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Charya AV, Holden VK, Pickering EM. Management of life-threatening hemoptysis in the ICU. J Thorac Dis 2021; 13:5139-5158. [PMID: 34527355 PMCID: PMC8411133 DOI: 10.21037/jtd-19-3991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/24/2020] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Ananth V Charya
- Division of Pulmonary and Critical Care Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Van K Holden
- Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Edward M Pickering
- Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonology, University of Maryland School of Medicine, Baltimore, MD, USA
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Segura-Salguero JC, Díaz-Bohada L, Lutz-Peña JR, Posada AM, Ronderos V. Perioperative management of massive hemoptysis during flexible bronchoscopy: Case report. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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3
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Perioperative management of massive hemoptysis during flexible bronchoscopy: Case report☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Manejo perioperatorio de hemoptisis masiva durante la realización de fibrobroncoscopia: reporte de caso. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Cordovilla R, Bollo de Miguel E, Nuñez Ares A, Cosano Povedano FJ, Herráez Ortega I, Jiménez Merchán R. Diagnosis and Treatment of Hemoptysis. Arch Bronconeumol 2016; 52:368-77. [PMID: 26873518 DOI: 10.1016/j.arbres.2015.12.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 11/11/2015] [Accepted: 12/07/2015] [Indexed: 12/20/2022]
Abstract
Hemoptysis is the expectoration of blood from the tracheobronchial tree. It is commonly caused by bronchiectasis, chronic bronchitis, and lung cancer. The expectorated blood usually originates from the bronchial arteries. When hemoptysis is suspected, it must be confirmed and classified according to severity, and the origin and cause of the bleeding determined. Lateral and AP chest X-ray is the first study, although a normal chest X-ray does not rule out the possibility of malignancy or other underlying pathology. Multidetector computed tomography (MDCT) must be performed in all patients with frank hemoptysis, hemoptoic sputum, suspicion of bronchiectasis or risk factors for lung cancer, and in those with signs of pathology on chest X-ray. MDCT angiography has replaced arteriography in identifying the arteries that are the source of bleeding. MDCT angiography is a non-invasive imaging technique that can pinpoint the presence, origin, number and course of the systemic thoracic (bronchial and non-bronchial) and pulmonary arterial sources of bleeding. Endovascular embolization is the safest and most effective method of managing bleeding in massive or recurrent hemoptysis. Embolization is indicated in all patients with life-threatening or recurrent hemoptysis in whom MDCT angiography shows artery disease. Flexible bronchoscopy plays a pivotal role in the diagnosis of hemoptysis in patients with hemoptoic sputum or frank hemoptysis. The procedure can be performed rapidly at the bedside (intensive care unit); it can be used for immediate control of bleeding, and is also effective in locating the source of the hemorrhage. Flexible bronchoscopy is the first-line procedure of choice in hemodynamically unstable patients with life-threatening hemoptysis, in whom control of bleeding is of vital importance. In these cases, surgery is associated with an extremely high mortality rate, and is currently only indicated when bleeding is secondary to surgery and its source can be accurately and reliably located.
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Affiliation(s)
- Rosa Cordovilla
- Servicio de Neumología, Complejo Asistencial Universitario de Salamanca, Salamanca, España.
| | | | - Ana Nuñez Ares
- Servicio de Neumología, Complejo Hospitalario Universitario de Albacete, Albacete, España
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Adachi T, Oki M, Saka H. Management Considerations for the Treatment of Idiopathic Massive Hemoptysis with Endobronchial Occlusion Combined with Bronchial Artery Embolization. Intern Med 2016; 55:173-7. [PMID: 26781019 DOI: 10.2169/internalmedicine.55.5261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This paper describes endobronchial embolization using silicone spigots (EESS), which is a potential treatment option for hemoptysis. A 63-year-old man with massive hemoptysis was treated with EESS to the left B(3), and bronchial artery embolization (BAE) was subsequently performed. However, the patient's hemosputum persisted and we performed another bronchoscopy. Bleeding was found from the left B(1+2). This was also treated with EESS. Subsequently, the patient achieved complete hemostasis with no complications for four months. EESS can prevent suffocation and can be a definitive treatment for achieving hemostasis in patients with recurrent hemoptysis after BAE.
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Affiliation(s)
- Takashi Adachi
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, Japan
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Adachi T, Ogawa K, Yamada N, Nakamura T, Nakagawa T, Tarumi O, Hayashi Y, Nakahara Y. Bronchial occlusion with Endobronchial Watanabe Spigots for massive hemoptysis in a patient with pulmonary Mycobacterium avium complex infection. Respir Investig 2015; 54:121-4. [PMID: 26879482 DOI: 10.1016/j.resinv.2015.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/28/2015] [Accepted: 09/14/2015] [Indexed: 11/15/2022]
Abstract
The safety of occlusion with Endobronchial Watanabe Spigots (EWS) for the management of hemoptysis associated with chronic respiratory tract infection has not yet been established. A 57-year-old woman diagnosed as having pulmonary Mycobacterium avium complex (MAC) infection presented to our hospital with hemoptysis. She underwent bronchoscopy for bronchial occlusion with EWS, which resulted in the resolution of hemoptysis. Subsequently, she underwent bronchial artery embolization and then EWS were removed. During placement of EWS, no worsening of infection was observed. After removal of EWS, there was no recurrence of hemoptysis. Bronchial occlusion with EWS for hemoptysis associated with pulmonary MAC infection can be performed safely.
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Affiliation(s)
- Takashi Adachi
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
| | - Kenji Ogawa
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
| | - Noritaka Yamada
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
| | - Toshinobu Nakamura
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
| | - Taku Nakagawa
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
| | - Osamu Tarumi
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
| | - Yuta Hayashi
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
| | - Yoshio Nakahara
- Department of Respiratory Medicine, National Hospital Organization, Higashinagoya National Hospital, 5-101 Umemorizaka, Meito-ku, Nagoya, Aichi 468-8620, Japan.
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9
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Bylicki O, Vandemoortele T, Laroumagne S, Astoul P, Dutau H. Temporary endobronchial embolization with silicone spigots for moderate hemoptysis: a retrospective study. ACTA ACUST UNITED AC 2012; 84:225-30. [PMID: 22832560 DOI: 10.1159/000339421] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Accepted: 05/07/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The management of airway bleeding is generally performed in an emergency to prevent hypoxemia and lung flooding. When the bleeding arises from peripheral lesions that are not visible endoscopically, bronchoscopic options have limited curative intents. Endobronchial embolization using silicone spigots (EESS) is a novel approach. OBJECTIVES We analyzed the efficacy and safety of EESS in a retrospective study. METHODS We retrospectively reviewed charts of patients referred to our center for moderate hemoptysis (MH) who underwent EESS. Successful management is defined as immediate bleeding cessation. RESULTS From December 2008 to January 2012, 9 patients were treated with EESS in our endoscopy unit. The MH originated from the left upper lobe in 4 cases, the right upper lobe in 3 cases and the right middle lobe and left lower lobe in 1 case each. Thirteen spigots were inserted. The success rate was 78%. Of the 9 patients, 7 were referred to interventional radiology for bronchial artery embolization, with a success rate of 86%, and 2 were referred for thoracic surgery. One patient had EESS as definitive treatment; the silicone spigots were bronchoscopically removed after a median of 4 days in 6 of the remaining 8 patients. Only 2 patients had hemoptysis recurrence after a median follow-up of 107 days (ranging from 13 to 1,017 days). None of the patients died from hemoptysis. CONCLUSION EESS is an original, temporary technique that requires only a flexible bronchoscope and biopsy forceps for placement and removal. EESS ensures airway protection while waiting for definitive management.
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Affiliation(s)
- O Bylicki
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hôpital Nord, University of the Mediterranean, Marseille, France
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Misra RP, Dietl CA. Massive hemoptysis after aspiration of a toothpick. Ann Thorac Surg 2011; 91:921-2. [PMID: 21353033 DOI: 10.1016/j.athoracsur.2010.08.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 08/12/2010] [Accepted: 08/16/2010] [Indexed: 10/18/2022]
Abstract
A 42-year-old man presented with massive hemoptysis. His past medical history was significant for a bayonet injury to the left chest several years ago. A chest computed tomographic scan showed a radio-opaque foreign body in the left lower lobe. A left thoracotomy was performed because of unrelenting hemoptysis in association with a foreign body that could not be retrieved by bronchoscopy. At surgery, a toothpick covered with blood was retrieved from the left lower lobe bronchus. A left lower lobectomy was performed because a lung abscess was present. Postoperatively, the patient confirmed that 1 year prior he had fallen asleep with a toothpick in his mouth while intoxicated.
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Affiliation(s)
- Rajeev P Misra
- Department of Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87131-0001, USA
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Lee P, Mehta AC, Mathur PN. Management of complications from diagnostic and interventional bronchoscopy. Respirology 2009; 14:940-53. [PMID: 19740256 DOI: 10.1111/j.1440-1843.2009.01617.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
From the humble beginnings as a mere curiosity, the art of bronchoscopy has progressed at a rapid pace. The millennium ushers in new technologies and refinements in established techniques to facilitate early detection of cancer, precise targeting of pulmonary nodules and infiltrates, near-total staging of the mediastinum with combined endoscopic modalities and more effective palliation of inoperable tumours. Bronchoscopists are faced with an increasing myriad of tools and equipment, each promising to carry out better than the previous. It is opportune to review the complications of established bronchoscopic techniques and how to manage them as well as new complications associated with novel technologies. In this article, we provide a concise overview of diagnostic and therapeutic bronchoscopic modalities, discussion of associated complications and their management strategies.
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Affiliation(s)
- Pyng Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.
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Hemoptises graves/maciças – A intervenção do pneumologista**Painel do XXIII Congresso da SPP (9 de Novembro de 2007), Guarda. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008; 14 Suppl 4:S227-41. [DOI: 10.1016/s0873-2159(15)30331-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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13
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Dutau H, Palot A, Haas A, Decamps I, Durieux O. Endobronchial embolization with a silicone spigot as a temporary treatment for massive hemoptysis: a new bronchoscopic approach of the disease. Respiration 2006; 73:830-2. [PMID: 16636529 DOI: 10.1159/000092954] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2005] [Accepted: 12/28/2005] [Indexed: 11/19/2022] Open
Abstract
A 39-year-old-woman was treated successfully by a combination of endobronchial and bronchial artery embolization for massive hemorrhage originating from the posterior segment of the right upper lobe. Endobronchial embolization was performed using a silicone spigot placed via flexible bronchoscopy in order to prevent alveolar inundation preceding and during the time of bronchial artery embolization. Massive hemorrhage is a rare and severe condition associated with a high mortality that requires rapid intervention and management. We describe a case that emphasizes the efficacy of a multidisciplinary approach including the use of a new bronchoscopic technique.
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Affiliation(s)
- Hervé Dutau
- Thoracic Endoscopy Unit, Sainte Marguerite Hospital, Marseille, France.
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Abstract
Bleeding occurs in up to 10% of patients with advanced cancer. It can present in many different ways. This article provides a qualitative review of treatment options available to manage visible bleeding. Local modalities, such as hemostatic agents and dressings, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization, are reviewed in the context of advanced cancer, as are systemic treatments such as vitamin K, vasopressin/desmopressin, octreotide/somatostatin, antifibrinolytic agents (tranexamic acid and aminocaproic acid), and blood products. Considerations at the end of life are described.
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Affiliation(s)
- Jose Pereira
- Department of Oncology, University of Calgary, Palliative Care Office, Room 710, South Tower, Foothills Medical Centre, 1403-29th Avenue NW, Calgary, Alberta, T2N 2T9, Canada.
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Håkanson E, Konstantinov IE, Fransson SG, Svedjeholm R. Management of life-threatening haemoptysis. Br J Anaesth 2002; 88:291-5. [PMID: 11878664 DOI: 10.1093/bja/88.2.291] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Massive haemoptysis represents a major medical emergency that is associated with a high mortality. Here we present two cases of life-threatening haemoptysis, the first caused by rupture of an aortic aneurysm into the lung in a 37-yr-old woman with polyarteritis nodosa and the second caused by massive bleeding from an angiectatic vascular malformation in the right main bronchus in a 21-yr-old woman. Fibreoptic bronchoscopy played an essential role in the diagnostic process and management of the respiratory tract. Diagnosis in the first case was obtained by CT scan and the aneurysm was treated surgically. In the second case, bronchial arteriography contributed to both definitive diagnosis and treatment. Initial cardiorespiratory management, diagnostic procedures and definitive therapy are described and reviewed. Adequate early management of the cardiorespiratory system is essential to the outcome. Aggressive measures to elucidate the cause of haemoptysis and prompt therapy are warranted because of the high risk of recurrence.
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Affiliation(s)
- E Håkanson
- Department of Cardiothoracic Anaesthesia and Intensive Care, Linköping Heart Center, University Hospital, Sweden
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Abstract
Bedside fiberoptic bronchoscopy is a valuable tool in the diagnosis and treatment of various respiratory conditions in critically ill patients. The fiberoptic bronchoscope allows direct airway inspection, facilitating the diagnosis of benign and malignant airway lesions. In addition, pulmonary secretions or tissue samples can be collected using the bronchoscope and techniques that allow sampling of the lower airways with minimal or no upper airway contamination. Collection of lower airway samples is important in the diagnosis of pulmonary infiltrates in immunocompromised patients, in many patients with ventilator-associated pneumonia, and in selected patients with CAP. The fiberoptic bronchoscope can be used for therapeutic interventions, such as insertion of an endotracheal tube, removal of an aspirated foreign body, clearance of tenacious secretions, promotion of hemostasis in patients with hemoptysis, instillation of drugs, and assistance in the placement of tracheobronchial prostheses (i.e., airway stents). If proper preprocedural training and planning are done and the patient is monitored carefully during the procedure, fiberoptic bronchoscopy can be performed quickly and safely at the bedside in most critically ill patients.
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Affiliation(s)
- J M Liebler
- Department of Medicine, Oregon Health Sciences University, Portland, USA
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Smythe WR, Gorman RC, DeCampli WM, Spray TL, Kaiser LR, Acker MA. Management of exsanguinating hemoptysis during cardiopulmonary bypass. Ann Thorac Surg 1999; 67:1288-91. [PMID: 10355398 DOI: 10.1016/s0003-4975(99)00214-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Large-volume hemoptysis during cardiopulmonary bypass is an infrequent, but life-threatening event. Rapid airway clearance and control are the primary prerequisites for successful management. METHODS The cases of 3 patients with different sources of exsanguinating hemoptysis during cardiopulmonary bypass managed initially with rigid bronchoscopy were reviewed. RESULTS In all patients, airway control was rapidly established and weaning from cardiopulmonary bypass CPB was accomplished. Two patients survived the operative procedure. The other patient died in the operating room of unremitting bilateral pulmonary hemorrhage. CONCLUSIONS Major hemoptysis during cardiopulmonary bypass is best dealt with initially by rapid airway control and cessation of bypass in an expeditious manner. An algorithm for suggested management is provided. The rigid bronchoscope is the optimal tool for initial management and it should always be available. Definitive treatment is determined by the cause and the persistence of hemorrhage once these maneuvers have been performed.
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Affiliation(s)
- W R Smythe
- The University of Pennsylvania Medical Center and Department of Surgery, Children's Hospital of Philadelphia, USA
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Abstract
Massive hemoptysis accounts for a minority of all patients with hemoptysis but poses a major challenge for the acute and long-term treatment. Massive hemoptysis can lead to asphyxiation and airway obstruction, shock, and exsanguination. Bronchoscopy plays an integral part in managing massive hemoptysis in diagnosis and treatment (Table 5). Specifically, bronchoscopy allows lateralization and more specific localization of bleeding that is critically important for effective management. Furthermore, acute control of bleeding can sometimes be achieved with instruments and catheters placed through the bronchoscope or by agents instilled into the airways through the bronchoscope.
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Affiliation(s)
- R A Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, Ohio, USA
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