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PubMed2002

Massive hemoptysis: what place for medical and surgical treatment.

OBJECTIVE: The objective of the study was to define timing of surgical treatment in management of massive hemoptysis. METHODS: We performed a retrospective review of all patients admitted for massive hemoptysis in the intensive care unit of our thoracic surgery department. Treatment was managed according to the patient's status, the etiology of bleeding, the findings of bronchoscopy and computed tomographic scan. Therapeutic measures available were medical treatment, tracheal intubation (single or double lumen tube), interventional endoscopy, arterial embolisation and surgical treatment. RESULTS: Between September 1996 and December 2001, 43 patients were treated (nine females and 34 males with mean age of 54 years, range from 32 to 79). The mean red cell blood transfusion per patient was 1.57 Units. The patients were classified into three groups: Group 1, 11 patients were operated on immediately close to the bleeding crise (five pneumonectomy and six lobectomy); Group 2, five patients for whom operation was delayed from the 7th to the 22nd day after cessation of bleeding (five lobectomy); Group 3, 27 patients were treated by non-surgical methods (medical treatment, endobronchial treatment, percutaneous embolisation). Fifteen patients underwent an arterial embolization, which was complete in 13 cases. Among the five patients of group 2, cessation of bleeding was obtained by bronchial embolisation in four cases. Considering the whole series, 10 (23%) patients died: three (19%) patients in group 1, zero in group 2, seven (26%) in group 3. In two patients who were suffering from tumor necrosis, hemoptysis relapsed leading to death. CONCLUSION: Emergency thoracotomy for massive hemoptysis is at high risk. In case of bleeding from the arterial bronchial vessels, embolization may enable to postpone surgery and operate secondarily. In case of bleeding from the pulmonary vessels (tumor necrosis), surgical treatment must be immediate. An algorithm for management is proposed.

Acute Disease↗
PubMedDate not supplied

Fatal hemoptysis from Behcet's disease in a child.

OBJECTIVE: To present a case of pulmonary artery aneurysms (PAAs) in a child with Behcet's disease (BD). NATURE OF THE STUDY: Case report and review of the literature. MATERIALS AND METHODS: The patient had a complete autopsy, drug screen and serological testing. A medical history was obtained and the literature was reviewed. RESULTS: A 10-year-old African-American boy had massive hemoptysis while at home and died shortly thereafter in the emergency department of a local hospital. He had had two other episodes of hemoptysis in the past 2 months. At autopsy, he had bilateral inflammatory aneurysms of the lower lobe branches of the pulmonary arteries. The left aneurysm had eroded into the adjacent bronchus and accounted for the fatal hemoptysis. The right ventricle had endocardial fibrosis. Systemic vasculitis was absent. The child did not have oral, genital, eye or skin lesions at autopsy, or by clinical history. Based on the autopsy findings, a diagnosis of BD was made. CONCLUSIONS: We present the very unusual case of a 10-year-old African-American boy who died from hemoptysis resulting from bilateral pulmonary aneurysms caused by BD.

Aneurysm, Ruptured↗
PubMed2006

[Acute hemoptysis].

Hemoptysis is a frightening symptom for patients and is often a manifestation of a severe underlying disease. The main threat in the acute phase remains asphyxiation resulting from flooding of the airways with blood. In massive hemoptysis, correctly inserted double-lumen endotracheal tubes maintain airway patency. Finding the etiology and site of the hemoptysis is imperative. After excluding extrapulmonary sites of bleeding, computed tomography and bronchoscopy are complementary and may indicate pathologies not detectable by chest radiograph. An interdisciplinary approach including pneumologist, thoracic surgeon and radiologist in the management of hemoptysis is essential.

Acute Disease↗
PubMed2003

Massive hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT.

PURPOSE: To evaluate the diagnostic accuracy of chest computed tomography (CT) in the prediction of a nonbronchial systemic arterial supply in patients with massive hemoptysis. MATERIALS AND METHODS: Forty consecutive patients with massive hemoptysis underwent contrast material-enhanced CT. Massive hemoptysis was defined as the expectoration of 300-600 mL of blood per day. Two CT features were considered to be suggestive of a nonbronchial systemic arterial supply: (a) pleural thickness of more than 3 mm adjacent to the parenchymal lesion and (b) enhancing vascular structures within the extrapleural fat layer. Conventional angiography was used as the standard of reference. CT scans were evaluated by two radiologists in consensus. The CT findings were compared with those of conventional angiography. The sensitivity, specificity, predictive values, and accuracy of CT for predicting the presence of a nonbronchial systemic arterial supply were assessed. RESULTS: In the determination of a nonbronchial systemic arterial supply, CT had a sensitivity of 80%, specificity of 84%, positive predictive value of 73%, negative predictive value of 91%, and accuracy of 84%. Sensitivity was highest for predicting the branches of subclavian and axillary arterial supply and was lowest for predicting the internal mammary arterial supply. Specificity and accuracy were highest for predicting the intercostal arterial supply. CONCLUSION: CT demonstrates acceptable sensitivity, specificity, and accuracy in the prediction of a nonbronchial systemic arterial supply in patients with massive hemoptysis.

Adult↗
PubMed1996

Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization.

PURPOSE: To determine the efficacy of bronchial artery embolization in the control of massive hemoptysis due to pulmonary tuberculosis. MATERIALS AND METHODS: Between 1988 and 1994, 140 patients (125 men and 15 women; mean age, 31.5 years) who presented with massive hemoptysis (more than 300 mL of blood in 24 hours) underwent bronchial artery embolization. Fifty-one patients had received no antituberculosis drugs. Bronchial artery embolization was performed on the side with the greater abnormality on the chest radiograph. Catheters (4 F) and a gelatin sponge were used for embolization. Inflammatory hypervascularity was seen in all patients (five patients had contrast material extravasation and 10 patients had pseudoaneurysms). RESULTS: Almost complete control of hemoptysis was achieved in 102 patients. Of the remaining 38 patients with a notable amount of bleeding after the procedure, 29 were treated successfully with conservative measures and nine underwent re-embolization. Seven patients who underwent re-embolization had recurrent bleeding; four of these patients underwent successful surgery, and three died of aspiration. Two patients developed transient paraparesis 6 hours after the procedure. Nine patients reported transient referred pain to the ipsilateral orbit during injection of the gelatin sponge. One patient had transient dysphagia. CONCLUSION: Patients with massive hemoptysis due to pulmonary tuberculosis should first be treated with bronchial artery embolization.

Adult↗
PubMed1985

Pulmonary cavitation and massive hemoptysis in invasive pulmonary aspergillosis. Influence of bone marrow recovery in patients with acute leukemia.

The influence of bone marrow recovery on the clinical and radiographic course of invasive pulmonary aspergillosis in patients with acute leukemia has not been well characterized. We studied 26 patients with acute leukemia and invasive pulmonary aspergillosis, comparing those who recovered from chemotherapy-induced granulocytopenia (Group 1, 15 patients) with those who did not (Group 2, 11 patients). Radiographic evidence of pulmonary cavitation was not seen in any Group 2 patient, but developed in 11 of 15 (73%) Group 1 patients (p less than 0.005). In these patients, cavitation always occurred after marrow recovery, an average of 2.0 days (range: 0 to 6 days) after the granulocyte count exceeded 500/mm3. Eight patients in Group 1 and 2 in Group 2 experienced a total of 38 episodes of hemoptysis. Four of the 26 patients, all in Group 1, developed massive hemoptysis (greater than 150 ml of blood per episode), leading to 1 death. In 3 of these 4 patients, cavitation preceded the episode of massive hemoptysis. At the time of massive bleeding, the granulocyte count was greater than 500/mm3, the platelet count greater than 38,000/mm3, and the other coagulation parameters were normal in all 4 patients. Our findings demonstrate that in patients with acute leukemia undergoing chemotherapy, bone marrow recovery markedly influences the clinical and radiographic course of invasive pulmonary aspergillosis. Development of a granulocyte count greater than 500/mm3 is associated with pulmonary cavitation, and on occasion with massive hemoptysis.

Acute Disease↗
PubMed1993

Therapeutic embolization of bronchial artery: a successful treatment in 209 cases of relapse hemoptysis.

Still today bronchial artery embolization (BAE) is an important procedure in the management of hemoptysis, as an alternative to, or in association with, surgical or medical therapy. From 1974 to 1990, BAE was performed in 209 patients who suffered from hemoptysis with different etiopathogeneses and severity. Bronchiectasis were the most frequent indication (46%) followed by tuberculosis (31%), cystic fibrosis (16%), lung cancer (4%), and aspergillosis (3%). BAEs were performed by means of polyvinyl alcohol particles and absorbable gelatin sponge. In a few cases complete occlusion of the main truncus of particularly large bronchial arteries was obtained by use of Gianturco steel coin (5 mm o) technique. In the last seven years, together with the traditional angiographic techniques, selective digital angiography (SDA) was performed, above all in preliminary control phases, to evaluate occlusion during embolization. SDA reduced catheterization time and the mean quantity of contrast administered, decreasing side effects; 98% of hemoptysis was controlled in the first twenty-four hours, the other 2% in the following forty eight hours; 16% relapses occurred within the first year; 27 patients needed reembolization (15 patients twice, 11 patients three times, 1 patient five times). No complications were seen. If diagnosis, therapeutic indications, operative technique, and equipment selection are adequate, BAE has a high reliability in patients affected by relapsing hemoptysis, which is difficult to resolve.

Angiography, Digital Subtraction↗
PubMed1996

Evaluation and management of hemoptysis in infants and children. A report of nine cases.

Hemoptysis is an occasional complication of adult pulmonary disease and is rare in children. The most common causes in adults are infection, bronchiectasis, pulmonary neoplasm, cystic fibrosis, pulmonary infarct, and trauma; in children the most common causes are infection and congenital abnormalities of the cardiopulmonary vasculature. Nine cases of hemoptysis in seven infants and two children will be presented. Two cases were fatal, thus illustrating the importance of rapid and definitive therapy early in the course. One of the fatal cases is the first case report in the otolaryngological literature of fatal hemoptysis in the newborn as a result of vascular anomalies associated with an absent left pulmonary artery. Eight cases of various causes, including small vessel vascular abnormality, trauma, recurrent pulmonary infection, and laryngotracheal papilloma, are discussed. The literature is reviewed, embryology is discussed, and a mechanism of death is theorized for the patient with the congenital vessel anomaly. Management considerations for hemoptysis in infants and children are discussed.

Anti-Bacterial Agents↗
PubMed2000

Managing life-threatening hemoptysis: has anything really changed?

STUDY OBJECTIVES: To delineate current chest clinicians' approaches to the management of patients with life-threatening hemoptysis. DESIGN: Survey during a computer-assisted interactive continuing medical education presentation. SETTING: The 1998 American College of Chest Physicians (ACCP) Annual Scientific Assembly. PARTICIPANTS: Chest clinicians attending the respiratory emergency symposium. RESULTS: Most clinicians (86%) had cared for patients with life-threatening hemoptysis, and 28% had cared for patients with fatal events during the previous year. Those clinicians favored management in the ICU setting (95%) with early endotracheal intubation (85%), and they tended to use a large-bore, single-lumen endotracheal tube (57%). The majority (64%) favored the early performance of diagnostic bronchoscopy during the first 24 h. Most clinicians (79%) used the flexible instrument, a higher frequency than respondents at a similar symposium on hemoptysis at the 1988 ACCP meeting (48%; p < 0.0001). Most current clinicians (77%) had experience with endobronchial measures to control bleeding, but few (14%) found them to be consistently worthwhile. Chest CT scanning was often helpful in diagnosis (55%). In their management of bleeding, half of these clinicians favored the use of interventional angiography, even in operable patients, which is a substantial change from 1988 when 23% had favored this approach (p < 0.0001). CONCLUSIONS: During the past decade, life-threatening hemoptysis has remained an important problem. Flexible bronchoscopy and interventional angiography have become increasingly established, more widely accepted approaches to patient care.

Angiography↗
PubMed1979

Selection of patients with hemoptysis for fiberoptic bronchoscopy.

One hundred ten hospitalized patients with hemoptysis were reviewed to identify factors that would characterize those with malignancy and to evaluate the usefulness of fiberoptic bronchoscopy (FB) in the diagnosis of hemoptysis. Seventy patients underwent FB. This procedure was diagnostic in 22/28 (79 percent) of the carcinoma patients and in 26/42 (62 percent) of the patients with a nonmalignant cause of hemoptysis. The following three characteristics indicate a high probability of malignancy: 1) age greater than 40 years, 2) any abnormality on the chest roentgenogram, 3) hemoptysis lasting greater than one week. If any of these factors are present, FB should be done. Other factors to be considered include presence of anemia, weight loss, persistent cough, long smoking history and risk of bronchoscopic complications.

Adult↗
PubMed1988

Utility of fiberoptic bronchoscopy in patients with hemoptysis and a nonlocalizing chest roentgenogram.

The need for fiberoptic bronchoscopy in the patient with hemoptysis and a normal or nonlocalizing chest roentgenogram remains a subject of debate. Currently, diagnostic fiberoptic bronchoscopy is recommended as the investigative procedure of choice. To develop predictors that identify the patient in whom fiberoptic bronchoscopy is most likely to be diagnostic, we reviewed our community's experience with this population over a five-year period. We identified 196 patients with hemoptysis and a normal or nonlocalizing chest roentgenogram who underwent fiberoptic bronchoscopy. Three quarters were active or previous smokers. We examined the relationship of advancing age, sex, smoking, nonspecific roentgenographic findings and the amount, duration, and previous bouts of hemoptysis to the incidence of a diagnostic fiberoptic bronchoscopy. Twelve patients (6 percent) had bronchogenic carcinoma and 33 (17 percent) another specific cause for the hemoptysis identified by fiberoptic bronchoscopy. By univariate and discriminant analyses, we found that the three factors of age of 50 years or more, male sex, and smoking of 40 pack-years or more best predicted a diagnosis of malignancy. Bleeding in excess of 30 ml daily was associated with an increase in overall diagnostic yield. The presence of two of the three factors associated with malignancy or bleeding in excess of 30 ml daily (or both) identified 100 percent of the patients with bronchogenic carcinoma and 82 percent of all of the diagnostic fiberoptic bronchoscopic procedures. use of these criteria in selecting the patient for fiberoptic bronchoscopy could have reduced our use of the bronchoscope by 28 percent, with the remaining patients safely observed.

Adolescent↗
PubMed1989

Treatment of hemoptysis patients by thrombin and fibrinogen-thrombin infusion therapy using a fiberoptic bronchoscope.

We report the results of a simplified fiberoptic bronchoscopy-based procedure for thrombin and fibrinogen-thrombin infusion therapy in hemoptysis patients. A total of 33 patients with frequent bloody sputum or hemoptysis received either thrombin (19 cases) or fibrinogen-thrombin (14 cases) infusion therapy. Massive hemoptysis was present in ten patients receiving thrombin therapy and nine patients receiving fibrinogen-thrombin therapy. Thrombin therapy was very effective in 14 cases, effective in one case and ineffective in four cases. Fibrinogen-thrombin therapy was very effective in 11 cases and somewhat effective in three cases; two of these three patients had tuberculosis and the third required emergency surgery for removal of a foreign object in the bronchus. We conclude that infusion therapy using a fiberoptic bronchoscope is a simple and effective low-risk technique of choice for the treatment of hemoptysis patients.

Bronchoscopes↗
PubMed1990

Bronchial artery embolization for severe hemoptysis in cystic fibrosis.

We studied the long-term outcome after BAE for life-threatening hemoptysis in patients with CF. Data from pulmonary function tests were available for 18 of the 25 patients followed. A case-control comparison revealed that these 18 patients died sooner than hemoptysis-free patients with CF matched for age, sex, and pulmonary function (p less than 0.02), with the excess mortality occurring within the first three months after BAE. Of all 25 patients followed, six died of cardiorespiratory failure within three months of BAE; in two of them, hemoptysis was a contributing cause of death. The 19 patients who lived more than three months after BAE had a mean survival after embolization of 3.5 years (five were still alive at the end of the study). Most patients experienced long intervals (greater than 1 year) free of major hemoptysis. Extended follow-up (mean, 35 months) revealed a higher incidence of recurrent severe bleeding than previously reported for 13 of these patients followed a mean of 11 months. Repeat BAE for severe recurrence was performed successfully in eight of nine patients, without complication.

Adult↗
PubMed2000

Recurrent hemoptysis in tuberculosis with non-cavitary lung disease as a symptom of mild hemophilia A in a young adult.

Hemoptysis in patients with tuberculosis is usually associated with smear-positive and cavitary lung disease. The present case describes a patient suffering from recurrent hemoptysis associated with tuberculosis who had smear-negative and non-cavitary lung disease, and who was subsequently diagnosed as having mild hemophilia A. Although mild hemophilia A sometimes escapes detection until adolescence, there has been no reported case of mild hemophilia A detected by recurrent hemoptysis due to pulmonary tuberculosis. Here, we report a rare case of recurrent hemoptysis in a patient with tuberculosis who had smear-negative and non-cavitary lung disease and who was finally shown to have hemophilia A.

Adolescent↗
PubMed1999

Internal mammary artery embolization for hemoptysis.

PURPOSE: The purpose of this study was to determine the factors influencing development of blood supply from the internal mammary artery and to discuss the value of embolization of the abnormal branches from this vessel using small particles following occlusion of the normal distal branches using microcoils in treating hemoptysis. MATERIAL AND METHODS: Five patients with hemoptysis underwent internal mammary artery embolization with coaxial microcatheter systems. Bronchoscopy, chest radiographs, and CT were performed to determine the site and extent of the basic disease before embolotherapy in all patients. RESULTS: In all patients, pulmonary lesions had extended from the lung to the adjacent pleural surface at the anterior lung field. Four patients underwent embolization from the proximal portion of the internal mammary artery following distal coil embolization. One patient who underwent only proximal embolization had recurrent bleeding. CONCLUSION: The internal mammary artery contributes to the perfusion of lesions responsible for hemoptysis when the basic lesion involves the pulmonary parenchyma adjacent to the anterior pleural surface. Initial distal occlusion of the internal mammary artery may improve the efficacy of embolization of this artery for hemoptysis.

Aged↗
PubMed1985

Cryptogenic hemoptysis. Clinical features, bronchoscopic findings, and natural history in 67 patients.

We reviewed the clinical outcome of 67 patients with hemoptysis and a normal or nonlocalizing chest roentgenogram and nondiagnostic fiberoptic bronchoscopic examination. During a 38 +/- 22 (SD) month period after bronchoscopy, 57 (85%) patients remained well without evidence of active tuberculosis or overlooked bronchogenic carcinoma, and 9 patients died of nonpulmonary conditions. One patient developed bronchogenic carcinoma 20 months after bronchoscopy and resolution of symptoms. Hemoptysis had resolved completely before hospital discharge in 38 (57%) patients, within 6 months in 60 (90%), and recurred in only 3. Five patients (7.5%) had intermittent episodes of bleeding for more than 1 year. Fiberoptic bronchoscopy effectively excludes specific underlying causes of hemoptysis in the setting of a normal chest roentgenogram. The prognosis for patients with cryptogenic hemoptysis is generally good, usually with resolution of bleeding within 6 months of evaluation.

Adult↗
PubMed1999

Munchausen's syndrome. A case of factitious hemoptysis.

Factitious hemoptysis is the bleeding type of Munchausen's syndrome, rarely reported in the literature (only seventeen cases). After a careful and detailed literature review, the authors report the case of a 22-year-old working-woman, with a history of asthma, Mediterranean anaemia and recurrent hemoptysis, who was admitted several times to the cardiovascular and Respiratory Sciences Department in the Carlo Forlanini Hospital in 1994 for an asthmatic attack and wheeziness at rest. During the admissions the patient underwent laboratory tests (such as the examination of sputum specimens, urinalysis, tuberculin test, cold agglutinins and pneumotropic virus tests) and diagnostic studies (fiberoptic bronchoscopy with bronchoalveolar lavage, computerized tomography and radiography of the chest, bronchial arteriography, bronchography, perfusion and ventilation lung scan), because she continually presented with hemoptysis, in order to spot and discover the nature of the bleeding. Since such examinations failed (a few of them-namely fiberoptic bronchoscopies--were even performed when she was coughing up blood) and psychiatric consultations revealed the presence of psychologically traumatic events in the patient's history which could explain the psychopathic traits of her personality (in fact she was aggressive and unstable in interpersonal relations), a diagnosis of factitious hemoptysis in Munchausen's syndrome was made.

Adult↗
PubMed1999

[Impact of gender and influence of tobacco on the etiology of patients with hemoptysis].

OBJECTIVE: To evaluate the importance of the sex and the influence of tobacco on the etiology of patients with hemoptysis. METHODS: We analyzed and compared the etiology of 394 consecutive patients with hemoptysis, divided in two groups: I (males) and II (females), and stratified in relation to tobacco. RESULTS: 305 males (77.4%) and 89 females (p < 0.0001). Lung cancer was more frequent in both groups (26.9%), especially squamous cell carcinoma, but nonmalignant etiologies were more common when we considered all globally (73.1%), including chronic obstructive lung disease (COPD) (14.9%) or bronchiectasis (20.4%) as the more frequent diseases, and 14.2% of unknown etiology (5.2% if we excluded bronchitis or lung infections). Lung tuberculosis was decreased (1.5%) in relation to a increased frequency of its sequelaes or residual lesions (10%). The initial increased frequency of lung cancers or COPD in males and bronchiectasis or heart diseases in females disappeared after the stratification and elimination of the tobacco effect. CONCLUSIONS: Hemoptysis was more frequent in males and nonmalignant etiologies were more common in both groups, with similar rates as in previous literature and a low number of cases with a unknown etiology associated to a protocolized study and the increased use of diagnostic procedures. In our study, the etiology of patients with hemoptysis was sex independent, to show that the susceptibility to tobacco illness was similar in both sexes.

Adolescent↗