Management of Hemoptysis

Management of Hemoptysis

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  MANAGEMENT OF HEMOPTYSIS Dr R.S Dhaliwal MBBS,MS,DNB(Surg),M.Ch,DNB(CTV Surg) FACS,FCCP,FNCCP,FICA,FIACS Prof & HOD , Cardiovascular & Thoracic Surgery, P.G.I.M.E.R, Chandigarh,India
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  INTRODUCTION • Hemoptysis- Expectoration of blood originating from the tracheobronchial tree or pulmonary parenchyma • Massive Hemoptysis – Expectoration Of >600 ml blood in 24 hrs • Very important symptom which brings the patient to the doctor quickly • Can occur directly or indirectally due to any chest disease
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  Etiology • Pulmonarytuberculosis – active or its late sequallae • Bronchiectasis • Bronchial carcinoma • Lung abcess • Aspergilloma • Pulmonary infarct • Necrotizing Pneumonia • Chest trauma –airways injury • Pulmonary AV malformation and telangiectasis • Iatrogenic –PA catheter Bronchoscopic biopsy • Cardiac Disorders –MS, Eisenmenger, Cyanotic CHD • Diffuse parenchymal disease-SLE,Wegner’s granuloma • Idiopathic
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  Investigations • SputumCytology • X-Ray Chest • CT Scan • Bronchoscopy • Angiography • Tuberculin test or ELISA tests
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  Management Objects ofManagement - Prevent asphyxiation Localize site of bleeding Arrest the bleeding Determine cause of hemoptysis Treat the patient definitively
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  Medical Management •Head low with bleeding side dependent • Sedation- Non narcotics • Volume Replacement - IV fluids -Blood transfusion • Clear airways of blood and secretions • Cough Suppressants • ATT- Use in active T.B. with hemoptysis -broad spectrum antibiotics
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  Methods to controlhemoptysis • Endobronchial Measures Ice cold saline Lavage Ballon Tamponade Pulmonary Isolation • Arterial Embolization • Mechanical Ventilation with PEEP • Vasoactive Drugs • Radiotherapy • Intracavitary Treatment
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  Surgical Therapy •Surgical rather than medical methods reduce mortality.Lung resections is most effective method to control massive hemoptysis and prevent recurrance of hemoptysis • Higher mortality in emergency surgery • Ongoing bleeding at time of surgery – most imp. factor for mortality. • Spillage of blood,pus and infected secretions in dependent normal lung–main cause of problems • Poor PFT –Very imp. cause of mortality & morbidity
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  Criteria for SurgicalTherapy • Localized site of bleeding • Adequate pulmonary functions • No medical contrindications • Resectable Br. carcinoma without distant metastases • No mitral valve disease ( requiring cardiac surgery)
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  Indications for Urgentsurgery • Fungus ball (almost all cases will rebleed after any control method) • Lung abcess ( erosion of a large vessel) • Failure of control methods • Cavity - with a movable mass, emptying and quick refilling, persistent radiodensity • Obstruction of the main or lobar bronchus due to a clot - can not be removed during rigid bronchoscopy • Endobronchial methods and arterial embolization can control hemoptysis In majority of patients temporarily
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  Surgical Techniques •Pulmonary Resections - Segmentectomy Lobectomy, or Pneumonectomy • Physiological Lung Exclusion • Collapse Therapy - Thoracoplasty or plombage • Cavernostomy and packing • Bronchial arteries ligation & ligation of chest wall collateral vessels • Anesthesia-Isolation of bleeding lung essential Single lung ventilation with Double lumen tubes Standard endotracheal tube in normal bronchus Endobronchial blocking catheters or gauze packing of bleeding bronchus also tried.
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  Pulmonary Resections •Standard treatment for massive / recurrent hemoptysis of any etiology.Removal of bleeding diseased lobe or lung is ideal. Postolateral thoracotmy is usual incision. Vascular adhesions present between lung and chest wall in T.B &infective diseases – makes it time consuming,more blood loss and difficult . May need pleuro pneumon-ectomy with higher mortality and complications like BPF, Empyema and space problems
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  Physiological Lung Exclusion • Life saving Alternative/Adjunct to a difficult or hazardous lung resection due to dense vascular adhesions,fibrosis and calcification between chest wall and lung • PHYSIOLOGICAL BASIS INVOLVED PART OF LUNG ISOLATED BY DIVISION OF * PULMONARY ARTERY * BRONCHUS & BRONCHIAL ARTERIES * VIABILITY OF ISOLATED LUNG MAINTAINED BY * VASCULAR ADHESIONS WITH CHEST WALL * INTACT PULMONARY VEINS FOR DRAINAGE
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  SURGICAL TECHNIQUE •ANTERO LATERAL THORACOTOMY • J STERNOTOMY • MINIMUM LUNG MOBILISATION- NEAR HILUM • PULMONARY ARTERY LIGATION DONE EXTRA OR INTRAPERICARDIALLY * INVOLVED BRONCHUS DIVIDED AND CLOSED * PULMONARY VEINS PRESERVED
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  RESULTS • Hospitalmortality Nil • Post Operative Empyema Nil • Residual Space Nil • Recurrance of Hemoptysis 1 (FOB - other side Bleeding ) • Follow up up to 18 yrs No Problem No BPF or Empyema
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  CONCLUSIONS PHYSIOLOGICAL LUNGEXCLUSION IS AN EFFECTIVE ALTERNATIVE OPERATION FOR CONTROL OF MASSIVE OR RECURRENT HEMOPTYSIS WHERE LUNG RESECTION IS DIFFICULT/HAZARDOUS DUE TO DENSE FIBROSIS, VASCULAR ADHESIONS & CALCIFICATION
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  Other Surgical techniques • Collapse Therapy - Thoracoplasty or plombage • Cavernostomy and packing • Bronchial arteries ligation & ligation of chest wall collateral vessels