Topical and endobronchial management

Bronchial irrigation, vasoconstrictive agents, and topical coagulants

Cold saline lavage (4 °C), topical epinephrine (1:20 000), and topical thrombin and fibrinogen-thrombin solutions have been used with success in episodic case reports.

Endobronchial blockade and laser photocoagulation

Endobronchial balloon tamponade with embolectomy catheters (Fogarty) or pulmonary artery catheters have been used to control hemorrhage, to stabilize patients, and to treat patients with massive hemoptysis who are not considered suitable for embolization and/or surgery. The balloon remains inflated for 24 to 48 h at a maximum filling pressure between 30 and 50 mmHg (Jolliet eta/ 1992). Laser photocoagulation has been used with success in patients with bleeding from airway neoplasms.

Arterial embolization

Bronchial embolization has become a mainstay in the treatment of life-threatening hemoptysis. Embolization is an attractive alternative to surgery in patients with bilateral disease, multiple bleeding sites, or borderline pulmonary reserve. In the largest available single series, acute cessation of bleeding was reported in 91 per cent of 360 patients undergoing bronchial embolization ( Rabkin et.a[ 198.7). A long-term success rate of 78 per cent was reported in the same series. Recurrent bleeding is most common if the underlying process is hypervascularization. The technical failure reported is 4 to 13 per cent. Although highly successful in controlling acute bleeding, embolization may be associated with complications such as spinal cord ischemia (in 5 per cent of patients the anterior spinal artery originates from the right bronchial artery) and vascular obstruction to other organs. Fortunately, the frequency of 'ectopic' embolization in reported series is below 2 per cent.

Surgery

To the extent that surgery removes the bleeding lesion and the source vessels, resection is successful in arresting bleeding acutely as well as in preventing recurrence provided that the disease is localized to the resected segment and does not progress. All available series that compare surgical with medical therapy are observational; a randomized controlled trial of medical versus surgical therapy of massive hemoptysis has not yet been conducted. Older series are clearly in favor of surgical treatment, whereas more recent studies report lower mortality with medical management than with resection. Moreover, appropriate interpretation of medical mortality between series requires comparison of mortality rates among patients deemed operable but managed medically, since being considered inoperable itself suggests a poor prognosis (Corey and Hla . . ..1987). Nowadays, surgery seems best reserved for operable patients when bronchial embolization is not available, technically impossible, or unsuccessful, when the volume of hemoptysis requires definitive initial treatment (i.e. it is more than 1000 ml/24 h or is associated with hemodynamic or major respiratory compromise), or when the cause of massive hemoptysis is unlikely to be arrested by bronchial embolization (pulmonary artery perforation by a pulmonary artery catheter or mycetoma with profuse systemic collateral supply).

Contraindications to surgery are bilateral pulmonary disease with inability to localize the bleeding site, unresectable cancer, hemoptysis secondary to valvular heart disease, bleeding diathesis, or diffuse vasculitic process.

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