative explanations are proposed. First, an endothelial disorder was responsible for a diffuse vasculopathy that involved veins, pulmonary arteries, and aorta. Second, a vasculopathy of the Hugh-Stovin type, characterized by phlebitis and pulmonary thromboembolism, caused pulmonary hypertension and low cardiac output. The low flow state favorized aortic thrombosis and, at the site of interaction between the clot and the arterial wall, arteritis developed as an epiphenomenon, which induced arterial dilatation. Combined idiopathic pulmonary artery and aortic thrombosis and ectasia is rare and calls for corroboration of sporadic observations such as the current one.

Systemic blood flow to the lung after bronchial artery occlusion in anesthetized sheep

To compare the effectiveness of different embolizing agents in reducing or redistributing bronchial arterial blood flow, we measured systemic blood flow to the right lung and trachea in anesthetized sheep by use of the radioactive microsphere method before and 1 h after occlusion of the bronchoesophageal artery (BEA) as follows: injection of 4 ml ethanol (ETOH) into BEA (group 1, n = 5), injection of approximately 0.5 g polyvinyl alcohol particles (PVA) into BEA (group 2, n = 5), or ligation of BEA (group 3, n = 5). After occlusion, angiography showed complete obstruction of the bronchial vessels. There were no changes in tracheal blood flow in any of the groups. Injection of ETOH produced a 75 +/- 14% (SD) reduction in flow to the middle lobe (P less than 0.02) and a 75 +/- 13% reduction to the caudal lobe (P less than 0.01), whereas injection of PVA produced a smaller reduction in flow to these two lobes (41 +/- 66 and 51 +/- 54%, respectively). After BEA ligation there was a 52 +/- 29% reduction in flow to the middle lobe and a 53 +/- 38% reduction to the caudal lobe (P less than 0.05). This study has significant implications both clinically and experimentally; it illustrates the importance of airway collateral circulation, in that apparently complete radiological obstruction of the BEA does not necessarily mean complete obstruction of systemic blood flow. We also conclude that, in experimental studies in which the role of the bronchial circulation in airway pathophysiology is examined, ETOH is the agent of choice.

Clinical spectrum of pulmonary tuberculosis in older patients: comparison with younger patients

We compared the clinical-radiographic presentations of bacteriologically proven tuberculosis in 72 elderly (mean age: 71 yr) and 73 younger patients (mean age: 39 yrs). The tuberculin test (2 TU PPD) was positive in 55% and 92%, respectively. The prevalence of cough, dyspnea, anorexia, and weight loss was higher in the elderly (p less than .05), and night sweats were more prevalent in the younger patients (p less than .01). The radiographic pattern was not different between both groups (p greater than .10): "usual" apicoposterior lesions (with or without other abnormalities) were found in more than 70% of both groups; isolated "unusual" lesions consisted in both groups mainly of anterobasal infiltrations and sometimes of pleural effusions, rounded nodules, or miliary patterns. Yet, initially a wrong diagnosis was made more often in the elderly (p = .05). Malignancy, chronic pulmonary disease, and immunosuppression were more frequently encountered in the elderly (p less than .05), whereas alcoholism and smoking were more frequent in the younger patients (p less than .001). Tuberculosis-related mortality occurred in 6 elderly and 1 younger patient.

[Abnormal systemic artery originating from descending aorta to normal basal segments of left lung. Report 2 cases]

Two patients with a large abnormal systemic artery originating from the descending aorta several centimeters above the diaphragm to the four basal segments of normal left lower lobe (without cystic change like that found in the bronchopulmonary sequestration) were treated. No pulmonary artery was found to supply the basal segments. The patients suffered from repeated hemoptysis. In one patient the abnormal artery was incidentally found during bronchial arteriography. Lower lobectomy was performed in the two patients. Microscopic examination of specimens revealed some dilated small blood vessels with extremely thin walls and their rupture may be the cause of hemoptysis. Abnormal systemic artery must be suspected if hemoptysis or local murmur during chest examination cannot be explained by other conditions, and care must be taken not to injure the artery in isolating pleural adhesion and pulmonary ligament.

Fatal hemoptysis: aortobronchial fistula as a preventable cause of death

Hemoptysis as a result of leaking aortic aneurysms occurs rarely and has a high fatality rate. A case of chronic hemoptysis resulting from an aortobronchial fistula in a patient with an aortic prosthesis is reported. Hemoptysis, even when chronic, should prompt investigation of the possibility of a leaking graft in patients with prosthetic aortic grafts. Chest x-ray and bronchoscopy usually yield nonspecific findings. Aortography may demonstrate an aortic aneurysm and is the preferred diagnostic procedure; however, an aggressive surgical approach is often necessary.

Hemoptysis in trauma

In an attempt to more clearly delineate the importance and pathophysiology of moderate-severe hemoptysis, a clinical and experimental study was performed. The clinical portion consisted of a retrospective review of 344 patients undergoing thoracotomy for penetrating trauma. There were 138 patients with injuries to the trachea, mainstem bronchi or lungs. Six with GSW to the chest had severe hemoptysis in the Emergency Department (ED) and had a cardiac arrest just after endotracheal intubation. At thoracotomy, all six had air in their coronary arteries and could not be resuscitated, Of 14 patients with posterolateral OR thoracotomies, three had significant (20-30 mm Hg) drops in systolic pressure plus increased aspiration of blood into the dependent lung when turned onto their sides. Of 12 patients surviving surgery, six with continued aspiration of blood required prolonged ventilatory support. In an experimental study, minimally heparinized (0.07 units/ml) blood was infused into the lower trachea of 17 anesthetized normovolemic supine dogs at 0.15 ml/kg/min. The PaO2 fell from 100 +/- 11 to 65 +/- 16 mm Hg after infusion of 4.5 ml/kg of blood. At the same time peak ventilator pressure rose only minimally (8.5 +/- 1.7 to 11.2 +/- 3.1 mm Hg). The PCO2, mean PA pressure, PAWP, CVP, and cardiac output were essentially unchanged. In a second study of 18 dogs, reducing the systolic BP by one third reduced cardiac output by almost 48% and oxygen transport by 58%. After 4.5 ml/kg blood were infused into the trachea, the PaO2 fell from 84 +/- 19 to 52 +/- 9 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)