Severe Hemoptysis Associated with Bacterial Pulmonary Infection: Clinical Features, Significance of Parenchymal Necrosis, and Outcome

PURPOSE

Severe hemoptysis (SH) associated with non-tuberculosis bacterial lower respiratory tract infection (LRTI) is poorly described, and the efficacy of the usual decision-making process is unknown. This study aimed at describing the clinical, radiological patterns, mechanism, and microbiological spectrum of SH related to bacterial LRTI, and assessing whether the severity of hemoptysis and the results of usual therapeutic strategy are influenced by the presence of parenchymal necrosis.

METHODS

A single-center analysis of patients with SH related to bacterial LRTI from a prospective registry of consecutive patients with SH admitted to the intensive care unit of a tertiary referral center between November 1996 and May 2013.

RESULTS

Of 1504 patients with SH during the study period, 65 (4.3%) had SH related to bacterial LRTI, including non-necrotizing infections (n = 31), necrotizing pneumonia (n = 23), pulmonary abscess (n = 10), and excavated nodule (n = 1). The presence of parenchymal necrosis (n = 34, 52%) was associated with a more abundant bleeding (volume: 200 ml [70-300] vs. 80 ml [30-170]; p = 0.01) and a more frequent need for endovascular procedure (26/34; 76% vs. 9/31; 29%; p < 0.001). Additionally, in case of parenchymal necrosis, the pulmonary artery vasculature was involved in 16 patients (47%), and the failure rate of endovascular treatment was up to 25% despite multiple procedures.

CONCLUSIONS

Bacterial LRTI is a rare cause of SH. The presence of parenchymal necrosis is more likely associated with bleeding severity, pulmonary vasculature involvement, and endovascular treatment failure.

Morphological Analysis of Bronchial Arteries and Variants with Computed Tomography Angiography

The aim of our study was to determine the prevalence of anatomical variants of bronchial arteries using computed tomographic angiography in a population of northeastern Mexico. An observational, transversal, descriptive, comparative, retrospective study was performed using 139 imaging studies of Mexican patients in which we evaluated the following parameters from the left and right bronchial arteries: artery origin, branching pattern, arterial ostium, vertebral level of origin, diameter, and mediastinal trajectory. The anatomies of the bronchial arteries were similar in both genders, except distribution for vertebral origin level (p  0.006) and the diameter (p  0.013). Left and right arteries were similar, except for the mediastinal trajectory in reference to the esophagus (p < 0.001) as well as the arterial diameter (p < 0.001) and lumen diameter.

Bronchial artery embolisation in management of hemoptysis--A retrospective analysis in a tertiary university hospital

BACKGROUND

Bronchial artery embolisation (BAE) becomes a mainstay in the treatment of hemoptysis.

OBJECTIVE

To characterise patients with hemoptysis undergoing bronchial artery angiography (BAA) for embolisation, evaluating outcomes.

METHODS

We retrospectively evaluated patients with acute severe or chronic recurrent hemoptysis admitted to the Pulmonology department and submitted to BAA for purpose of embolisation.

RESULTS

A total of 88 patients were submitted to BAA, 47 (53.4%) were male, with a mean age of 61.4 ± 15.8 years. In 64 (72.7%) patients, hemoptysis presented as chronic recurrent episodes. Hemoptysis was considered severe in 40 (45.5%) patients. Bronchiectasis (other than cystic fibrosis) (n=35; 38.0%) and tuberculosis sequelae (n=31; 35.2) were the major aetiology for hemoptysis. The main angiographic abnormality was hypertrophy and tortuosity (n=68; 77.3%). BAE was performed in 67 (76.1%) of the 88 patients submitted to BAA. Immediate success was achieved in 66 (98.5%) patients. Recurrence of hemoptysis occurred in 25 (37.3%) patients, and was related to presence of shunting (p=0.049). The procedure-related complications were self-limited.

CONCLUSION

Our results suggest that BAE is a safe and effective treatment for acute severe and chronic recurrent hemoptysis, supporting the current literature. Besides this, bleeding recurrence was relatively high, and correlated with presence of systemic pulmonary shunting.

Predictors of recanalization in patients with life-threatening hemoptysis requiring artery embolization

INTRODUCTION

Artery embolization (AE) is a safe and useful procedure in the management of massive hemoptysis. The objective of our study was to describe the experience of AE in a tertiary referral center, to characterize angiographic findings at the time of recurrence, and to analyze factors associated with these findings.

MATERIAL AND METHODS

Observational retrospective study of patients presenting with life-threatening hemoptysis. All consecutive patients with at least one episode of hemoptysis that required AE during a 13-year period were included. The effects of i)time to recurrence; ii)use of coils, and iii)number of arteries embolized on the likelihood that the recurrence was secondary to recanalization were assessed.

RESULTS

One hundred seventy-six patients were included in the study. Twenty-two patients (12.5%) died due to hemoptysis. Probability of recurrence-free survival at one month was 0.91 (95%CI: 0.87 to 0.95), at 12months was 0.85 (95%CI: 0.79 to 0.91), and after 3 years was 0.75 (95%CI: 0.66 to 0.83). A longer time to recurrence was associated with a higher probability that the hemorrhage affected the same artery (estimate=0.0157, z-value=2.41, p-value=0.016).

CONCLUSION

AE is a safe and useful technique in the management of massive and recurrent hemoptysis. Nevertheless, recurrence after embolization is not uncommon. Recurring hemoptysis due to recanalization is related to time to recurrence, but not to the use of coils or number of arteries embolized.

Preparation and characterization of ketoprofen-loaded microspheres for embolization

To deliver drug locally and relieve the syndrome of pain after uterine artery embolization, N-[tris (hydroxymethyl) methyl] acrylamide-gelatin microspheres were prepared based on inverse suspension polymerization and then separated into a number of subgroups (150-350, 350-560, 560-710, 710-1,000, and 1,000-1,430 μm) by wet-sieving. The microspheres were dried by lyophilization or by washing with anhydrous ethanol. And ketoprofen was loaded by soaking dried blank microspheres into concentrated ketoprofen ethanol solution. The ketoprofen loading level in different subgroups of microspheres was measured and found higher when the microspheres were dried by lyophilization. Equilibrium water content and mean diameters of microspheres decreased after drug loading, especially in subgroups with larger size. The microspheres went through the catheter without any difficulty. Compression and relaxation tests were performed on microspheres before lyophilization, embosphere™, microspheres after lyophilization and ketoprofen loading microspheres. The Young's moduli were 54.74, 64.19, 98.15, and 120.44 kPa, respectively. The release of ketoprofen from microspheres in different subgroups was studied by using the USPII method and T-cell apparatus, respectively. The results indicate that the release rate of ketoprofen depends upon the diameter of microspheres, the type of dissolution apparatus and the flow rate of media in the case that T-cell apparatus was applied. The CH50 test shows that the activation of complement by ketoprofen-loaded microspheres was lower than by blank ones.

[Treatment of non-cystic fibrosis bronchiectasis]

Bronchiectasis is currently growing in importance due to both the increase in the number of diagnoses made as well as the negative impact that its presence has on the baseline disease that generates it. A fundamental aspect in these patients is the colonization and infection of the bronchial mucous by potentially pathogenic microorganisms (PPM), which are the cause in most cases of the start of the chronic inflammatory process that results in the destruction and dilatation of the bronchial tree that is characteristic in these patients. The treatment of the colonization and chronic bronchial infection in these patients should be based on prolonged antibiotic therapy in its different presentations. Lately, the inhaled form is becoming especially prominent due to its high efficacy and limited production of important adverse effects. However, one must not overlook the fact that the management of patients with bronchiectasis should be multidisciplinary and multidimensional. In addition to antibiotic treatment, the collaboration of different medical and surgical specialties is essential for the management of the exacerbations, nutritional aspects, respiratory physiotherapy, muscle rehabilitation, complications, inflammation and bronchial hyperreactivity and the hypersecretion that characterizes these patients.

Hemoptysis in children

CONTEXT

Pulmonary hemorrhage and hemoptysis are uncommon in childhood, and the frequency with which they are encountered by the pediatrician depends largely on the special interests of the center to which the child is referred. Diagnosis and management of hemoptysis in this age group requires knowledge and skill in the causes and management of this infrequently occurring potentially life-threatening condition.

EVIDENCE ACQUISITION

We reviewed the causes and treatment options for hemoptysis in the pediatric patient using Medline and Pubmed.

RESULTS

A focused physical examination can lead to the diagnosis of hemoptysis in most of the cases. In children, lower respiratory tract infection and foreign body aspiration are common causes. Chest radiographs often aid in diagnosis and assist in using two complementary diagnostic procedures, fiberoptic bronchoscopy and high-resolution computed tomography. The goals of management are threefold: bleeding cessation, aspiration prevention, and treatment of the underlying cause. Mild hemoptysis often is caused by an infection that can be managed on an outpatient basis with close monitoring. Massive hemoptysis may require additional therapeutic options such as therapeutic bronchoscopy, angiography with embolization, and surgical intervention such as resection or revascularization.

CONCLUSIONS

Hemoptysis in the pediatric patient requires prompt and thorough evaluation and treatment. An efficient systematic evaluation is imperative in identifying the underlying etiology and aggressive management is important because of the potential severity of the problem. This clinical review highlights the various etiological factors, the diagnostic and treatment strategies of hemoptysis in children.

Aetiology, diagnosis and management of infective causes of severe haemoptysis in intensive care units

PURPOSE OF THE REVIEW

Infective causes of severe haemoptysis have progressively shifted to causes related to chronic inflammatory lung diseases. Physicians should, however, recognize the most common of them, for example necrotizing parenchymal infections, tuberculosis and mycetoma.

RECENT FINDINGS

The recent increase in the incidence of a devastating Panton-Valentine leukocidin-associated staphylococcal pneumonia has reminded us of the crucial role of prompt diagnosis and management. General supportive care should be administered to prevent asphyxiation in addition to starting appropriate antibiotics as soon as possible. Once the bleeding has been controlled, the diagnostic strategy should integrate a detailed medical history, physical examination, Gram stain of the respiratory specimens and chest radiograph. Computed tomography scan has dramatically improved the diagnosis and the treatment of infective causes of severe haemoptysis by assessing the cause and mechanism(s) of haemoptysis. Although bronchial arteries are the major source of bleeding, nonbronchial systemic and pulmonary arteries' involvement should be feared, especially in haemoptysis related to tuberculosis and mycetoma.

SUMMARY

Endovascular therapy should be first attempted to control the bleeding and then elective surgery performed in case of localized lesion and adequate pulmonary function. Fibreoptic bronchoscopy with broncho-alveolar lavage remains the cornerstone of diagnosis in immunocompromised hosts with haemoptysis and in the rare cases of alveolar haemorrhage related to infectious diseases.