2. Bronchoscopy in Haemoptysis Ashraf Madkour, MD, Dr.med., FCCP Department of Chest diseases, Ain Shams University, Cairo, Egypt.

3. Haemoptysis is a common presenting complaint in patients with pulmonary diseases. The development of bronchoscopy has provided an entirely new approach to the diagnosis of haemoptysis & bronchoscopic control of haemoptysis. Introduction:

4. Haemoptysis:Haemoptysis: –severity, approach BronchoscopyBronchoscopy –Timing and Choice of bronchoscope –Bronchoscopic Treatment Cold saline lavageCold saline lavage Topical vasoconstrictive agentsTopical vasoconstrictive agents Fibrinogen/thrombinFibrinogen/thrombin Endobronchial tamponadeEndobronchial tamponade Laser, Argon Plasma Coagulation, CryotherapyLaser, Argon Plasma Coagulation, Cryotherapy Topics:

5. Blood Circulation in the lungs : 2 Components Low pressure Pulmonary Circulation SBP = 15-20 mmHg DBP = 5-10 mmHg Patients with normal PAP ( no PAH) rarely bleed: only 5% of massive hemoptysis High pressure Bronchial Circulation = systemic pressures Bronchial arteries & collaterals originate from the aorta The source of bleeding in most cases One right BA Two left BAs

6. Determined by Amount & Rapidity of bleeding Cardio-respiratory reserve: Effect on gas exchange Severity of Haemoptysis: Non massive haemoptysis* Massive haemoptysis* 200-600 ml/24h 200-600 ml/24h Medical emergencyMedical emergency 90% originates from bronchial circulation 90% originates from bronchial circulation Occur in 5% of haemoptysis Mortality in 80% Mortality in 80% Asphyxiation rather than exsanguination Asphyxiation rather than exsanguination Flooding of the airways and alveoli with blood Flooding of the airways and alveoli with blood >150 ml/attack (Life threatening haemoptysis) >150 ml/attack (Life threatening haemoptysis) <200ml/24h <200ml/24h *no uniform definitions

7. History & physical examinationHistory & physical examination –(Exclude Hematemesis, ENT source) Chest x-ray ± CT scan radiology hemoptysis - Copy.pptChest x-ray ± CT scan radiology hemoptysis - Copy.ppt radiology hemoptysis - Copy.ppt radiology hemoptysis - Copy.ppt Lab:Lab: –CBC, Coagulation studies, Blood transfusion matching & ABG Assess severity:Assess severity: –Non massive: Establish diagnosis → CT, Lab, FOBEstablish diagnosis → CT, Lab, FOB –Massive: Approach to case of haemoptysis

9. Identify the site of bleedingIdentify the site of bleeding –Comparable to CT for detecting the site of bleeding especially in massive haemoptysis. –Detect subtle airway lesions not apparent in CT e.g. ulcers not detected by CT Allow endobronchial managementAllow endobronchial management –Control active bleeding by different techniques Allow sampling form suspected lesionsAllow sampling form suspected lesions –Bronchial aspirates: –Bronchial aspirates: cytology, AFB & culture. –Endo-bronchial or transbronchial biopsy –Endo-bronchial or transbronchial biopsy from central or peripheral tumors. Is bronchoscopy necessary??

10. Bronchoscopy: Choice of bronchoscope

11. Advantages: Requires local anesthesia Tolerable by patient Easy to manipulate & simplicity of use Reach peripheral airways Flexible maneuverability allow to perform BAL from segmental and subsegmental bronchi.Disadvantages: Unguaranteed ventilation Narrow suction channel ?? Limited interventional procedures application?? Fiberoptic bronchoscope

12. Advantages: Wide suction channel Ensure ventilation Improving visualization Allow interventional procedures application e.g. –Gauze socked with adrenaline, Iced cooled saline, Laser, Electrocautery, CryotherapyDisadvantages: Requires general anesthesia Insufficient maneuverability to perform BAL Need special skills Don’t reach peripheral airways. Rigid bronchoscope

13. Non-massive hemoptysis: better with early vs delayed did not alter Tx decisions or clinical outcome.Visualizing site of bleeding is better with early vs delayed FOB, but timing did not alter Tx decisions or clinical outcome. Massive hemoptysis: FOB → wiFOB → will delay timely and effective management. Early rigid bronchoscopy → will improve clinical outcomeEarly rigid bronchoscopy → will improve clinical outcome ( safeguarding airway patency, preserving ventilation, and allowing better clearance of the airways, improving visualization). Combined rigid & FOBCombined rigid & FOB may be helpful in controlling haemoptysis form upper lobes and peripheral bronchi. Bronchoscopy: Timing

16. Repeated suctioningRepeated suctioning Cold saline irrigationCold saline irrigation Topical vasoconstrictive agentsTopical vasoconstrictive agents Glues and gauzesGlues and gauzes –Fibrinogen/thrombin –Cyanoacrylate glue –Oxidized regenerated cellulose (ORC) mesh Endobronchial tamponadeEndobronchial tamponade Laser, Argon Plasma Coagulation, CryotherapyLaser, Argon Plasma Coagulation, Cryotherapy There are no controlled trials in bronchoscopic techniques used to slow or stop bleeding.There are no controlled trials in bronchoscopic techniques used to slow or stop bleeding. Bronchoscopic Treatment

17. Lateral positionLateral safety position Suction:Suction: –Bronchoscopic –large bore: oral-pharynx Bleeding siteBleeding site –Note site –remember how to get back Tamponade the bleeding bronchus:Tamponade the bleeding bronchus: –Continuous or intermittent suction and gravity dependent clot formation stops most bleeding. Bronchoscopic Treatment: Suction

18. BI18 Do not remove freshly formed clot Once a clot forms, it is important to NOT remove it once bleeding has stopped. Inspection bronchoscopy (with or without clot removal can be performed the following day Large blood clot causing a cast of the distal airway

19. Bronchoscopic Treatment: Cold saline lavage Cold (4°C) N/S 0.9% can be applied as small aliquots (50ml) or lavage (avg. volume of 500 ml, range 300–750 ml).* Cold (4°C) N/S 0.9% can be applied as small aliquots (50ml) or lavage (avg. volume of 500 ml, range 300–750 ml).* large aliquots of iced saline Immediate administration of large aliquots of iced saline using a wedged or partially wedged bronchoscope. *Conlan AA et al J Thorac Cardiovasc Surg 1983; 85:120–124

20. Agent – topical epinephrine (1:20,000)Agent – topical epinephrine (1:20,000) Effective in mild to moderate hemoptysis:Effective in mild to moderate hemoptysis: e.g. Bx, bronchial brushing Not useful for massive bleeding:Not useful for massive bleeding: the drug gets diluted and washed away. High plasma levels following endobronchial application. Significant CVS effects – hypertension & tachyarrthythmias. Bronchoscopic Treatment: Topical vasoconstrictive agents Cahill BC et al Clin Chest Med 1994;15:147–167

21. Thrombin and Fibrinogen- ThrombinEndoscopic instillation of Thrombin and Fibrinogen- Thrombin Infusion in patients whom BAE was not possible. Infuse: –5 to 10 ml of a 1,000 U/mI thrombin solution –5 to 10 ml of a 1,000 U/mI thrombin solution (thrombin for topical use, Warner-Lambert) –5 to 10 ml of a 2 % fibrinogen solution –5 to 10 ml of a 2 % fibrinogen solution (fibrinogen, Green Cross, Japan) Bronchoscopic Treatment: Fibrinogen/thrombin Tsukamoto et al Chest 1989; 96: 473–476

22. biocompatible adhesive solidifies on contact with humidity.N ‐ butyl cyanoacrylate ‐ biocompatible adhesive that solidifies on contact with humidity. A well known tissue glue used extensively in vascular and gastrointestinal field of medicine. Injected into the bleeding airway through catheter via FOB producing Endobronchial sealing. Bronchoscopic Treatment: Cyanoacrylate glue Bhattacharyya P et al. Chest 2002; 121: 2066–2069

23. Oxidized regenerated cellulose (ORC) mesh Bronchoscopic Treatment: Topical hemostatic Tamponade therapy Control of hemoptysis: achieved in 56 of 57 (98%) patients, who remained free of hemoptysis for the first 48 h. Not suitable for proximal sites of bleeding such as the trachea Temporary measure Valipour A et al. Chest 2005; 127:2113–2118

24. fogarthy embolectomy catheter or a tamponade balloon.Occluding the bleeding airway with fogarthy embolectomy catheter or a tamponade balloon. 4 Fr – segmental bronchi and 14 Fr for main stem bronchi. Bronchoscopic Treatment: Endobronchial tamponade

26. Double lumen, detachable Head, Freitag’s balloon Catheter This balloon catheter can stay in place (for several days) after removal of the bronchoscope rendering simple and safe patient’s transference to the OR, rigid bronchoscopy facilities or to the Angiographer for possible embolization.This balloon catheter can stay in place (for several days) after removal of the bronchoscope rendering simple and safe patient’s transference to the OR, rigid bronchoscopy facilities or to the Angiographer for possible embolization. Deflated ‐ few min 3 times/day to preserve mucosal viability and to check for bleeding recurrenceDeflated ‐ few min 3 times/day to preserve mucosal viability and to check for bleeding recurrence Successful in 26/27 bleeding >100mlSuccessful in 26/27 bleeding >100ml Bronchoscopic Treatment: Endobronchial tamponade Freitag L, et al. 3yrs experience with a new balloon catheter for the management of hemoptysis. Eur Respir J 1994; 7: 2033–2037 Freitag L, et al. 3yrs experience with a new balloon catheter for the management of hemoptysis. Eur Respir J 1994; 7: 2033–2037.

27. Lateralization possible not localization Urgent single lumen Intubation of the non- affected lungUrgent single lumen Intubation of the non- affected lung to protect non ‐ bleeding lung from aspiration Bronchoscopic Treatment: Endobronchial tamponade

28. Silicone Spigot Bronchoscopic Treatment: Endobronchial tamponade Dutau H et al. Respiration. 2006; 73: 830 ‐ 2

29. Nd-YAG laser: Effective when source of bleeding is visible→ endoluminal tumors simultaneous coagulation and devascularization of tissuesWhile suctioning, laser allows for simultaneous coagulation and devascularization of tissues surrounding the artery, leading to carbonization of the bleeding site. Bronchoscopic Treatment: Laser Photocoagulation

30. BeforeAfter

31. Noncontact electrocoagulation toolNoncontact electrocoagulation tool Argon plasma medium is employed to conduct high ‐ frequency electrical current through a flexible probeArgon plasma medium is employed to conduct high ‐ frequency electrical current through a flexible probe Blood is a good conductor for the high frequency current.Blood is a good conductor for the high frequency current. Effective dessication of a bleeding bronchus.Effective dessication of a bleeding bronchus. Shallow depth of penetration (2–3 mm vs 5-10 mm by Laser)Shallow depth of penetration (2–3 mm vs 5-10 mm by Laser) Bronchoscopic Treatment: Argon Plasma Coagulation

32. coagulation or cut result.Its’ application requires “dry” contact of the probe with mucosal lesion in order to produce coagulation or cut result. Can be effective with simultaneous suctioning of blood and secretions. Bronchoscopic Treatment: Bronchoscopic Treatment: Electrocautery

33. Cryotherapy: endoluminal malignanciesendoluminal malignancies Freezing causes vasoconstriction and development of microthrombi in venules & capillaries.Freezing causes vasoconstriction and development of microthrombi in venules & capillaries. Bronchoscopic Treatment: Cryotherapy

34. BI34 Avoid adverse effects on respiration, cardiac, and hemodynamic status: Beware anxiolytics and narcotics on Respiration Beware anxiolytics and narcotics on Respiration Reversing agents should be available Reversing agents should be available Consider intubation with a large endotracheal tube; Consider intubation with a large endotracheal tube; inserted over the bronchoscope. inserted over the bronchoscope.

35. not only for diagnosis emergency management of endobronchial bleedingIn cases of hemoptysis, bronchoscopy may be of value not only for diagnosis, but frequently for emergency management of endobronchial bleeding as well. many bronchoscopic modalities lack of large prospective, controlled studies has not allowed for concrete therapeutic guidelines.Although there are many bronchoscopic modalities for the management of hemoptysis, the lack of large prospective, controlled studies has not allowed for concrete therapeutic guidelines. Conclusion

36. personal experience local availability of equipment major role for the choice of therapeutic modalitiesThe Bronchoscopists personal experience together with local availability of equipment plays the major role for the choice of therapeutic modalities. goal is establishing airway patency and provisionally control bleeding transferred for embolization or surgery.The common goal is establishing airway patency and provisionally control bleeding until the patient is transferred for embolization or surgery. Conclusion

37. Thank you for your attention