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(Chest. 2002;121:2066-2069.)
© 2002 American College of Chest Physicians

New Procedure: Bronchoscopic Endobronchial Sealing*

A New Mode of Managing Hemoptysis

Parthasarathi Bhattacharyya, MD, DNB, DM; Anjan Dutta, MBBS, DA; Ananta Narayan Samanta, MBBS and Samrat Roy Chowdhury, MBBS

* From the EKO Bronchoscopy Centre, Calcutta, India

Correspondence to: Parthasarathi Bhattacharyya, MD, DNB, DM, EKO Bronchoscopy Centre, 54, Jawaharlal Nehru Road, Calcutta, India, 700 071; e-mail: papai{at}caltiger.net.in


   Abstract
TOP
 Abstract
Introduction
 Methods and Materials
 Results
 Discussion
 References
 
Six patients with hemoptysis were treated by endobronchial sealing, with n-butyl cyanoacrylate, of the bleeding segment or subsegment. There was an immediate arrest of bleeding without any recurrence for a mean follow-up period of 127 (± 67.17) days. Endobronchial sealing appears to be an effective method of managing hemoptysis.

Key Words: endobronchial sealing • fiberoptic bronchoscopy • hemoptysis • n-butyl cyanoacrylate


   Introduction
TOP
 Abstract
 Introduction
Methods and Materials
 Results
 Discussion
 References
 
Hemoptysis is a common clinical problem.1 The source of bleeding lies, usually, in the tracheobronchial tree and rarely in the nose, pharynx, or larynx.2 Management of hemoptysis aims to stop the bleeding, replenish the blood loss, and treat the underlying etiology. Hemostasis is often difficult to achieve when the conservative treatment fails. Several bronchoscopic techniques, such as the bronchial tamponade, have been used to arrest bleeding.3 We have adopted a method of treating hemoptysis by selective placement of a catheter in the bleeding segment (or subsegment), with the help of a fiberoptic bronchoscope, and instillation of a sealant, n-butyl cyanoacrylate, a biocompatible glue that has been used successfully in several other hemostatic and sealing procedures.6


   Methods and Materials
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 Abstract
 Introduction
 Methods and Materials
Results
 Discussion
 References
 
Selection of Patients
Patients with prolonged (> 7 days) hemoptysis despite continued conservative therapy were selected for the endoscopic procedure. Proper informed consents were obtained. A total of six patients (4 were male, 2 were female), with an average (±SD) age of 56.1 (± 8.33) yr, were treated with the endoscopic procedure (Table 1) . Each patient was clinically evaluated for the possible site and cause of bleeding, and the approximate amount of blood loss was determined. The baseline investigations, such as percentage hemoglobin, packed cell volume, total and differential leukocyte count, erythrocyte sedimentation rate, prothrombin time, partial thromboplastin time, platelet count, and chest roentgenograms were obtained in all of them. CT scan (thorax) was done in four patients. There was no coagulation problem in any of the patients. Sputum smears for acid-fast bacilli were negative in all the patients on at least three different occasions. Two patients (Table 1) , who were diagnosed to have pulmonary tuberculosis from the radiologic appearances, showed good clinical response to antitubercular drugs. One patient with past history of treatment for tuberculosis had multiple patchy areas of fibrosis and bronchiectasis. In the other three patients, the etiologic diagnoses were not clear. Fine needle and/or transbronchial needle aspirations revealed no malignancy on cytological examinations in two patients. The aspiration smears did not reveal any infective agent on Gram and Ziehl-Neelsen staining. The patients, however, responded positively to antibiotics. There was no contraindication to bronchoscopy in any of the patients according to the guidelines of the American Thoracic Society.7


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  		Table 1.. Details of Bronchoscopic Endobronchial Sealing

 
Fiberoptic bronchoscopy was done in the morning hours after an overnight fasting. After mild sedation (intramuscular injection of promethazine, 25 mg, with atropine, 0.6 mg, 30 min before the procedure), the nose, pharynx, and upper airways were sprayed with lidocaine (4% solution), and fiberoptic bronchoscopy was performed (Pentax FB 18 P bronchoscope; Pentax; Tokyo, Japan) through transnasal route. Intra-airway spray of lidocaine (2%) was used as necessary. Blood from the tracheobronchial wall was cleared by saline, and the bleeding segment/site was detected. This was further confirmed by asking the patient to cough, resulting in fresh bleeding. A polyethylene catheter with an outer diameter of 2 mm was passed through the bronchoscope channel to place it slowly into the bleeding segment (Figure 1) . Thereafter, 0.5 mL n-butyl cyanoacrylate glue was injected through the catheter with a water column behind, which was just adequate to flush the glue into the targeted area. The catheter was withdrawn within a few seconds along with the bronchoscope. The scope was passed again after 2 to 3 min to confirm the absence of bleeding. The same procedure was repeated until the hemostasis was achieved. Fresh bleeding was noticed after removal of the clot in one patient, but the procedure was successfully performed at the same sitting after ensuring hemostasis with bronchoscopic wedging and local instillation of adrenaline solution.



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  		Figure 1.. (A) A catheter meant for passing through the fiberoptic bronchoscopic channel for gluing; (B) the bronchoscope in situ, with the catheter tip out from the distal end; and (C) placement of the catheter in the bleeding subsegment and instillation of the glue endobronchially.

 

   Results
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 Abstract
 Introduction
 Methods and Materials
 Results
Discussion
 References
 
The bleeding stopped immediately following the procedure in all the patients. Repeat endoscopic examination after a few minutes revealed the glue as a shiny white substance on the adjacent bronchial wall in two patients; no glue was seen in the bronchoscopic examinations performed after 72 h. All the patients experienced post-procedure cough on the same evening or the next morning, and five of them required cough suppressants. One patient complained of expectoration of a whitish crispy material and resumption of bleeding in the same afternoon. The procedure was successfully repeated the next morning. All the patients complained of expectoration of granular material for a few days after the procedure. They were discharged from hospital in stable condition after 4 to 7 days.

There was no recurrence of bleeding in any patient during the follow-up period, which lasted from 70 to 250 days (Table 1) , except in one patient in whom there were patchy areas of bronchiectasis and a past history of treatment for tuberculosis. She had a relapse of scanty bleeding after 1 month that stopped after conservative treatment.


   Discussion
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 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
References
 
Hemoptysis poses serious problems, especially when the conservative treatment fails. In such circumstances the problem is managed with several bronchoscopic (both rigid and fiberoptic) and nonbronchoscopic interventions. Cold saline lavage with 50-mL aliquots of iced saline at 4°C (total of 500 mL) showed good results when instilled through a rigid bronchoscope in 23 patients; recurrence of hemoptysis was observed in two cases.8 9 Wedging of the bleeding segment with the flexible bronchoscope tip is effective in controlling bleeding after transbronchial lung biopsy.10 Local administration of adrenaline solution (1:20,000), thrombin (Warner Lambert; New York, NY), and fibrinogen-thrombin (Green Cross; Tokyo, Japan) have been attempted in a small number of cases.10 11 The ND-Yag laser used bronchoscopically can effectively stop bleeding from endobronchial pathology and can also allow more definite therapy at the same sitting.12 13 Balloon tamponading of the bleeding bronchial segment is also helpful, with variable success rates.14 15 16 None of these procedures is completely satisfactory.

Bronchial artery embolization effectively stops bleeding from a bronchial arterial source, although failures and complications occur despite technical and instrumental excellence.1 17 18 19 There is also occasional difficulty in cannulating the vessel, and complications, including vessel perforation, intimal tears, and postbronchial artery occlusion sequences, are reported.1 20 Though rare, problems secondary to inadvertent ectopic embolism are also seen.1 Superselective bronchial catheterization may avert such complications to a great extent.21 Radiation therapy may be helpful in patients who have aspergilloma with hemoptysis.22 Surgical resection is sometimes the only plausible solution in some situations, but there have been reports of significant mortality and morbidity.23 24 25 Surgery is currently recommended when the facilities for bronchial artery embolization are not available or deemed technically impossible or unsuccessful; when the bleeding is so massive that any delay in arranging the embolization is very risky; and when the underlying cause is unlikely to be controlled by embolization, as in a case of suspected rupture of pulmonary artery or a mycetoma with profuse collateral arterial supply.3

We have adopted sealing of the bleeding segment or subsegment with n-butyl cyanoacrylate. It is a biocompatible adhesive that solidifies quickly on exposure to humidity with antibacterial effects.26 Cyanoacrylate glues are already in use in different procedures in deep tissues with high degrees of success and safety.4 5 6 27 28 They have been used to prevent postoperative air leak from the bronchial stamp after lung resectional surgery.4 27 The cyanoacrylate glues have prothrombotic properties such as increased platelet aggregation and possible enhancement of local thromboxane production.29 30 Although cyanoacrylates are significantly safe, they are volatile and chemically active materials reported to cause eczema, rhinitis, and asthma in occupational exposure.31 Occupational contact dermatitis has also been reported.32 There is also a chance of spillage of the glue more proximally on the bronchial tree or even at the tip of the endoscope.

In using cyanoacrylate for endobronchial sealing for hemoptysis, we have not found any significant side effects. Moreover, the glue is expectorated gradually over the next few days. In conclusion, it appears that endobronchial sealing with n-butyl cyanoacrylate glue is a simple, less invasive, and safe procedure to control hemoptysis.


   References
TOP
 Abstract
 Introduction
 Methods and Materials
 Results
 Discussion
 References
 

  1. Crocco, JA, Rooney, JJ, Frankushen, DS, et al (1968) Massive hemoptysis. Arch Intern Med 121,495-498[CrossRef][ISI][Medline]
  2. Isreal, RH, Poe, RH (1987) Hemoptysis. Clin Chest Med 8,197-205[ISI][Medline]
  3. Dweik, RA, Stoller, JK (1999) Role of bronchoscopy in massive hemoptysis. Clin Chest Med 20,89-105[CrossRef][ISI][Medline]
  4. Labenz, J, Borsch, G (1992) Bleeding gastric and duodenal varicose veins: endoscopic embolization using tissue adhesive [German]. Dtsch Med Wochenschr 117,1274-1277[Medline]
  5. Sabanathan, S, Eng, J, Richardson, J (1993) The use of tissue adhesive in pulmonary resections. Eur J Cardiol Thorac Surg 7,657-660[Abstract]
  6. Sheta, SM, Hida, T, McCuen, BW, II (1990) Cyanoacrylate tissue adhesive in the management of recurrent retinal detachments caused by macular hole. Am J Ophthal 109,28-32[ISI][Medline]
  7. Sokolowski, RW, Burgher, LW, Jones, FL, et al (1987) Guidelines for fiberoptic bronchoscopy in adults. Am Rev Respir Dis 136,1066-1069[ISI][Medline]
  8. Conlan, AA, Hurwitz, SS (1980) Management of massive hemoptysis with rigid bronchoscope and cold saline lavage. Thorax 35,901-904[Abstract]
  9. Conlan, AA, Hurwitz, SS, Krige, L, et al (1983) Massive hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg 85,120-124[Abstract]
  10. Zavala, DC (1976) Pulmonary hemorrhage in fiberoptic transbronchial biopsy. Chest 70,584-588[Abstract/Free Full Text]
  11. Tsukamoto, T, Sasaki, H, Nakamura, H (1989) Treatment of hemoptysis patients by thrombin and fibrinogen thrombin infusion therapy using fiberoptic bronchoscope. Chest 96,473-476[Abstract/Free Full Text]
  12. Dweik, RA, Mehta, AC (1996) Bronchoscopic management of malignant airway disease. Clin Pul Med 3,43-51
  13. Edmondstone, WM, Nanson, EM, Woodcock, AA, et al (1983) Life threatening hemoptysis controlled by laser photocoagulation: short report. Thorax 38,788-789[ISI][Medline]
  14. Patel, SR, Stoller, JK (1995) The role of bronchoscopy in hemoptysis. Wang, KP Mehta, AC eds. Flexible bronchoscopy ,298-321 Blackwell Scientific Cambridge, UK.
  15. Saw, EC, Gottlieb, LS, Yokoyama, T, et al (1976) Flexible fiberoptic bronchoscopy and endobronchial tamponade in the management of massive hemoptysis. Chest 70,589-591[Abstract/Free Full Text]
  16. Swersky, RB, Chang, JB, Wisoff, BG, et al (1979) Endobronchial balloon tamponade of hemoptysis in patients with cystic fibrosis. Ann Thorac Surg 27,262-264[ISI][Medline]
  17. Wholey, MH, Chamarro, HA, Rao, G, et al (1976) Bronchial artery embolization for massive hemoptysis. JAMA 236,2501-2504[Abstract]
  18. Rabkin, JE, Astafjev, VI, Gothman, LN, et al (1987) Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 163,361-365[Abstract/Free Full Text]
  19. Brinson, GM, Noone, PG, Mauro, MA, et al (1998) Bronchial artery embolization for the treatment of hemoptysis in patients with cystic fibrosis. Am J Respir Crit Care Med 157,1951-1958[Abstract/Free Full Text]
  20. Roberts, AC (1990) Bronchial artery embolization therapy. J Thorac Imaging 5,60-72[ISI][Medline]
  21. Tanaka, N, Yamakado, K, Murashima, S, et al (1997) Superselective bronchial artery embolization for hemoptysis with a coaxial microcatheter system. J Vasc Interv Radiol 8,65-70[ISI][Medline]
  22. Shneerson, JM, Emerson, PA, Phillips, RH (1980) Radiotherapy for massive hemoptysis from an aspergilloma. Thorax 35,953-954[ISI][Medline]
  23. Yeoh, CB, Hubaytar, RT, Ford, JM (1967) Treatment of massive hemoptysis in pulmonary tuberculosis. J Thorac Cardiovasc Surg 54,503-510[ISI][Medline]
  24. Sehhat, S, Oreizie, M, Moinedine, K (1978) Massive pulmonary hemorrhage: surgical approach as a choice of treatment. Ann Thorac Surg 25,12-15[Abstract]
  25. Knott-Craig, CJ, Oostuizen, G, Rossouw, G, et al (1993) Management and prognosis of massive hemoptysis: recent experience with 120 patients. J Thorac Cardiovasc Surg 105,394-397[Abstract]
  26. Giray, CB, Us, D, Gunay, C, et al (1993) Antibacterial and cytotoxic effects of n-butyl-2-cyanoacrylate used as a tissue adhesive [Turkish]. Mikrobiyol Bul 27,154-163[Medline]
  27. Eastman, DP, Robicsek, F (1998) Application of cyanoacrylate adhesive (Krazy Glue) in critical cardiac injuries. J Heart Valve Dis 7,72-74[ISI][Medline]
  28. Sung, JJ, Yeo, W, Suen, R, et al (1998) Injection sclerotherapy for variceal bleeding in patients with hepatocellular carcinoma: cyanoacrylate versus sodium tetradecyl sulphate. Gastrointest Endosc 47,235-239[CrossRef][ISI][Medline]
  29. Eng, J, Sabanathan, S (1989) Tissue adhesive in bronchial closure. Ann Thorac Surg 48,683-685[Abstract]
  30. Papathiofenis, FJ (1989) Prothrombotic cytotoxicity of cyanoacrylate tissue adhesive. J Surg Res 47,309-312[ISI][Medline]
  31. Kopferschmit-Kuber, MC, Stenger, R, Blaumeiser, M, et al (1996) Asthma, rhinitis, and urticaria following occupational exposure to cyanoacrylate glues. Rev Mal Respir 13,305-307[ISI][Medline]
  32. Conde-Salazar, L, Rojo, S, Guimaraens, D (1998) Occupational allergic contact dermatitis from cyanoacrylate. Am J Contact Dermat 9,188-189[CrossRef][Medline]




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