Bronchoscopy-Guided Topical Hemostatic Tamponade Therapy for the management of Life-Threatening Hemoptysis Arschang Valipour,MD:Alois Kreuzer,MD:Hubert koller,MD Wolfgang Koessler,MD;and Otto Chris Burghuber,MD,FCCP Chest 2005;127;2113-2118

Study objects Acute massive hemoptysis: life-threatening condition: High mortality:23-85% Main threat:asphyxation of blood Primary goal of Treatment: airway maintenance and control of bleeding Followed by Identifying of the site of and the underlying cause of bleeding Double-lumen endotracheal tubes:achieve some of these goals but…

Study objects Therapeutic strategies: Early bronchoscopy Interventional angiography(BAE) Surgery Temporary control of hemoptysis using Bronchoscopy: cold saline solution lavage instillation of topical vasoconstictive agents balloon tamponade therapy Endobronchial blocking techniques:Forgaty balloon catheter →occlude the bleeding bronchus on a segmental level Bronchoscopy guided topical hemostatic tamponade therapy(THT): Overcome most problems mentioned above.

Material and methods Setting: Interventional bronchoscopy unit of a 300-bed respiratory and critical care medicine referral center in Vienna Patients:from Jan 2000 to Jan 2004, 486 patients required bronchoscopy for hemoptysis 76 pts required emergency bronchoscopy for massive hemoptysis Definition of Massive hemoptysis: bleeding rate > 150mL/hour of expectorated blood ≥ 150mL of expectorated blood on one occasion clinical consequences:PaO2 < 60mmHg

Material and methods Bronchoscopy Rigid bronchoscope was inserted in a standard manner and bleeding side identified Patients head down(approximately 10°) toward the bleeding side Flexible bronchoscope with aspiration channel through the rigid bronchoscope Through flexible bronchoscope to confirm the bleeding site and clear the pph airways from blood Bronchoscope was placed into a wedge position in the bleeding bronchus and Cold saline solution lavage Cold saline solution lavage was started, instillation of a 1:20,000 epinephrine solution Pts who were treated followings this procedure were excluded

Material and methods Bronchoscopic THT: Performed on pts with persistent endobronchial bleeding despite wedging,cold saline solution lavage, regional instillation of epi Hemostatic agent: oxidized regenerated cellulose(ORC) sterile, knitted fabric after saturated with blood, brownish or black gelatinous mass; Aids in the formation of a clot Serving as a hemostatic adjunct

Material and methods Effectiveness of Therapy: ORC mesh:adhere to irregular surfaces and crevices, endobronchial tamponade; subsegmental to lobar bronchus level Bleeding severity and bronchus diameter:4-10 layers of mesh Effectiveness of Therapy: Massive hemoptysis was controlled and free of hemoptysis for 48 hrs Cx rates,duration of hospitalization,neccessity of BAE or repeat bronchosocopy, intensive care and surgery

Results Patient characteristics Initial 76 pts, 6 were failure to visual endobronchial lesion 13 pts:responded well to topical instillation and/or iced saline solution lavage 57 pts remained

Results Underlying diagnosis of life-threatening hemoptysis

Results Bronchoscopy-guided THT Site of bleeding: stem bronchus(10) subsegmental(18),segmental(29), THT performed in 56 of 57 pts:98% All 56 pts free of hemoptysis for the first 48 hrs Recurrent hemoptysis: between 3 and 6 days mild:<30ml expectorated blood moderate: 30 ~ 100ml In 6 recurrent hemoptysis pts:underwent BAE BAE in 6 pts:4 was successful

Results Complications, Morbidity, and Mortality Complications of THT : postobstuctive pneumonia In 5 pts Morbidity: Mean duration of hospitalization:15.3±10.1 days Mortality: 1-year survival rate:70% None of the dead died from recurrence of hemoptysis

Results Bronchoscopic Follow-up studies N=14 No recurrence of hemoptysis ORC absorbed in all pts without visible and histologic foreign body reaction

Discussion Life-threatening hemoptysis: Bronchoscopic guided THT using ORC: immediate control of hemoptysis in 98% of pts 6 pts:recurrence of mild to moderate hemoptysis: →BAE Complications:umcomplicated pneumonia

Discussions Severe endobronchial bleeding immediate control of the airways is imperative Achieved by double lumen tube:isolate and ventilate the lungs separately But Difficult place properly, obstructed by clots Also Hemoptysis control: Iced saline solution lavage or regional instillation of vasoconstictive agents: →useful in mild-to-moderate hemoptysis :13 of 76 pts:17%

Discussions THT:bleeding did not cease after these measures Major factors for Hemostatic material such as ORC hemostatic effect tissue compatibilty, absorption characteristics Hemostasis: selective tamponade of bleeding bronchus After saturation with blood, thrombus formation Oxidized cellulose:caustic activities →artificial coagulum Tissue compatibility of ORC : due to low pH →foreign body reaction↓,bactericidal environment Absorption times:7 ~ 20 days without foreign body reactions

Discussions Bleeding resume:despite bronchoscopy: BAE, surgery BAE:control of bleeding:60 to 95% Not successful:23%, due to technical failure, collaterals Surgical approach: specific, large-vessel bleeding parenchymal source

Conclusion Endobronchial THT using ORC: Safe practicable technique