Management of massive hemoptysis with the rigid bronchoscope and cold saline lavage

Abstracts

BACKGROUND: Massive hemoptysis is a high morbidity and high mortality condition, independently of the treatment administered. A variety of methods are used to control the acute bleeding. The instillation of iced saline solution through a rigid bronchoscope was described in 1980. OBJECTIVE: To establish the efficacy of repeated instillations of iced saline solution (4ºC) using a rigid bronchoscope for the acute control of massive hemoptysis. METHOD: A group of 94 patients with massive hemoptysis was treated with rigid bronchoscopy and lavage with iced saline solution of the actively bleeding lung. The absence of bleeding recurrence within the following 15 days was considered a therapeutic success. The causes of hemoptysis included: pulmonary tuberculosis: 78 (83%), among which 48 had active disease, and 30 had tuberculosis sequelae, bronchiectasis (6), lung cancer (5), intracavitary aspergilloma (3), and unknown (2). The bleeding site was found in 93 patients (99%). The mean saline volume used in the bronchoscopy was 528 mL, ranging from 160 mL to 2,500 mL. RESULTS: All patients stopped bleeding during the procedure. Fifteen patients were submitted to some kind of procedure (surgery, embolization, or radiation therapy) within 15 days, and the efficacy of lavage could not be assessed. Twenty of the 79 patients followed-up for more than 15 days had recurrence of hemoptysis. Cold saline lavage was repeated once in 13 patients, twice in 6 patients, and 3 times in one patient. CONCLUSION: The control of tracheobronchial hemorrhage through bronchoscopy and lavage with iced saline is an effective procedure and can be repeated in case of re-bleeding. It is a safe procedure, and allows the definitive treatment to occur in better clinical conditions.

Hemoptysis; Tuberculosis; Bronchoscopy

INTRODUÇÃO: A hemoptise volumosa é uma condição com alta morbidade e mortalidade, independentemente do tratamento instituído. Vários métodos são utilizados para o controle do sangramento agudo. A instilação de soro fisiológico gelado através de broncoscópio rígido foi descrita em 1980. OBJETIVO: Determinar a eficácia de instilações repetidas de soro fisiológico gelado a 4ºC através de broncoscópio rígido no controle agudo de hemoptise maciça. MÉTODO: Uma série de 94 pacientes, com hemoptise maciça, foi tratada durante sangramento ativo com broncoscopia rígida e lavagem do pulmão sangrante com soro fisiológico gelado. Foi considerado sucesso terapêutico a ausência de sangramento nos 15 dias subseqüentes. Causas de hemoptise, com o respectivo número de pacientes: tuberculose pulmonar, 78 (83%), sendo tuberculose ativa em 48 e seqüela de tuberculose em 30; bronquiectasias, seis; câncer de pulmão, cinco; aspergiloma intracavitário, três, e desconhecida, dois. O sítio de sangramento foi localizado em 93 pacientes (99%). O volume médio de soro infundido durante a broncoscopia foi de 528ml e variou de 160ml a 2.500ml. RESULTADOS: O sangramento cessou durante o procedimento em todos os pacientes. Em 15 pacientes foi feita alguma intervenção (cirurgia, embolização ou radioterapia) num prazo menor que 15 dias, e nestes a eficácia da lavagem não pôde ser avaliada. A hemoptise recorreu em 20 dos 79 pacientes acompanhados por mais de 15 dias. Houve necessidade de nova lavagem com soro fisiológico uma vez em 13 pacientes, duas vezes em seis e três vezes em um paciente. CONCLUSÃO: O controle imediato da hemorragia traqueobrônquica com a administração de soro fisiológico gelado através de broncoscopia rígida é efetivo e pode ser repetido em caso de recorrência do sangramento. O procedimento é seguro e permite que o tratamento definitivo possa ser realizado em melhores condições clínicas.

Hemoptise; Tuberculose; Broncoscopia

ORIGINAL ARTICLE

Management of massive hemoptysis with rigid bronchoscopy and cold saline solution^*

Giovanni Antonio Marsico^I; Carlos Alberto Guimarães^II; Jorge Montessi^III; Antonio Miguel Martins da Costa^IV; Levi Madeira^V

^IThoracic surgeon

^IIAssociate Professor and Thoracic surgeon

^IIIThoracic Surgeon, Adjunct Professor at the Universidade Federal de Juiz de Fora and Coordinator of the Thoracic Surgery Department of the Hospital Universitário da Universidade Federal de Juiz de Fora

^IVPulmonologist

^VAssistant Professor of the Faculdade de Medicina (Medical School) Gama Filho- Rio de Janeiro. Former Thoracic Surgeon

^{Correspondence}

ABSTRACT

BACKGROUND: Massive hemoptysis is a high morbidity and high mortality condition, regardless of the treatment administered. A variety of methods are used to control the acute bleeding. The introduction of cold saline solution through a rigid bronchoscope has been previously described.

OBJECTIVE: To determine the efficacy of repeated flushing with cold (4°C) saline solution using a rigid bronchoscope for the acute control of massive hemoptysis.

METHOD: Ninety-four massive hemoptysis patients were treated with rigid bronchoscopy and washes of the actively bleeding lung with cold saline solution. The absence of bleeding over the following 15 days constituted therapeutic success.

Among the 94 patients, the causes of hemoptysis included 78 with pulmonary tuberculosis (48 had the active form and 30 had tuberculosis sequelae), 6 with bronchiectasis, 5 with lung cancer, 3 with aspergilloma and 2 with unknown etiology. In 93 of the patients, the bleeding site was located. The mean saline volume used in the bronchoscopy was 528 mL (range, 160 mL to 2500 mL).

RESULTS: All patients stopped bleeding during the procedure. Fifteen patients were submitted to some kind of procedure (surgery, embolization, or radiation therapy) within 15 days, and the efficacy of the lavage could not be assessed. Of the 79 patients who were monitored for more than 15 days, hemoptysis recurred in 20 and cold saline lavage was repeated: once in 13 patients, twice in 6 patients, and 3 times in 1 patient.

CONCLUSION: The control of tracheobronchial hemorrhage through bronchoscopy and cold saline flushes is an effective procedure and can be repeated in case of re-bleeding. It is a safe procedure and allows the definitive treatment to occur under more favorable conditions.

Key words: Hemoptysis. Tuberculosis. Bronchoscopy.

Introduction

In massive hemoptysis, regardless of the treatment modality, there are high rates of morbidity and mortality. The criteria used to characterize hemoptysis as massive vary, based primarily on the quantity of blood lost over a given time span, which, in a 24-hour period, can be from 100 ml to 600 ml or more.^(1-5)

In the majority of cases, death results from choking. Occasionally, the cause of death is acute anemia. Of the patients who, despite indication and being good candidates for surgery, were not operated upon, 80% died within a year due to recurrence of the hemoptysis. In massive hemoptysis, the risk of death by choking is imminent. Therefore, the patients need intensive care, constant monitoring and cannot be isolated. There are multiple reports of sudden death due to a new bleeding episode while a patient was waiting for diagnosis or treatment.^(2-4,6,7)

Several factors influence the evolution of voluminous hemoptysis, and characterization of the pulmonary hemorrhage is controversial. The volume of eliminated blood is important but is not the only determining factor. The following should be considered: a) the volume of exteriorized hemoptysis does not always correspond to the total hemorrhage (a great amount of blood may be retained in the tracheobronchial tree); b) a single episode of massive hemoptysis involves a greater risk of airway obstruction and alveolar flooding than multiple episodes during a 24-hour period involving an equal amount of bleeding; c) small and persistent hemoptysis episodes are capable of gradually deteriorating overall condition and pulmonary function; d) coughing is a defense mechanism which is effective against choking but is frequently absent in debilitated patients; e) when pulmonary function was previously impaired, even temporarily, the amount of blood necessary to cause choking is smaller; f) bleeding mechanisms such as those caused by a fistula between the aorta and the lung or by pulmonary abscess are considered more difficult to control than those related to lung infiltrates; g) severe concurrent diseases such as cardiopathy, kidney failure and diabetes worsen the prognosis; h) coagulopathy or anticoagulant use. Therefore, based on these conditions, it was suggested that the word "massive" be abandoned and a broader definition, such as life-threatening hemoptysis, adopted.^{(1,2,4,5,8,9-13)}

Several methods are used to control life-threatening hemoptysis, such as bronchial artery embolization, endobronchial lavage with cold saline solution, pneumoperitoneum, pneumothorax, bronchial blockage, selective bronchial intubation, laser treatment and vasopressin. In 1980, Conlan and Hurwitz⁽¹⁴⁾ showed that it was possible to control life-threatening hemoptysis with rigid bronchoscopy and endobronchial lavage with cold (4º C) saline solution.

The objective of the present study was to verify the acute and latent efficacy of endobronchial lavage with cold saline solution through rigid bronchoscopy in the control of life-threatening hemoptysis.

Patients and Methods

At the Institute of Phthisiology and Pulmonology of the Universidade Federal do Rio de Janeiro, 94 patients who presented hemoptysis of 400 ml or more over 24 hours were studied prospectively between July, 1984 and July 1990. During active bleeding episodes, the patients were submitted to rigid bronchoscopy and endobronchial lavage with saline solution chilled to 4º C. Patient ages ranged from 17 to 72 (mean, 34) and 65 of the patients were male.

Treatment was standardized for all patients and included chest X-ray; deep perforation of a vein (preferably the right internal jugular), blood transfusion (only when hematocrit was below 30%), arterial gas assessment, cardiac monitoring, oximetry, preanesthesia (1 mg/kg of meperidine, combined with intramuscular atropine) when possible, topical anesthesia with 2% lidocaine (gluteal or cricothyroid), sedation with intravenous benzodiazepine (early stages of the study) or with intravenous midazolam (later stages), and rigid bronchoscopy.

In the 94 patients who were actively bleeding, continuous oxygenation was used and the patients were positioned in dorsal decubitus with a transverse pad under the shoulders before the rigid bronchoscope was introduced, passing the vocal chords and reaching the trachea. In order to identify at least the main bronchus originating the hemorrhage, we sought to remove as much blood as possible through successive tracheal aspirations. The bleeding bronchus was then separately intubated. We started endobronchial lavage with 4º C saline solution, infusing 30–50 ml each time and aspirating at successive 10–20 second intervals. The flushing was repeated until the bleeding stopped. During the procedure, we tried to identify the lobar or segmental bronchus responsible for blood drainage. Frequently, the bronchoscope was withdrawn up to the trachea to better ventilate the nonbleeding lung. The material which was aspirated was sent for neoplastic cell testing, direct fungus testing and fungus culture, direct testing for acid-alcohol resistant bacilli and mycobacterium culture. Other exams were performed according to the diagnostic hypothesis.

After initial control of the hemoptysis, patients were sent to the intensive care unit, where they were positioned in lateral decubitus on the side of the bleeding, with their feet elevated and the headboard lowered. They were maintained on continuous oxygenation. Chest X-rays were taken and arterial gases were assessed daily. Morphine-like drugs were given to decrease cough reflex and achieve mild sedation. Broad-spectrum antibiotics were given. In order to clear the bronchial tree, flexible bronchoscopy was performed on subsequent days. If clinical and radiological data suggested active pulmonary tuberculosis, antituberculosis drugs were started immediately, even before bacteriological confirmation.

The patients were monitored for at least 6 months. In order for the therapy of rigid bronchoscopy and endobronchial lavage with cold saline solution to be considered effective, at least 15 hemorrhage-free days were required. This period was sufficient for any pharmacological treatment to take effect, as well as for adequate study and appropriate preparation of those patients for whom surgery was indicated.

Results

Pulmonary tuberculosis, in its many forms, was present in 78 (83%) of the patients. Of these, 41 (44%) had drug-sensitive active tuberculosis, 7 (6.4%) had multidrug resistant tuberculosis and 30 (32%) suffered from tuberculosis sequelae.

In addition, bronchiectasis was diagnosed in 6 (6.4%) patients, lung cancer in 5 (5.3%) and intracavitary mycetoma in 3 (3.2%). It was not possible to establish a diagnosis in 2 patients: the study was considered inappropriate in 1, and the anatomopathological pulmonary biopsy was inconclusive in the other (Table 1).

Previous hemoptysis, varying from hemopoeitic to great volumes, was reported in 40 (42.5%) of the 94 patients. In the presence of chronic inflammatory diseases or tuberculosis sequelae, the incidence was higher (56.7%).

Using rigid bronchoscopy and cold saline solution washes, immediate control of pulmonary hemorrhage was achieved in all 94 patients. The volume of cold saline solution used in the lavage varied from 160 ml to 2500 ml (mean, 582 ml). The mean duration of the procedure was 30 minutes.

Following the procedure, other methods of control or definitive treatment (clinical, surgical or radiographic) were used whenever possible. In 15 of the patients, it was not possible to evaluate the efficacy of endobronchial lavage over the subsequent 15 days. Since the procedure made those patients more fit, surgery, bronchial artery embolization or radiation therapy was carried out before the 15 days had elapsed.

Due to new hemoptysis episodes, 31 (33%) of the patients had to undergo at least one additional endobronchial pulmonary lavage with cold saline, 20 (21.3%) of them within the 15-day period. In 13 of those 20 patients, a second lavage was necessary, a third in 6 and a fourth in 1. Of the 31 patients who required additional lavages, 11 (35.4%) had active pulmonary tuberculosis, and more lavages were required in these patients. These additional lavages with cold saline solution were performed during the period from 12 hours up to 9 days after the initial procedure, and 6 were carried out within the first 2 days.

All 122 rigid bronchoscopies were performed during active bleeding. At the first bronchoscopy, the bleeding lung was identified in 93 (99%) of the 94 patients. In 54 (57.5%) of them, the bleeding was from the right lung, and it was from the left in 36 (38.7%). Bilateral bleeding, alternating between the upper lobes, was seen in 3 (3.2%) of the patients. In 49 (52.7%) of the cases, it was possible to identify the lobar location of the bleeding site: upper lobes in 29, lower lobes in 19 and middle lobes in 1. Lobar location was not always a concern, especially in lungs already destroyed by disease, since they presented partial bronchial stenosis and sever bronchial tree distortion. This condition often precluded the introduction of the rigid bronchoscope beyond the main bronchus.

Of the 30 patients with pulmonary tuberculosis sequelae, 18 (60%) presented bilateral involvement, and 4 (57%) of 7 had multidrug resistant tuberculosis. Of the 94 patients studied, 61 (65%) presented unilateral pulmonary lesions and 9 (14.7%) of those died. Bilateral lesions were present in 33 (35%), and 15 (45.4%) of those patients died. In 14 (15%) of the patients, severe unilateral or bilateral alveolar hemorrhage occurred. Of those 14, 10 had active pulmonary tuberculosis and 4 had pulmonary tuberculosis sequelae. Of the 10 with active pulmonary tuberculosis, the 7 with unilateral lesions died and the 3 with bilateral disease survived. Of the 4 with pulmonary tuberculosis sequelae, 3 died. Therefore a total of 10 (71.4%) of the patients with severe alveolar hemorrhage died.

Among the 41 patients with active drug-sensitive tuberculosis, 23 were treatment naïve and 18 had chronic pulmonary tuberculosis. Of the same 41 patients, 33 (80.5%) had unilateral lesions and 8 (19.5%) had bilateral lesions. In addition, in 30 (73.2%) of these patients, the hemoptysis was controlled with endobronchial lavage and cold saline solution, and they were treated with rifampicin, hydrazide and pyrazinamide. Of those 30, 25 (83.3%) were cured and 5 (16.7%) died. Only 1 death was attributed to hemoptysis recurrence (9 days after the first episode) and sepsis. The other causes of death were respiratory failure in 1, liver failure and malnutrition in 1 and sepsis in 2. Since their admission to the hospital, none of these 41 drug-sensitive tuberculosis patients had presented adequate stability to become candidates for surgery. After the initial control with cold saline solution, bronchial artery embolization was performed in 7 (17.1%) of them, among which, the only death was due to hemoptysis recurrence 24 hours after embolization (9 days after the first bleeding episode). Of the 41 patients with drug-sensitive tuberculosis, 4 were submitted to pulmonary resection: 1 for having refused specific medication; 1 for life-threatening hemoptysis recurrence after 3 months of corrective treatment and negative cultures; 1 without previous diagnosis; and 1 who had an impacted clot at the entrance of the right upper lobe bronchus. In this latter case, the clot could not be removed even after the bleeding had been controlled, and pulmonary resection was indicated due to risk of clot liberation and hemorrhage recurrence. In the global analysis of these 41 drug-sensitive tuberculosis patients submitted to several procedures and therapies for the control and treatment of life-threatening hemoptysis, 8 (19.5%) died and 33 (80.5%) were cured (Table 2).

Of the 30 patients with residual pulmonary tuberculosis, 18 (60%) had bilateral pulmonary lesions and 12 (40%) had unilateral lesions. To control hemoptysis, we used only rigid bronchoscopy and cold saline solution in 12 of them, all of whom had contraindications for the surgical treatment due to impaired lung function. Within this group, 5 (41.7%) died within the first months of follow up due to recurrence of life-threatening hemoptysis. At the end of 6 months of follow up, 2 (40%) were still living. Two patients in whom hemoptysis was controlled through endobronchial lavage with cold saline solution and bronchial artery embolization underwent pulmonary resection. Both died due to postoperative complications. In the group of 11 patients who underwent elective surgery after being submitted to endobronchial lavage with cold saline solution, only 1 death occurred (Table 3).

We monitored 7 patients with multidrug resistant tuberculosis. Initially, hemoptysis was controlled with cold saline solution, although, between days 6 and 10, 3 died from respiratory failure and sepsis. Three were operated upon, of whom 2 were cured and 1 died. Bronchial artery embolization was performed in 1 patient who refused surgical treatment. The patient was monitored for 6 months, during which there was no hemoptysis relapse.

Of the 6 patients with bronchiectasis, after initial control of hemoptysis with cold saline solution and preoperative preparation, 5 underwent surgery. One refused the surgery and was hemorrhage-free after 6 months.

The 5 lung cancer patients had large, nonresectable, centralized pulmonary tumors. After their hemoptysis had been controlled with cold saline solution, 3 underwent radiation therapy and did not bleed again during the 6-month follow up and 2 died (hemoptysis-free) within the same 6-month period.

After the initial control with cold saline solution, the 3 patients with intracavitary pulmonary mycetoma were submitted to surgical treatment and responded well.

The two patients with hemoptysis of unknown etiology remained hemoptysis-free for a year.

Discussion

Life-threatening hemoptysis has a recidivistic character and evolves with high morbidity and mortality. Once the hemoptysis control-diagnosis-treatment sequence has been established, the results improve.^(2,6,15-18)

Pulmonary tuberculosis, in its various manifestations, is the main cause of life-threatening hemoptysis, with an incidence of 52% to 73%. Active pulmonary tuberculosis contributes to 38% to 50% of the cases. In developed countries, bronchiectasis, rather than tuberculosis, is the main cause of life-threatening hemoptysis.^(4,15-20)

In 1980, Conlan and Urwitz⁽¹⁴⁾ published the results obtained from 12 patients who had life-threatening hemoptysis (600 ml or more in 24 hours) controlled with rigid bronchoscopy under general anesthesia and endobronchial lavage with cold (4º C) saline solution. Previously, in 1983, Conlan et al.⁽¹⁵⁾ confirmed the results in 23 additional patients. The volume of cold saline solution used varied from 300 ml to 750 ml (mean, 500 ml). Hemoptysis is probably halted due to vasoconstriction and arterial spasm induced by the cold saline solution. Blood flow reduction leads to thrombi formation and vascular occlusion.^(2,14,15)

We achieved immediate hemoptysis control in all of our 94 patients. The volume of cold saline solution used varied from 160 ml to 2500 ml (mean, 582 ml). Under topical anesthesia and sedation, patients were submitted to 122 rigid bronchoscopies and endobronchial lavages with cold saline solution. The procedure allowed us to control bleeding, define the hemoptysis site and make the diagnosis. Bronchoscopy caused no deleterious effect in terms of exacerbating the bleeding.

Bronchoscopy under anesthesia has some inherent disadvantages: anesthesia risk, the need for an experienced anesthesiologist and the need to have an operating room available on demand.⁽¹⁾

In life-threatening hemoptysis, the use of a rigid bronchoscope is imperative. The broad internal diameter allows adequate pulmonary ventilation, fast and efficient blood and clots aspiration, good endoscopic vision and selective lung intubation. The main disadvantages of using a fiberoptic bronchoscope are the small aspiration channel, which is easily obstructed with blood and clots; difficult endoscopic observation due to the lens being frequently obscured by blood and inadequate pulmonary ventilation.

After the bleeding has been controlled, the flexible device can be introduced through the bronchoscope lumen, or through orotracheal or tracheostomy canulas.^{(7, 9, 15, 16, 18, 21-23)}

Once the bleeding site has been identified, embolization, as well as other precise and selective types of surgery, can be performed. Only endoscopic examination can accurately locate the site of the bleeding. ^(24–31)

Through rigid bronchoscopy, Garzon et al.⁽²¹⁾ identified the hemoptysis site in 74 (100%) of the patients studied. In the literature, an 85% to 100% success rate has been shown. ^{(2,6,9,16,17,31,32)}

In 93 (99%) of the 94 patients, we were able to identify the hemoptysis site, almost always corresponding to single or widespread radiological lesions. In 3 (3.2%) of the 33 patients with bilateral lesions, we determined that hemoptysis occurred at different times in both superior lobes. Therefore, it is important that bronchoscopy be repeated at each new bleeding episode.

Rather frequently, we found tracheobronchial tree molds comprised of clots that resulted in atelectasis. Endoscopic removal of these clots leads to intensive bleeding due to the liberation of the previously retained blood. Although such removal is necessary; it is extremely dangerous to perform the procedure with the bronchoscope. Some of the cases of sudden death, characterized by fulminant hemoptysis, probably occur as a result of sudden clot release and liberation of retained blood. Fiberoptic bronchoscopy, performed on the days subsequent to the hemorrhage, was a preponderant factor for tracheobronchial clearance.

Approximately 80% of life-threatening hemoptysis originates in the bronchial arteries, 7% in the pulmonary arteries and 7% in the extrabronchial artery system.^{(24-26, 32-36)} Remy et al.^(24-26), using bronchial artery embolization, obtained immediate control of life-threatening hemoptysis in 85% of patients.

In 79 patients, during the first 15 days after endobronchial lavage with cold saline solution, no additional control methods or surgical treatments were used. Additional endobronchial lavage was necessary in 20 (25.3%) of these patients. We considered a 15-day period sufficient for arriving at a diagnosis and selecting a modality of clinical or surgical treatment.

Garzon and Gourin⁽¹⁸⁾, determined that, in surgery performed in the presence of life-threatening hemoptysis, 33% of the patients died. Of those who presented mild bleeding, only 7% died. Alveolar hemorrhage is an expected complication, with high morbidity and mortality. The ideal manner in which to manage these patients is to transform the emergency surgery into an elective procedure, with controlled hemoptysis and known pulmonary function. Borderline pulmonary function reinforces surgical indication, since it leads to increased risk of death by choking.^{(6,7,17,37, 38)}

Temporary or definitive impairment of pulmonary function is a negative predictor. We accompanied 14 patients with severe alveolar hemorrhage, 10 (71.4%) of whom died. Among the 33 who had bilateral pulmonary disease, 15 (45.4%) died. Tracheostomy is considered a lifesaving measure for those who evolve with bloody alveolar flooding or for those with extensive pulmonary disease. It facilitates lung ventilation, blood or secretion aspiration and is an appropriate preoperative preparation.

Throughout the study, we verified that all who bled massively invariably evolved with bronchopulmonary infection, especially those with large cavitary lesions. Seven deaths were directly attributed to infection. Thus, we started prescribing broad-spectrum antibiotics for unspecified microbes.

Conlan et al.⁽¹⁵⁾ used rigid bronchoscopy, cold (4º C) saline solution and tuberculostatic agents to control and treat active pulmonary tuberculosis and life-threatening hemoptysis in 11 patients, 9 (81.8%) of whom were cured.

Among our 41 patients with active pulmonary tuberculosis, after initial control of the bleeding with bronchoscopy and endobronchial lavage, 30 received rifampicin, hydrazide and pyrazinamide and 25 (83.3%) of them survived. We verified that, after 10 days, there was no relapse. Of the 41, 5 (16.7%) who were not stable enough to undergo surgical treatment died, but only one of the deaths resulted (after 9 days of antituberculosis drug use) from hemoptysis. Eleven (26.8%) of the patients with controlled hemoptysis, were treated with other control methods or received definitive treatment less than 15 days after the initial procedure.

Garzon and Gourin⁽¹⁸⁾ operated on 33 patients with active pulmonary tuberculosis, 25 with life-threatening hemoptysis. Crocco et al.⁽⁴⁾ operated on 16 patients under the same conditions. None of these authors used control methods. Perhaps most of pulmonary resections could have been avoided; if the hemoptysis had been controlled, the tuberculostatic agents would have had time to take effect.

Of the 30 patients with pulmonary tuberculosis sequelae and life-threatening hemoptysis, only 13 (43.3%) were fit for surgical treatment. In 12 (40%), hemoptysis was controlled with only rigid bronchoscopy and endobronchial lavage with cold saline. The authors were then able to study and evaluate the patients without hemoptysis. However, none of the patients had sufficient respiratory function to allow pulmonary resection. At the end of 6 months, 5 (41.7%) died due to hemoptysis recurrence. After endobronchial lavage with cold saline solution, we performed bronchial artery embolization in 7 (23.3%) patients, of whom 5 (71.4%) died: 2 due to hemoptysis recurrence, 1 due to infective complications and 2 who underwent surgery with borderline respiratory function and had complications in the postoperative period. Of the 11 (36.7%) patients who were operated upon after the hemoptysis had been controlled with bronchoscopy and cold saline solution, 10 (91%) survived and 1 (9%) died.

According to the medical literature, surgical mortality in patients with pulmonary tuberculosis sequelae and life-threatening hemoptysis varies from 26% to 36%. ^{(4,6,15,17-19, 22, 23)}

With rigid bronchoscopy and cold saline solution at 4º C, immediate control of life-threatening hemoptysis was obtained by Conlan et al.⁽¹⁵⁾ in 8 patients with bronchiectasis, 3 of whom were operated upon and 5 were stabilized. In the present study, we controlled bronchiectasis in 6 patients, allowing for study and appropriate mapping of the bronchial tree. Five patients underwent surgery and were cured. One patient refused the surgery and experienced no bleeding during the subsequent 6 months.

Life-threatening hemoptysis is rare in cases of lung cancer, occurring in only those 4% to 7.5% of patients whose tumors are, in general, centralized and nonresectable.^(35,36) Conlan et al.⁽¹⁵⁾ used cold saline solution washes to control hemoptysis in 6 such patients, 3 of whom were then treated conservatively and 3 of whom were then submitted to radiation therapy.

We performed follow up on the 5 (5.3%) of our patients who were suffering from lung cancer and life-threatening hemoptysis, all of whom were in a very advanced stage of the disease. They were treated with cold saline solution and remained hemorrhage-free for 15 days. Three were submitted to radiation therapy, and 2 who were not stable enough to be treated died after 3 months, although without presenting hemoptysis.

In cases of intracavitary mycetoma and hemoptysis, both the short-term and long-term effects of bronchial artery embolization are precarious.^(27,36)

We performed follow-up exams on 3 patients with fungal colonization of the tuberculous cavity and life-threatening hemoptysis that was immediately controlled with cold saline solution. Two days after the procedure, 1 patient was submitted to thoracostomy and, after 15 days, to pulmonary resection.

We concluded that endobronchial lavage with saline solution chilled to 4º C is an effective method of initial control in patients with hemoptysis of 400 ml or more in 24 hours. In addition, when there is life-threatening hemoptysis, we found it possible to identify the bleeding site in 99% of the patients. Furthermore, in patients with active pulmonary tuberculosis, the use of rigid bronchoscopy, cold saline solution and antituberculosis drugs to control hemoptysis prevented pulmonary resection and provided cure in 83.3% of the patients. Moreover, endobronchial lavage with cold saline solution allowed pulmonary resection to be performed while the hemoptysis was under control.

References

Submitted: 02/12/2002. Accepted, after revision: 14/06/2003.

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*

This study is a tribute to the Phthisiology and Pulmonology Institute of the Universidade Federal do Rio de Janeiro, which was closed as of February, 2000.

Publication Dates

• Publication in this collection
  02 Mar 2004
• Date of issue
  Oct 2003

History

• Received
  02 Dec 2002
• Accepted
  14 June 2003