Bronchoscopy in HaemoptysisBronchoscopy in Haemoptysis

Ashraf MadkourAshraf Madkour, , MD, Dr.med., FCCPMD, Dr.med., FCCPDepartment of Chest diseases,

Ain Shams University, Cairo, Egypt.

• Haemoptysis is a common presenting complaint in patients with pulmonary diseases.

• The development of bronchoscopy has provided an entirely new approach to the diagnosis of haemoptysis & bronchoscopic control of haemoptysis.

Introduction:Introduction:

• Haemoptysis:Haemoptysis:– severity, severity, approachapproach

• BronchoscopyBronchoscopy – Timing and Choice of bronchoscopeTiming and Choice of bronchoscope– Bronchoscopic TreatmentBronchoscopic Treatment

• Cold saline lavageCold saline lavage• Topical vasoconstrictive agentsTopical vasoconstrictive agents• Fibrinogen/thrombinFibrinogen/thrombin• Endobronchial tamponadeEndobronchial tamponade• Laser, Argon Plasma Coagulation, CryotherapyLaser, Argon Plasma Coagulation, Cryotherapy

Topics:Topics:

Blood Circulation in the lungs : 2 Components

Low pressure

Pulmonary Circulation

SBP = 15-20 mmHg

DBP = 5-10 mmHg

Patients with normal PAP ( no PAH) rarely bleed: only 5% of

massive hemoptysis

High pressure

Bronchial Circulation= systemic pressures

Bronchial arteries & collaterals originate from the aorta

The source of bleeding in most cases

One right BA

Two left BAs

Determined byDetermined byAmount & Rapidity of bleedingCardio-respiratory reserve: Effect on gas exchange

Severity of Haemoptysis:Severity of Haemoptysis:

Non massive haemoptysis*

Massive haemoptysis* Massive haemoptysis*

• 200-600 ml/24h 200-600 ml/24h •Medical emergency Medical emergency • 90% originates from bronchial circulation90% originates from bronchial circulation• Occur in 5% of haemoptysisOccur in 5% of haemoptysis• Mortality in 80%Mortality in 80%• Asphyxiation rather than exsanguinationAsphyxiation rather than exsanguination• Flooding of the airways and alveoli with bloodFlooding of the airways and alveoli with blood• >150 ml/attack (Life threatening haemoptysis)>150 ml/attack (Life threatening haemoptysis)

• <200ml/24h <200ml/24h

*no uniform definitions*no uniform definitions

• History & physical examinationHistory & physical examination– (Exclude Hematemesis, ENT source)(Exclude Hematemesis, ENT source)

• Chest x-ray ± CT scan Chest x-ray ± CT scan radiology hemoptysis - Copy.ppt

• Lab:Lab: – CBC , Coagulation studies, Blood transfusion matching & ABGCBC , Coagulation studies, Blood transfusion matching & ABG

• Assess severity:Assess severity:– Non massive: Non massive:

• Establish diagnosis → CT, Lab, FOBEstablish diagnosis → CT, Lab, FOB

– Massive:Massive:

Approach to case of haemoptysisApproach to case of haemoptysis

• Identify the site of bleeding Identify the site of bleeding – Comparable to CT for detecting the site of bleeding

especially in massive haemoptysis.– Detect subtle airway lesions not apparent in CT e.g.

ulcers not detected by CT

• Allow endobronchial managementAllow endobronchial management– Control active bleeding by different techniques

• Allow sampling form suspected lesionsAllow sampling form suspected lesions– Bronchial aspirates: Bronchial aspirates: cytology, AFB & culture.– Endo-bronchial or transbronchial biopsy Endo-bronchial or transbronchial biopsy from

central or peripheral tumors.

Is bronchoscopy necessary??Is bronchoscopy necessary??

Bronchoscopy: Bronchoscopy: Choice of bronchoscopeChoice of bronchoscope

Advantages:Advantages:• Requires local anesthesia• Tolerable by patient• Easy to manipulate & simplicity of use• Reach peripheral airways• Flexible maneuverability allow to perform BAL from

segmental and subsegmental bronchi.

Disadvantages: Disadvantages: • Unguaranteed ventilation• Narrow suction channel ?? • Limited interventional procedures application??

Fiberoptic bronchoscopeFiberoptic bronchoscope

Advantages:Advantages:• Wide suction channel • Ensure ventilation• Improving visualization

• Allow interventional procedures application e.g.– Gauze socked with adrenaline, Iced cooled saline, Laser,

Electrocautery, Cryotherapy

Disadvantages: Disadvantages: • Requires general anesthesia• Insufficient maneuverability to perform BAL• Need special skills• Don’t reach peripheral airways.

Rigid bronchoscopeRigid bronchoscope

Non-massive hemoptysis:Non-massive hemoptysis:• Visualizing site of bleeding is better with early vs better with early vs

delayeddelayed FOB, but timing did not alter Tx decisions or did not alter Tx decisions or clinical outcome. clinical outcome.

Massive hemoptysis:Massive hemoptysis:• FOB FOB → → wiwill delay timely and effective management.

• Early rigid bronchoscopyEarly rigid bronchoscopy → → will improve clinical will improve clinical outcomeoutcome (safeguarding airway patency, preserving ventilation, and

allowing better clearance of the airways, improving visualization).

• Combined rigid & FOB Combined rigid & FOB may be helpful in controlling haemoptysis form upper lobes and peripheral bronchi.

Bronchoscopy: Bronchoscopy: Timing Timing

• Repeated suctioningRepeated suctioning• Cold saline irrigationCold saline irrigation• Topical vasoconstrictive agents Topical vasoconstrictive agents • Glues and gauzesGlues and gauzes

– Fibrinogen/thrombinFibrinogen/thrombin– Cyanoacrylate glueCyanoacrylate glue– Oxidized regenerated cellulose (ORC) meshOxidized regenerated cellulose (ORC) mesh

• Endobronchial tamponadeEndobronchial tamponade• Laser, Argon Plasma Coagulation, CryotherapyLaser, Argon Plasma Coagulation, Cryotherapy

• There are no controlled trials in bronchoscopic There are no controlled trials in bronchoscopic techniques used to slow or stop bleeding. techniques used to slow or stop bleeding.

Bronchoscopic TreatmentBronchoscopic Treatment

• Lateral Lateral safety positionposition• Suction: Suction:

– Bronchoscopic – large bore: oral-pharynx

• Bleeding siteBleeding site– Note site – remember how to get back

• Tamponade the bleeding Tamponade the bleeding bronchus:bronchus:– Continuous or intermittent

suction and gravity dependent clot formation

stops most bleeding.

Bronchoscopic Treatment: Bronchoscopic Treatment: SuctionSuction

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Do not remove freshly formed clotDo not remove freshly formed clot

Once a clot forms, it is important to NOT remove it once bleeding has stopped. Inspection bronchoscopy (with or without clot removal can be performed the following day

Large blood clot causing a cast of the distal airway

Bronchoscopic Treatment: Bronchoscopic Treatment: Cold saline lavageCold saline lavage

• Cold Cold (4°C) N/S 0.9%(4°C) N/S 0.9% can be can be applied as small aliquots (applied as small aliquots (50ml50ml) or ) or lavage (avg. volume of lavage (avg. volume of 500 ml500 ml, range , range 300–750300–750 ml).* ml).*

• Immediate administration of large large aliquots of iced salinealiquots of iced saline using a wedged or partially wedged bronchoscope.

*Conlan AA et al J Thorac Cardiovasc Surg 1983; 85:120–124

• Agent – topical epinephrine (1:20,000)Agent – topical epinephrine (1:20,000)

• Effective in mild to moderate hemoptysis: Effective in mild to moderate hemoptysis: e.g. Bx, bronchial brushing

• Not useful for massive bleeding: Not useful for massive bleeding: the drug gets diluted and washed away.

• High plasma levels following endobronchial application.

• Significant CVS effects – hypertension & tachyarrthythmias.

Bronchoscopic Treatment: Bronchoscopic Treatment: Topical vasoconstrictive agentsTopical vasoconstrictive agents

Cahill BC et al Clin Chest Med 1994;15:147–167Cahill BC et al Clin Chest Med 1994;15:147–167

• Endoscopic instillation of Thrombin and Fibrinogen-Thrombin and Fibrinogen-Thrombin Thrombin Infusion in patients whom BAE was not possible.

• Infuse: – 5 to 10 ml of a 1,000 U/mI thrombin solution 5 to 10 ml of a 1,000 U/mI thrombin solution (thrombin for

topical use, Warner-Lambert)

– 5 to 10 ml of a 2 % fibrinogen solution 5 to 10 ml of a 2 % fibrinogen solution (fibrinogen, Green Cross, Japan)

Bronchoscopic Treatment: Bronchoscopic Treatment: Fibrinogen/thrombinFibrinogen/thrombin

Tsukamoto et al Chest 1989; 96: 473–476Tsukamoto et al Chest 1989; 96: 473–476

• N‐butyl cyanoacrylate ‐ biocompatible adhesive biocompatible adhesive

that solidifies on contact with humidity.solidifies on contact with humidity.

• A well known tissue glue used extensively in vascular and gastrointestinal field of medicine.

• Injected into the bleeding airway through catheter via FOB producing Endobronchial sealing.

Bronchoscopic Treatment: Bronchoscopic Treatment: Cyanoacrylate glue Cyanoacrylate glue

Bhattacharyya P et al. Chest 2002; 121: 2066–2069Bhattacharyya P et al. Chest 2002; 121: 2066–2069

Oxidized regenerated cellulose (ORC) meshOxidized regenerated cellulose (ORC) mesh

Bronchoscopic Treatment: Bronchoscopic Treatment:

Topical hemostatic Tamponade therapyTopical hemostatic Tamponade therapy

•Control of hemoptysis: achieved in 56 of 57 (98%) patients, who remained free of hemoptysis for the first 48 h.

• Not suitable for proximal sites of bleedingsuch as the trachea

• Temporary measure

Valipour A et al. Chest 2005; 127:2113–2118Valipour A et al. Chest 2005; 127:2113–2118

• Occluding the bleeding airway with fogarthy fogarthy embolectomy catheter or a tamponade embolectomy catheter or a tamponade balloon.balloon.

• 4 Fr – segmental bronchi and 14 Fr for main stem bronchi.

Bronchoscopic Treatment: Bronchoscopic Treatment: Endobronchial tamponadeEndobronchial tamponade

Bronchoscopic Treatment: Bronchoscopic Treatment: Endobronchial tamponadeEndobronchial tamponade

Double lumen, detachable Double lumen, detachable Head , Freitag’s balloon Head , Freitag’s balloon CatheterCatheter• This balloon catheter can This balloon catheter can stay in stay in

place (for several days)place (for several days) after removal after removal of the bronchoscope rendering of the bronchoscope rendering simple and safe patient’s transference simple and safe patient’s transference to the OR, rigid bronchoscopy to the OR, rigid bronchoscopy facilities or to the Angiographer for facilities or to the Angiographer for possible embolization.possible embolization.

• Deflated ‐ few min 3 times/day Deflated ‐ few min 3 times/day to to preserve mucosal viability and to preserve mucosal viability and to check for bleeding recurrencecheck for bleeding recurrence

• Successful in 26/27 bleeding >100mlSuccessful in 26/27 bleeding >100ml

Bronchoscopic Treatment: Bronchoscopic Treatment: Endobronchial tamponadeEndobronchial tamponade

Freitag L, et al. 3yrs experience with a Freitag L, et al. 3yrs experience with a newnew balloon catheter for the balloon catheter for the management of hemoptysis. Eur management of hemoptysis. Eur

Respir J 199Respir J 19944; 7: 2033–2037; 7: 2033–2037.

Lateralization possible not Lateralization possible not

localizationlocalization• Urgent single lumen Urgent single lumen

Intubation of the non-Intubation of the non-affected lungaffected lung to protect non‐bleeding lung from aspiration

Bronchoscopic Treatment: Bronchoscopic Treatment: Endobronchial tamponadeEndobronchial tamponade

Silicone SpigotSilicone Spigot

Bronchoscopic Treatment: Bronchoscopic Treatment: Endobronchial tamponadeEndobronchial tamponade

Dutau H et al. Respiration. 2006; 73: 830‐2Dutau H et al. Respiration. 2006; 73: 830‐2

Nd-YAG laser:Nd-YAG laser:• Effective when source of

bleeding is visible→ endoluminal tumors

• While suctioning, laser allows for simultaneous simultaneous coagulation and coagulation and devascularization of tissues devascularization of tissues surrounding the artery, leading to carbonization of the bleeding site.

Bronchoscopic Treatment: Bronchoscopic Treatment: Laser PhotocoagulationLaser Photocoagulation

Before After

• Noncontact electrocoagulation Noncontact electrocoagulation tooltool

• Argon plasma medium Argon plasma medium is is employed to cemployed to conduct high‐onduct high‐frequency electrical current frequency electrical current through a flexible probethrough a flexible probe

• Blood is a good conductor Blood is a good conductor for the for the high frequency current.high frequency current.

• Effective Effective dessication of a dessication of a bleeding bronchusbleeding bronchus. .

• Shallow depth of penetration Shallow depth of penetration (2–3 (2–3 mm vs 5-10 mm by Laser)mm vs 5-10 mm by Laser)

Bronchoscopic Treatment: Bronchoscopic Treatment: Argon Plasma Coagulation Argon Plasma Coagulation

• Its’ application requires “dry” contact of the probe with mucosal lesion in order to produce coagulation or cut coagulation or cut

result.result. • Can be effective with

simultaneous suctioning of blood and secretions.

Bronchoscopic Treatment: Bronchoscopic Treatment: Electrocautery

Cryotherapy: Cryotherapy: • endoluminal malignanciesendoluminal malignancies

• Freezing causes Freezing causes vasoconstrictionvasoconstriction and and development of development of microthrombimicrothrombi in venules & capillaries.in venules & capillaries.

Bronchoscopic Treatment: Bronchoscopic Treatment: CryotherapyCryotherapy

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Avoid adverse effects on respiration , cardiac, Avoid adverse effects on respiration , cardiac, and hemodynamic status: and hemodynamic status:

• Beware anxiolytics and narcotics on RespirationBeware anxiolytics and narcotics on Respiration

• Reversing agents should be availableReversing agents should be available

• Consider intubation with a large endotracheal tube; Consider intubation with a large endotracheal tube;

inserted over the bronchoscope. inserted over the bronchoscope.

• In cases of hemoptysis, bronchoscopy may be of value not only for diagnosisnot only for diagnosis, but frequently for emergency management of endobronchial emergency management of endobronchial bleeding bleeding as well. 

• Although there are many bronchoscopic many bronchoscopic modalities modalities for the management of hemoptysis, the lack of large prospective, controlled lack of large prospective, controlled studies studies has not allowed for concrete has not allowed for concrete therapeutic therapeutic guidelines.guidelines.

ConclusionConclusion

• The Bronchoscopists personal experience personal experience together with local availability of equipment local availability of equipment plays the major role for the choice of major role for the choice of therapeutic modalitiestherapeutic modalities.

• The common goal is establishing airway goal is establishing airway patency and provisionally control bleedingpatency and provisionally control bleeding until the patient is transferred for embolization transferred for embolization or surgeryor surgery..

ConclusionConclusion

Thank you for your attentionThank you for your attention