Diagnosis and Management of Massive Hemoptysis

1
Diagnosis and Management of Massive Hemoptysis

• Definition of massive hemoptysis (MH)
• Epidemiology of MH and time trends
• Prognosis of MH
• Diagnosis of MH
• Chest imaging
• Bronchoscopy
• Other

2
Diagnosis and Management of Massive Hemoptysis

• Treatment of massive hemoptysis
• Non-surgical options
• Airway management (e.g., tamponade, lavage)
• Bronchial embolization
• Other
• Surgical resection
• Medical vs. surgical therapy?

3
Diagnosis and Management of Massive Hemoptysis

• Definition of massive hemoptysis (MH)
• Epidemiology of MH and time trends
• Prognosis of MH
• Diagnosis of MH
• Chest imaging
• Bronchoscopy
• Other

4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
Diagnosis and Management of Massive Hemoptysis

• Definition of massive hemoptysis (MH)
• Epidemiology of MH and time trends
• Prognosis of MH
• Diagnosis of MH
• Chest imaging
• Bronchoscopy
• Other

11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
veins
29
Diagnosis and Management of Massive Hemoptysis

• Definition of massive hemoptysis (MH)
• Epidemiology of MH and time trends
• Prognosis of MH
• Diagnosis of MH
• Chest imaging
• Bronchoscopy
• Other

30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
Diagnosis and Management of Massive Hemoptysis

• Definition of massive hemoptysis (MH)
• Epidemiology of MH and time trends
• Prognosis of MH
• Diagnosis of MH
• Chest imaging
• Bronchoscopy
• Other

37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
Diagnosis and Management of Massive Hemoptysis

• Treatment of massive hemoptysis
• Non-surgical options
• Airway management (e.g., tamponade, lavage)
• Bronchial embolization
• Other
• Surgical resection
• Medical vs. surgical therapy?

47
, octreotide
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
(No Transcript)
52

• Desmopressin infusions (0.3 mcg/kg/min for 30
  minutes) were used
• in 6 patients with massive hemoptysis due to
  leptospirosis with
• rapid cessation of bleeding in all 6 patients.

From Am J Respir Crit Care Med 2003 167 726 -
728
53
Diagnosis and Management of Massive Hemoptysis

• Treatment of massive hemoptysis
• Non-surgical options
• Airway management (e.g., tamponade, lavage)
• Bronchial artery embolization
• Other
• Surgical resection
• Medical vs. surgical therapy?

54
(No Transcript)
55
There is substantial variation in bronchial
artery anatomy.
56
(No Transcript)
57
(No Transcript)
58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
(No Transcript)
63
(No Transcript)
64
(No Transcript)
65
(No Transcript)
66
(No Transcript)
67
(No Transcript)
68
(No Transcript)
69
N 16 patients with massive hemoptysis treated
with embolization
70
Diagnosis and Management of Massive Hemoptysis

• Treatment of massive hemoptysis
• Non-surgical options
• Airway management (e.g., tamponade, lavage)
• Bronchial embolization
• Other
• Surgical resection
• Medical vs. surgical therapy?

71
(No Transcript)
72
Rationale for Surgical Resection in Patients with
Massive Hemoptysis

• Large volume of expectorated blood and a rapid
  rate of hemoptysis are associated with increased
  mortality.
• At least in early series, in operable patients,
  mortality rates were lower in patients managed
  surgically than in medically managed patients
  (though medical management was conservative,
  i.e., without bronchial embolization,
  vasopressin).

73
equivalent
74
Sehhat, 1987)
75
(No Transcript)
76
(No Transcript)
77
(No Transcript)
78
(No Transcript)
79
(No Transcript)
80
Management of Hemoptysis in 2007

• Question What are the outcomes of cryptogenic
  hemoptysis?
• Cryptogenic hemoptysis Cause unknown after
  work-up
• Design Observational
• Methods Consecutive patients with cryptogenic
  hemoptysis admitted to Tenon Hospital (France)
  between December 1995 August 2004

From Savale L et al. Am J Respir Crit Care 2007
175 1181 - 1185
81
Management of Hemoptysis in 2007, contd.

• All patients had imaging and bronchoscopy
• Results Cryptogenic hemoptysis in 13 of all
  patients referred for hemoptysis (N 84 of 653)
• Data available in N 81
• Mean age 47.9 12.3 years
• Volume of blood on admission 190 ml (range 10
  1000 ml, median 100 ml)
• 35 with gt 200 ml

From Savale L et al. Am J Respir Crit Care 2007
175 1181 - 1185
82
Management of Hemoptysis in 2007, contd.

• Chest film with alveolar infiltrate in 20
• Bronchoscopy showed endobronchial blood in 93
  (N 75)
• Localized acute bleeding in 39
• Conservative management (no surgery, no
  bronchial arteriogram) in N 31 (mean 65 ml
  blood)
• Bronchial arteriography in N 50 (mean 270 ml)

From Savale L et al. Am J Respir Crit Care 2007
175 1181 - 1185
83
Management of Hemoptysis in 2007, contd.

• In all 50 bronchial arteriograms, abnormality
  found
• Arterial enlargement 86
• Local hypervascularity 64
• Systemic to pulmonary shunt 8
• Contrast extravasation 8
• Unable to cannulate artery (or spinal artery
  seen) in 14

From Savale L et al. Am J Respir Crit Care 2007
175 1181 - 1185
84
Management of Hemoptysis in 2007, contd.

• Bleeding controlled
• 100 of those treated conservatively (mean 65 ml
  blood 30 ml)
• 91 of those with bronchial arteriography
• Surgery needed in N 6 during initial
  hospitalization (because of failed bronchial
  arteriogram N 4 or uncontrolled bleeding N
  2) and N 3 later (because of recurrence)
• In 5 of 9, Dieulafoy disease (superficial vessel)

From Savale L et al. Am J Respir Crit Care 2007
175 1181 - 1185
85
Follow-up of Patients Treated for Cryptogenic
Hemoptysis

• Among 70 of 81 patients for whom follow-up was
  available for mean 47.3 months,
• No lung cancer developed
• Bleeding recurred in 14 (N 10), usually after
  1 month
• Among those treated conservatively, recurrence
  in 18
• Among those with bronchial arteriography,
  recurrence in 9 (p 0.17)

From Savale L et al. Am J Respir Crit Care 2007
175 1181 - 1185
86
Follow-up of Patients Treated for Cryptogenic
Hemoptysis

• Cumulative rate of control without recurrence
• 98.5 at 1 month
• 93.6 at 1 year
• 86.3 at 2 and 4 years (i.e., no recurrence
  after 2 years)

From Savale L et al. Am J Respir Crit Care 2007
175 1181 - 1185
87
Conclusions Regarding the Treatment of Massive
Hemoptysis in 2007

• In general, bronchial embolization is a
  reasonable first-line treatment for massive
  hemoptysis under the following conditions
• The source of bleeding has been lateralized.
• Experienced angiographers are available.
• Bleeding is not so profuse as to require a
  single, definitive treatment.
• The presumed cause of massive hemoptysis is
  likely to be controlled by bronchial
  embolization (e.g., not the PA, not mycetoma,
  etc.).

88
Indications for Surgical Resection of Massive
Hemoptysis in 2007

• The bleeding is life-threatening and is not
  controlled by alternate therapies (e.g.,
  bronchial embolization, etc.).
• Exsanguinating hemoptysis is occurring (e.g., gt
  1000 ml/24 hrs at gt 150 ml/hr).
• Life-threatening hemoptysis is not likely to be
  successfully controlled by bronchial
  embolization, e.g.,
• Mycetoma with many collaterals
• Pulmonary artery rupture (e.g., catheter-related)

89
Indications for Surgical Resection of Massive
Hemoptysis in 2007

• The bleeding is life-threatening and is not
  controlled by alternate therapies (e.g.,
  bronchial embolization, etc.).
• Exsanguinating hemoptysis is occurring (e.g., gt
  1000 ml/24 hrs at gt 150 ml/hr).
• Life-threatening hemoptysis is not likely to be
  successfully controlled by bronchial
  embolization, e.g.,
• Mycetoma with many collaterals
• Pulmonary artery rupture (e.g., catheter-related)