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Kansas City, MO
Dr. Reisz is Edward H. Hashinger Distinguished Professor and Chairman, Department of Medicine, University of Missouri Kansas City School of Medicine, and Truman Medical Center.
Correspondence to: George Reisz, MD, FCCP, Department of Medicine, Office of the Chair, University of Missouri Kansas City School of Medicine, 2301 Holmes St, Kansas City, MO 64108; e-mail: reiszg{at}umkc.edu
Hemoptysis is not a separate disease; rather it is a manifestation of multiple pathologic processes. Despite the potentially fatal outcome of hemoptysis, the underlying disease is usually otherwise benign and treatable.123 The risk of death is particularly high when hemoptysis is massive, and some investigators456 estimate the risk of mortality with untreated massive hemoptysis to be in excess of 75%. Others78 have found the risk of death to be lower and have advocated an initially conservative approach, although there may be significant mortality from subsequent bouts of hemoptysis in these patients. Some of the variation in mortality risk is due to the lack of the common definition of the term massive. However it is defined, it is clear that massive hemoptysis represents a significant and immediate risk to these patients.
Early studies456 found that emergent surgical resection dramatically reduced the number of deaths in patients with massive hemoptysis. Not surprisingly, investigators7 who found a lower mortality rate from hemoptysis have advocated a more conservative approach that reserves surgery for patients who do not respond to other treatment. Surveys at the American College of Chest Physicians Annual Scientific Assembly9 would suggest that chest clinicians are increasingly using a nonsurgical approach for patients with life-threatening hemoptysis. Additionally, resection is not always an option. Patients with tumors involving the carina, multiple sites of bleeding, poor lung function, or other major illnesses may not be appropriate for lung resection.
In the past few years, bronchial artery embolization has been used with success to control hemoptysis.1011 Embolization has been particularly successful in patients with cystic fibrosis who are prone to recurrent bouts of hemoptysis.12 Endoscopic argon plasma coagulation has been shown to be effective in the treatment of patients with hemoptysis caused by neoplastic disease.13
Valipour et al in this issue of CHEST (see page 2113) describe a novel technique for controlling massive hemoptysis. The authors of this study applied topical hemostatic tamponade therapy by inserting oxidized regenerated cellulose mesh through a flexible bronchoscope to achieve control of bleeding. This treatment is advantageous because it can be done in the bronchoscopy suite, the ICU, or the emergency department. Whether the results were due to the hemostatic effect of oxidized regenerated cellulose mesh, are simply a tamponade effect, or both, the results were very good.
Topical hemostatic tamponade effectively arrested the bleeding in 56 of the 57 patients treated. The one patient without immediate control of hemoptysis by topical hemostatic tamponade underwent successful surgical resection. In 6 of the 56 patients who achieved immediate control of hemoptysis by topical hemostatic tamponade there was recurrent bleeding of a lesser amount in the first few days following this therapy. Bronchial artery embolization was used in all of these six patients, and repeat topical hemostatic tamponade was used in two of the six patients with recurrent hemoptysis in whom hemoptysis had not been controlled by bronchial artery embolization. In a mean follow-up period of 10 months, no patient died from recurrent hemoptysis. There were remarkably few side effects from topical hemostatic tamponade given that the involved airway was intentionally occluded. Five patients subsequently developed postobstructive pneumonia. The material was completely reabsorbed in all patients undergoing repeat bronchoscopy.
Like all new techniques, one awaits results from other hands. This technique is not suitable for patients with a tracheal site of bleeding or for patients who would not tolerate temporary occlusion of the involved airway. Additionally, since the material is absorbed, long-term studies may find a high rate of late reoccurrence similar to that with bronchial artery embolization.
One difficulty in comparing studies is a lack of standardized terminology. Valipour et al used bleeding in excess of 150 mL/h to define massive or life-threatening hemoptysis. Gourin and Garzon5 defined massive hemoptysis as bleeding of > 600 mL per 24 h and found that surgical resection dramatically improved survival. Sehhat et al6 also favored a surgical approach in patients with massive hemoptysis, which was defined as bleeding of > 600 mL in 48 h. Corey and Hla7 defined major hemoptysis as bleeding of > 200 mL per 24 h, and massive hemoptysis as bleeding of > 1,000 mL per 24 h. Not surprisingly Corey and Hla7 found a much higher mortality in their patients with massive hemoptysis (58%) compared to the mortality in patients with major hemoptysis (9%).7 The study by Valipour et al in this issue of CHEST was not designed to be, nor should it be interpreted as, a comparative study of various techniques for controlling life-threatening hemoptysis.
Intensivists, pulmonary physicians, and thoracic surgeons will continue to face the challenge of massive hemoptysis. Emergent control is essential to save the lives of these patients. Topical hemostatic tamponade does not replace the other forms of therapy, but it does give us another effective tool. The selection of treatment will depend on multiple factors, including underlying pathology, patient response, and institutional expertise.
References
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