1. Bronchoscopy-Guided Topical Hemostatic Tamponade Therapy for the management of Life-Threatening Hemoptysis
Arschang Valipour,MD:Alois Kreuzer,MD:Hubert koller,MD
Wolfgang Koessler,MD;and Otto Chris Burghuber,MD,FCCP
Chest 2005;127;

2. Study objects Acute massive hemoptysis: life-threatening condition:
High mortality:23-85%
Main threat:asphyxation of blood
Primary goal of Treatment:
airway maintenance and control of bleeding
Followed by Identifying of the site of and the underlying cause of bleeding
Double-lumen endotracheal tubes:achieve some of these goals but…

3. Study objects Therapeutic strategies: Early bronchoscopy
Interventional angiography(BAE)
Surgery
Temporary control of hemoptysis using Bronchoscopy:
cold saline solution lavage
instillation of topical vasoconstictive agents
balloon tamponade therapy
Endobronchial blocking techniques:Forgaty balloon catheter
→occlude the bleeding bronchus on a segmental level
Bronchoscopy guided topical hemostatic tamponade therapy(THT):
Overcome most problems mentioned above.

4. Material and methods Setting:
Interventional bronchoscopy unit of a 300-bed respiratory and critical care medicine referral center in Vienna
Patients:from Jan 2000 to Jan 2004,
486 patients required bronchoscopy for hemoptysis
76 pts required emergency bronchoscopy for massive hemoptysis
Definition of Massive hemoptysis:
bleeding rate > 150mL/hour of expectorated blood
≥ 150mL of expectorated blood on one occasion
clinical consequences:PaO2 < 60mmHg

5. Material and methods Bronchoscopy
Rigid bronchoscope was inserted in a standard manner and bleeding side identified
Patients head down(approximately 10°) toward the bleeding side
Flexible bronchoscope with aspiration channel through the rigid bronchoscope
Through flexible bronchoscope to confirm the bleeding site and clear the pph airways from blood
Bronchoscope was placed into a wedge position in the bleeding bronchus and Cold saline solution lavage
Cold saline solution lavage was started, instillation of a 1:20,000 epinephrine solution
Pts who were treated followings this procedure were excluded

6. Material and methods Bronchoscopic THT:
Performed on pts with persistent endobronchial bleeding despite wedging,cold saline solution lavage, regional instillation of epi
Hemostatic agent: oxidized regenerated cellulose(ORC)
sterile, knitted fabric after saturated with
blood, brownish or black gelatinous mass;
Aids in the formation of a clot
Serving as a hemostatic adjunct

7. Material and methods Effectiveness of Therapy:
ORC mesh:adhere to irregular surfaces and crevices, endobronchial tamponade; subsegmental to lobar bronchus level
Bleeding severity and bronchus diameter:4-10 layers of mesh
Effectiveness of Therapy:
Massive hemoptysis was controlled and free of hemoptysis for 48 hrs
Cx rates,duration of hospitalization,neccessity of BAE or repeat bronchosocopy, intensive care and surgery

8. Results Patient characteristics Initial 76 pts,
6 were failure to visual endobronchial lesion
13 pts:responded well to topical instillation
and/or iced saline solution lavage
57 pts remained

9. Results
Underlying diagnosis of life-threatening hemoptysis

10. Results Bronchoscopy-guided THT Site of bleeding: stem bronchus(10)
subsegmental(18),segmental(29),
THT performed in 56 of 57 pts:98%
All 56 pts free of hemoptysis for the first 48 hrs
Recurrent hemoptysis: between 3 and 6 days
mild:<30ml expectorated blood
moderate: 30 ~ 100ml
In 6 recurrent hemoptysis pts:underwent BAE
BAE in 6 pts:4 was successful

11. Results Complications, Morbidity, and Mortality Complications of THT :
postobstuctive pneumonia In 5 pts
Morbidity:
Mean duration of hospitalization:15.3±10.1 days
Mortality:
1-year survival rate:70%
None of the dead died from recurrence of hemoptysis

12. Results Bronchoscopic Follow-up studies N=14
No recurrence of hemoptysis
ORC absorbed in all pts without visible and histologic foreign body reaction

13. Discussion Life-threatening hemoptysis:
Bronchoscopic guided THT using ORC:
immediate control of hemoptysis in 98% of pts
6 pts:recurrence of mild to moderate hemoptysis:
→BAE
Complications:umcomplicated pneumonia

14. Discussions Severe endobronchial bleeding
immediate control of the airways is imperative
Achieved by double lumen tube:isolate and ventilate the lungs separately
But Difficult place properly, obstructed by clots
Also Hemoptysis control:
Iced saline solution lavage or
regional instillation of vasoconstictive agents:
→useful in mild-to-moderate hemoptysis
:13 of 76 pts:17%

15. Discussions THT:bleeding did not cease after these measures
Major factors for Hemostatic material such as ORC
hemostatic effect
tissue compatibilty,
absorption characteristics
Hemostasis:
selective tamponade of bleeding bronchus
After saturation with blood, thrombus formation
Oxidized cellulose:caustic activities →artificial coagulum
Tissue compatibility of ORC :
due to low pH →foreign body reaction↓,bactericidal environment
Absorption times:7 ~ 20 days without foreign body reactions

16. Discussions Bleeding resume:despite bronchoscopy: BAE, surgery
BAE:control of bleeding:60 to 95%
Not successful:23%, due to technical failure, collaterals
Surgical approach:
specific, large-vessel bleeding
parenchymal source

17. Conclusion
Endobronchial THT using ORC:
Safe practicable technique