Inflammatory diseases: bronchiectasis and chronic bronchitis
Neoplasms: bronchogenic carcinoma, carcinoid tumor, endobronchial metastases
Bronchovascular fistula: thoracic aortic aneurysms
Foreign bodies, trauma
Table 38.2
Lung parenchyma conditions
Infections: pneumonia, tuberculosis, lung abscess, fungal infections, (aspergilloma) |
Inflammatory or immunological diseases (diffuse alveolar hemorrhage): Goodpasture syndrome, systemic lupus erythematosus (SLE), granulomatous polyangiitis (Wegener), microscopic polyarteritis |
Coagulopathies: thrombopenia, anticoagulant or antiaggregant drugs |
Procedure complications: transbronchial lung biopsy, fine needle aspiration |
Miscellaneous: cocaine inhalation, catamenial hemoptysis, antiangiogenic drugs (bevacizumab) |
Table 38.3
Lung vasculature conditions
Same causes as that originating in lung parenchyma |
Intrinsic pathology or pulmonary vasculature: pulmonary embolism, arteriovenous malformation, aneurysms and pseudoaneurysms |
Increased pulmonary capillary pressure: mitral stenosis, left heart failure |
Iatrogenic: perforation of the pulmonary artery after a Swan-Ganz catheter placement [9] |
Bronchoscopy in Hemoptysis
Bronchoscopy plays a key role in the diagnosis and management of hemoptysis.
It allows confirmation in doubtful cases, location of the bleeding point or, at least, location of the affected lung, and the determination of the cause if the lesion is visible or accessible to endoscopic examination. It also allows the isolation of the hemorrhagic segment or lobe to avoid the spreading of blood to the bronchial tree and reduce the risk of suffocation. In this sense performing rigid bronchoscopy complemented by flexible bronchoscopy carries a great advantage. In cases where a rigid bronchoscope is not at hand, flexible bronchoscopy as the only endoscopic procedure can also be very useful. It can be performed at the bedside and allows selective intubation or bronchial balloon blockade, as well as the application of local therapies. It can contribute, even temporarily, to control bleeding and the application of more definitive treatments such as embolization of bronchial arteries or even, in selected cases, surgical treatment (Figs. 38.1 and 38.2) [13].
Fig. 38.1
Algorithm for bronchoscopy in threatening hemoptysis. With permission. Original Source: Cordovilla R, Bollo de Miguel E, Nuñez Ares A, Cosano Povedano FJ, Herráez Ortega I, Jiménez Merchán R. Diagnosis and treatment of hemoptysis. Arch Bronconeumol. 2016;52(7):368–377. Copyright © 2016 SEPAR. Published by Elsevier España, S.L.U. All rights reserved
Fig. 38.2
Nonthreatening hemoptysis algorithm. With permission. Original Source: Cordovilla R, Bollo de Miguel E, Nuñez Ares A, Cosano Povedano FJ, Herráez Ortega I, Jiménez Merchán R. Diagnosis and treatment of hemoptysis. Arch Bronconeumol. 2016;52(7):368–377. Copyright © 2016 SEPAR. Published by Elsevier España, S.L.U. All rights reserved
Diagnostic Bronchoscopy
In the event of severe hemoptysis, diagnostic bronchoscopy can help in many ways:
- 1.
Confirmation of hemoptysis and exclusion of pseudohemoptysis
Although the clinical history, the characteristics of the episode, and the initial physical examination may suggest the digestive or respiratory origin of the bleeding, sometimes the aspiration of at least part of digestive bleeding content causes cough and can simulate a true hemoptysis (pseudohemoptysis) which requires an ENT examination, a high digestive endoscopy or bronchofibroscopy to differentiate.
- 2.
Diagnostic of at least the side of bleeding, in anticipation to specific treatment
Although imaging studies (chest CT scan) can identify the origin of bleeding and its cause sometimes with a superior performance than bronchoscopy [14, 15], this is still necessary. It should be indicated early, especially in massive or life-threatening hemoptysis. Bronchoscopy reveals or confirms the origin of bleeding, especially if it is performed within 48 h of the onset of the episode and in cases of significant bleeding in 73–93% of cases of massive hemoptysis [14, 16].
In the case of threatening hemoptysis, it is advisable to perform bronchoscopy as soon as possible if the patient is unstable and once the patient has been intubated [17, 18]. Endoscopy through the ET tube is safer since the airway is secure and the endoscope can be withdrawn every time oxygenation worsens or the working channel is occluded by clots.
Rigid bronchoscopy can be used for the diagnosis and initial evaluation of threatening hemoptysis, but the flexible bronchoscope has some advantages to it such as the ability to reach the distal airway more easily. It can be used in the setting more suitable for the patient: ICU, shock room, bronchoscopy room, etc., without the additional delays of having to transfer the patient to the OR to undergo rigid bronchoscopy, or the radiology room to perform angiotomography.
Bronchoscopy also proves its value in those cases of non-revealing radiological studies or those that show bilateral or non-localizing abnormalities. In any case, even in those nonthreatening episodes, it provides useful information in the event that bleeding increases dangerously in a sudden and unpredictable manner.
Location of the bleeding site requires direct visualization of active bleeding, which determines with certainty one bronchus or the responsible bronchial area. The most frequent endoscopic finding is hematic remains and clots (Fig. 38.3). Locating blood clots does not guarantee the origin of the bleeding. However, a combination of findings such as a great number of clots adhering to a particular bronchus can suggest, together with the imaging techniques, the responsible area. Blood remains should be aspirated through repeated small bronchial washes, in order to improve permeability and allow diagnostic examination of the underlying territory. However, in the presence of fresh clots adhering, it is not advisable to aspirate them given the risk of further bleeding. Subsequently, bronchoscopy can be repeated to evaluate whether they can be removed with a smaller risk of rebleeding.
A cryoprobe can be used for the removal of an adherent clot. In order to do that, a cryoprobe is placed in the center of the clot and freezing activated during 3–4 s. The clot will adhere to the end of the probe and extracted en bloc with the bronchoscope just like a foreign body would do. This procedure should be done through an ET tube or through a rigid bronchoscope in order to have complete control of the airway in the event of bleeding (Figs. 38.4 and 38.5).
- 3.
Causal diagnosis, in case of accessible bronchial lesions
Bronchoscopy allows us to perform an endobronchial inspection and evaluate mucosal changes: hypertrophic or malformed capillary vascular network, areas of inflammatory or infiltrative mucosal thickening, bronchial stenosis, endobronchial tumors, antracosis or antracoestenosis, broncholiths, etc. (Fig. 38.6). In many cases, the changes are nonspecific and, therefore, nondiagnostic [19].
In addition to the visual examination, flexible bronchoscopy allows collection of samples for cytohistological and microbiological studies: bronchial lavage and bronchoalveolar lavage in the presence of suspected alveolar hemorrhage and biopsies and/or bronchial brushing in the presence of lesions suspected of malignancy. In the case of highly vascular lesions, some authors recommend local instillation of 1–2 mL of adrenaline 1:20,000 dilution, to reduce the risk of further bleeding, although clinical evidence is low [20].
Fig. 38.3
(a) Right superior bronchial lobe clot. (b) Right inferior bronchial clot. (c and d) Active bleeding
Fig. 38.4
(a) Tracheal clot. (b) Cryoprobe extraction. (c) After extraction
Fig. 38.5
Right bronchial tree clot
Fig. 38.6
(a) Vascular lesion right superior bronchus. (b) Tumoral infiltration at right B6. (c) Endobronchial mass right superior bronchus
Bronchoscopy also plays a very important role in nonthreatening hemoptysis with no apparent radiological alteration.
The existence of a normal chest X-ray in the context of hemoptysis does not exclude the possibility of malignancy or other underlying pathology [4, 12, 21, 22]. The probability of malignancy in patients with hemoptysis and normal chest X-ray is low but may reach up to 10% in patients over the age of 40, with a history of smoking [23], even in patients with mild hemoptysis [24].
Bronchoscopy can detect an endobronchial lesion in 5% of patients with mild hemoptysis and normal chest X-ray [25], and HRCT detects bronchiectasis in up to 70% of cases of severe hemoptysis and normal chest X-rays [14]. Therefore, depending on the type of hemoptysis, bronchoscopy can be performed before or after the complementary radiological tests:
- 1.
Hemoptoic expectoration: If there are no risk factors for cancer, bronchoscopy is indicated when these episodes are recurrent, or when the amount of bleeding increases [25]. In the case of patients with recurrent hemoptysis, the first step is to perform a chest CT scan (HRCT or MDCTD) as it may be useful to select the most cost-effective endoscopic technique for diagnosis (flexible bronchoscopy or endobronchial ultrasound) [7, 14, 26, 27].
- 2.
Evident hemoptysis: If there is no known cause, a bronchoscopy is necessary, especially in patients with risk factors for malignancy. However, depending on the stability of the patient, it may be advisable to perform a chest CT scan first. The combined use of bronchoscopy and MDCT increases the diagnostic yield for locating the bleeding site [14].
If the patient has a normal CT scan, bronchoscopy can diagnose the cause of bleeding in up to 16% of the cases. This percentage increases up to 37% when clinical history is also taken into account [23]. If bronchoscopy does not reveal changes, the patient is considered to have cryptogenic hemoptysis. A combination of CT and negative bronchoscopy has a very low probability of malignancy (1%) after a 6-month follow-up [28].
Therapeutic Bronchoscopy
Therapeutic bronchoscopy is specifically indicated to eliminate, at least transiently, a risk situation generally in the context of massive or threatening hemoptysis. Therefore, it is an urgent action applied in combination with other life-support measures, which seek to recover and keep the patient clinically stable. Diagnosis can then be completed with imaging techniques if the status of the patient allows and apply definitive treatment. Bronchial, systemic, and/or pulmonary embolization or surgical embolization can be used according to the situation. Generally, first evaluation of the patient should be oriented to estimate the severity of the condition and decide which treatment is most convenient and where it will take place.
Hemoptoic sputum does not require hospitalization, but evident and life-threatening hemoptysis does. In the latter case, admission to the ICU is warranted. Next, a quick and accurate diagnosis should be performed in order to locate the place of bleeding and determine its cause simultaneously.
The objectives of treatment are:
Secure the airway.
Maintain adequate oxygenation.
Achieve hemodynamic stability.
Locate and stop bleeding.
Identify and treat the cause of hemoptysis.
Management of the patient during hospital admission includes a series of general measures:
- 1.
Rest in bed in lateral decubitus, the affected side down, with the intention of protecting the airway and avoid aspiration of blood in the unaffected lung.
- 2.
Control of clinical parameters (blood pressure, heart rate and respiratory rate, oxygen saturation) and quantification of hemoptysis.
- 3.
Supplemental oxygen supply if necessary.
- 4.
Control of cough by administering antitussives, avoiding respiratory physiotherapy techniques.
- 5.
Empirical antibiotic treatment, useful in hemoptysis associated with respiratory infections and, in general, to prevent further complications.
- 6.
Nothing per oral, to avoid aspiration to the airway, and to allow the performance of urgent tests like bronchoscopy, CT or arteriography.
- 7.
Establishment of large-caliber venous access for fluid administration, availability of a blood reserve, and, if necessary, transfusion of packed red blood cells.
- 8.
Antifibrinolytic agents: aminocaproic acid and tranexamic acid (AT) administration. They act by inhibiting the process of dissolution of the clot with the consequent reduction of hemorrhage. A Cochrane review [29] identifies two clinical trials evaluating the use of AT (Amchafibrin®), both orally and intravenously. The results indicate that they may reduce the duration of bleeding, but the number of studies is limited and there is insufficient evidence for this recommendation. However, a review of published patient series concludes that although a recommendation cannot be given with strong evidence, TA can reduce both duration and volume of the bleeding, with a low risk of short-term thromboembolic disease [30]. The recommended dose is 500 mg–1 g intravenously two or three times per day, or 1–1.5 g two to three times a day.
Protection of the Airway
If there is severe respiratory failure or risk of suffocation (large and rapid bleeding), orotracheal intubation is required, preferably with a thick tube (8–9 mm) to facilitate diagnostic and interventional bronchoscopy [33].
In addition, bronchial blockade may be necessary to control bleeding in order to preserve ventilation of the healthy lung [15, 34]. There are several options to accomplish this (Table 38.4):
- 1.
Perform the blockage with the orotracheal tube itself. This is possible in bleeding from the right bronchial tree, since the left main bronchus can be selectively intubated with the aid of the bronchoscope, so that the pneumatic balloon of the tube completely isolates the left lung. It should be taken into account that in tall patients, the tube may not be long enough to adequately reach the main bronchus.
- 2.
Use independent bronchial blockers that are placed through a conventional tube:
- 2.1.
Fogarty inflatable balloon catheter (n° 7 or higher). This inflatable balloon is introduced parallel to the bronchoscope and it is placed at the selected location under direct vision. This maneuver can be facilitated by rotating the head to the opposite side, in a similar way than left main bronchus intubation with the rigid bronchoscope, and bringing the end of the tube closer to the tracheal carina. This device cannot be securely anchored during long periods of time, but it may allow to block completely the bleeding site with enough time for a clot to form and adhere [33]. The introduction of the catheter independently of the bronchoscope instead of through its working channel allows continuous suctioning and improved vision.
- 2.2.
Arndt endobronchial blocker® catheter (Fig. 38.7). It can be inserted transiently attached to the end of the bronchoscope to be transported to its location (size n° [7–9]). It has a transparent head of three ports: one to fix the catheter of the blocking balloon, another for the introduction of the bronchoscope, and the third one for the connection to the respirator.
- 2.3.
EZ-Blocker®. It is a catheter Y-shaped at its distal end, to facilitate anchorage at the tracheal carina, and two balloons that can be inflated separately.
- 2.4.
Cohen Flexitip Endobronchial®. It is a balloon catheter curved at its distal end to facilitate placement.
- 2.1.
- 3.
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Perform intubation and blockage with a special orotracheal tube:
- 3.1.
Torque Control Blocker Univent Tube®, which has a bronchial blocker that prolongs the tube itself, designed to occlude any major bronchi with the tube located inside the trachea (Fig. 38.8).
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- 3.1.