Hemoptysis, Empyema




Hemoptysis, Empyema



Mohamed R. El Tahan



Abstract


A systematic approach should be accomplished through a multidisciplinary team to diagnose and treat severe life-threatening hemoptysis. Attention should be paid to awake tracheal intubation in patients with massive hemoptysis airway. Lung or lobar isolation can be established using a bronchial blocker or double-lumen tube. The roles of anesthesiologists are not limited to providing optimum lung isolation and safe intraoperative anesthesia but extend to improving postoperative patient outcomes, help in identification of the proper timing for surgical intervention and predict the feasibility of video-assisted thoracoscopic surgery surgery. Recruiting the collapsed lung or lobes following pleural decortication should be accomplished with increasing airway pressures with ruling out significant air leak.


Keywords


hemoptysis; empyema; thoracic; anesthesia; airway managment



Hemoptysis




Introduction


Hemoptysis may present as mild or as a life-threatening condition. Massive hemoptysis, a major medical emergency associated with a high mortality,1 has been defined in the literature by several different criteria, ranging from 100 to 600 mL of blood over wide-ranging periods of time.2,3 These variations in definition are impacted by the difficulty in quantifying the amount of blood expectorated, which may be overestimated by patients.3 In general, any hemoptysis that jeopardizes respiratory function should be considered a life-threatening medical emergency.1



Case Presentation


A 22-year-old male sustained several stab wounds to the back which penetrated into the right chest. He presented to the emergency department agitated and confused with severe hemoptysis, tachycardia, tachypnoea, and dyspnea. Physical examination revealed cyanosis, signs of respiratory distress, and absent breath sounds on the right chest. The arterial oxygen saturation was 83%, with a nonrebreather mask supplying oxygen at 15 L/min. Hemoglobin concentration was 7.5 g/dL and lactic acid was 3.7 mmol/L. Point-of-care sonography and chest radiograph showed a right hemopneumothorax. Electrocardiogram and transthoracic echocardiography showed no abnormalities.



Case Management


A chest tube was inserted to the right chest and a total of 1.2 L of blood was drained. Lactated Ringer’s solution 2.0 L and 2 units of type-crossmatched packed red blood cells were administered and was followed with improved blood pressure and the level of consciousness. Chest radiography and computed tomography (CT) confirmed the presence of right hemopneumothorax. Cervical and abdominal CT scanning showed no abnormalities. The patient was brought to the operating room (OR) for emergency exploration via right posterolateral thoracotomy.



Problem A: How Can We Reduce Risk by Intraoperative Monitoring?


Routine monitors included five-lead electrocardiograph with ST segment analysis, processed electroencephalographic-based control the depth of anesthesia, and train-of-four stimulation of the ulnar nerve. Transcutaneous multifunction pads for monitoring, defibrillation, and pacing were connected to the chest wall. The radial artery was cannulated and connected to a fluid responsiveness monitoring system to guide hemodynamic parameters. An 8.0-F cordis was placed in the right internal jugular vein, and a urethral Foley’s catheter was placed.


Rapid sequence induction was considered, a left-side double-lumen tube (DLT) was placed, and the proper DLT position was confirmed using a flexible 4.0-mm bronchoscope in both supine and lateral decubitus positions. Bronchoscopic examination showed significant bleeding from the right lower lobe, and the presence of major trachea-bronchial injury was ruled out. Surgery consisted of right thoracotomy and repair of the right lower lobe bronchial injury. The patient was extubated at the end of the procedure and postoperative course were uneventful.



Cause of Hemoptysis


Several causes for hemoptysis are presented in Table 48.1.



Table 48.1









































































































Common Causes of Hemoptysis
Origin Causes References
Esophagus Transesophageal echocardiography-induced injury of the bronchus 94
Pulmonary vessels Vasculitis (e.g., long-standing vasculitis, Churg-Strauss syndrome) 95,96
  Following the Fontan procedure 97
  Pulmonary artery aneurysm 98,99
  Pulmonary vein obstruction and stenosis 100
  Arteriovenous malformation 101
  Pulmonary artery rupture by pulmonary artery catheter 2
Tracheobronchial tree Traumatic intubation (e.g., violent intubation, deeply inserted a bougie intubating catheter in a patient with underlying endobronchial pathology 54,102
  Traumatic lower airway injuries 103,104
  Acquired trachea-bronchomalacia 105
  Tracheal bronchus 106
  Bronchopleural fistula 2
Alveolar Tuberculosis  
  Cavitating lung abscess 107
  Neoplasm 2
  Bullae 108
  Diffuse alveolar hemorrhage secondary to negative-pressure pulmonary edema, cannabis, or sevoflurane anesthesia 109,110
  Pulmonary aspergilloma 111
  Lymphangiomyomatosis 112
  Intrapulmonary sequestration 113
Cardiac Congenital heart disease 97
  Mitral stenosis or heart failure 2
Infradiaphragmatic Intrathoracic rupture of hepatic hydatid cyst 114
  Thoracic endometriosis (catamenial hemoptysis) 2



Preoperative Assessment


Suspected hemoptysis must be confirmed, its severity established, the origin of bleeding located, and the cause determined.3


The diagnostic workup and management of severe hemoptysis is often challenging and includes chest x-ray (CXR), lung sonography, CT scanning, angiography, and importantly, bronchoscopy to identify the origin of bleeding.2,3


Detailed clinical history and physical examination should be emphasized on the initial causes and severity of hemoptysis to guide the diagnostic and therapeutic measures.1,4


Confirmation of hemoptysis is based on the direct observation of bleeding or as they are reported by the patient. Hemoptysis should be differentiated from hematemesis or bleeding from the oral cavity and nasal fossa.5 Endoscopic examinations, such as rhinolaryngoscopy, gastroscopy, and bronchoscopy, may be needed to confirm the origin of the bleeding.


Location of origin and etiology can be identified and quantified during the initial efforts to control bleeding or when the patient condition has been stabilized.


Diagnostic tests should include3,5–7



  1. 1. Clinical laboratory tests including complete blood count, coagulation parameters, and biochemistry.
  2. 2. Pulse oximetry and arterial blood gases to determine the impact of hemoptysis on oxygenation and ventilation.
  3. 3. If indicated once bleeding is controlled, spirometry can be done to determine the patient’s pulmonary function. Spirometry should not be used in patients with active hemoptysis.6
  4. 4. Electrocardiogram to rule out pulmonary thromboembolism.
  5. 5. Transthoracic echocardiogram to detect endocarditis, mitral valve stenosis, congenital heart diseases, pulmonary hypertension, aortic aneurysm, or the presence of shunts because of arteriovenous malformations.
  6. 6. Cytologic study and sputum microbiology (e.g., Gram and Ziehl-Neelsen usual cultures and Lowëstein-Jensen).5 Mantoux in patients with suspected tuberculosis.5
  7. 7. Blood cultures or serologies if infectious disease is suspected.5
  8. 8. Anterior-posterior and lateral CXR are the usual initial imaging tests performed in patients with hemoptysis.3,5 CXR determines the site of bleeding in 45% to 65% of the cases and the cause in 25% to 35%.2,7,8 However, as much as 10% of pulmonary malignancies are occult on CXR, whereas 96% of which will be detected by CT.8
  9. 9. Chest multidetector CT3 must be performed in all patients with gross hemoptysis. It is useful to locate the origin of bleeding and give an idea about the proper isolation tool used (e.g., type of bronchial blocker [particularly in case of early takeoff origin of the right main bronchus] and proper size and side of double lumen tube [e.g., using the right-sided DLT in case of obstructed passage of the left main bronchus with a mass]).
  10. 10. Angiomultidetector CT is useful for identifying arteries which are the source of bleeding in hemoptysis and determining whether bronchial artery embolization is indicated or whether conservative treatment is sufficient.3,9 Performing a CT requires the patient to be transported into a remote setting where it may be challenging to manage a massive bleed. In certain situations, it is preferable to prophylactically secure the patient’s airway before transportation to the radiology suite, particularly for patients with life-threatening conditions2 (Fig. 48.1).
  11. 11. Flexible bronchoscopy has an important role in identifying the severity (from blood-streaked sputum to gross hemoptysis), cause, and origin of hemoptysis. It can be performed rapidly at the patient’s bedside in the intensive care unit (ICU) or in the OR.1,3 It can also be used for collecting samples for cytology and microbiologic studies, bronchial aspirate, or bronchoalveolar lavage.
  12. 12. Rigid bronchoscopy obviously provides better scope for suctioning but does not generally allow visualization of upper lobes and peripheral lesions.1,10 It allows localization of bleeding and provide a wide conduit for the instruments and catheters or materials instilled into the airways through the bronchoscope.11,12 However, rigid bronchoscopy is performed in the OR and ventilation is best with intermittent jet ventilation.

image
• Fig. 48.1 Images from a thoracic computed tomography angiographic study performed with a 16–detector row scanner. (From Bruzzi JF, Rémy-Jardin M, Delhaye D, Teisseire A, Khalil C, Rémy J. Multi-detector row CT of hemoptysis. RadioGraphics. 2006;26:3–22.)

Box 48.1




Therapeutic Options3




  1. 1. General Initial Management



  1. 2. Other Measures to be Considered in the Management of Hemoptysis Include3

    1. A. Administration of antitussives to control coughing, however, oversedation should be avoided owing to the fear of airway obstruction.5
    2. B. Empiric antibiotic treatment, useful in hemoptysis associated with respiratory infection and, in general, to prevent subsequent complications.

      Antifibrinolytics (e.g., aminocaproic acid, tranexamic acid [TA]).3 The clinical benefit of using TA has mixed results in the literature. Tscheikuna et al. enrolled 46 patients with hemoptysis completed the study. There were 21 in the TA group and 25 in the placebo group. The placebo group had a tendency not to have underlying lung disease and more patients who had a normal CXR. The benefit of TA in shortening the days of hemoptysis were not shown in this study.14 Some investigators demonstrated that TA is effective in shortening the duration and volume of hemoptysis with low risk of thromboembolic complications. Moen et al. performed an analysis of 13 publication that represented the best evidence to answer the clinical question. Main outcomes included bleeding time, bleeding volume, and occurrence of thromboembolic complications after start of treatment. Based on results from the metaanalysis, no difference in remission of bleeding within 1 week was found between the TA and placebo groups. However, overall bleeding time was significantly shorter for the TA group. The authors concluded that limited research on the use of TA for treatment of hemoptysis exists. Because etiology of hemoptysis, as well as length of treatment, dosage, and form of TA administration varied between the studies, strong recommendations are difficult to give. Current best evidence, however, indicates that TA may reduce both the duration and volume of bleeding, with low risk of short-term thromboembolic complications in patients with hemoptysis.15 Interestingly, inhaled TA (500 mg 3 times daily) can be used safely and effectively to control bleeding in patients with nonmassive hemoptysis.16


    3. C. Autologous plasma rich platelets have been shown to stop bleeding immediately in 14 out of 20 patients with massive hemoptysis for 7 days.17
    4. D. Desmopressin, a fast-acting blood-saving agent, can be used to control hemoptysis in various hereditary and acquired clotting disorders.18

  2. 3. Specific Treatment

    A coordinated emergency team response is essential to guarantee the best chances of patient survival.7 A systematic approach for definitive treatment of the patients with or without life-threatening hemoptysis has been developed from the previous reviews,2,3,5,19,20 as shown in Fig. 48.2. The main steps are as follows:



    1. A. Massive life-threatening hemoptysis:

      1. i. In patients with unstable hemodynamic status, initial general treatment measures are considered to stabilize the patient’s conditions. Immediate bronchoscopy should be performed in a well-equipped area (e.g., OR or ICU) to identify the cause and origin of the bleeding, secure the airway, administering topical measures to control bleeding (e.g., bronchial lavage, cryotherapy),21,22 and applying topical hemostatic agents (e.g., cold saline3 or less effective epinephrine diluted at 1:20,00023), sealants (e.g., Fibrinogen-thrombin [Tissucol], oxidized regenerated cellulose mesh [Surgicel] or silicone plugs [Watanabe spigot]),3 laser photocoagulation,24 or argon plasma electrocoagulation.3 More definitive treatment options include angiographic embolization,25,26 emergency surgery for lung resection,27 or bronchial artery ligation surgery.28 Extracorporeal membrane oxygenation (ECMO) could be considered as a rescue strategy in case of life-threatening aortobronchial fistula.29
      2. ii. Patients with stable hemodynamic status should be subjected to either angiographic multidetector CT scanning or angiography to predict the value of bronchial artery embolization (Fig. 48.3). Reembolization or emergency surgery could have an important role in case of uncontrolled bleeding after embolization.

    2. B. Mild to moderate hemoptysis:

      1. i. Multidetector or volumetric high-resolution CT scanning should be considered as a diagnostic tool.
      2. ii. Early bronchoscopy within 48 hours after presentation should be considered if the origin of bleeding could not be identified. Bronchial lavage, cryotherapy, applying topical hemostatic agents or sealants, or selective bronchial blockage of the affected area should be considered in patients with active bleeding. Caution should be exercised in patients with no active bleeding during removal of remaining blood and examination should be postponed if the clot is adhered.

image
• Fig. 48.2 A systematic definitive treatment approach for patients with or without life-threatening hemoptysis. It is produced from the previous reviews.2,3,5,19,20CT, Computed tomography; DLT, double-lumen endobronchial tube; SLT, single-lumen tube. ABCDE are the general measures as shown in Box 48.1.

image
• Fig. 48.3 Management of massive hemoptysis guided by early multidetector computed tomography scan. (From Khalil A, Fedida B, Parrot A, Haddad S, Fartoukh M, Carette M-F. Severe hemoptysis: from diagnosis to embolization. Diag Inter Radiol. 2015;96:775.)


Airway Protection



Objectives


Securing the airway by using the largest SLT possible (≥8.0 mm inner diameter) is the most important priority to enable passage of a flexible bronchoscope with a large working channel allowing extraction of obstructing blood clots and placement of bronchial blockers.7,19 The main goals of anesthesia include volume resuscitation, isolating the bleeding lung or lobe to protect the normal lung, and providing sufficient oxygenation.30



Preparations and Monitoring


Rescue medications and equipment, including two rigid, large-bore Yankauer-type suction catheters attached to separate suction devices should be available.31


In addition to the standard monitors, including heart rate, noninvasive blood pressure, and pulse oximetry, invasive arterial catheterization and central venous catheterization are recommended. Large diameter intravenous catheters should be placed to allow for rapid fluid administration.30


The patient should be placed with the bleeding side down,7,20,30 until lung isolation can be achieved.



Awake Endotracheal Intubation


Awake endotracheal intubation should be considered in emergency life-threatening hemoptysis with risks of airway obstruction, asphyxiation caused by flooding of the alveoli with blood, which might cause irreversible progressive hypoxia,32 or bronchospasm during rapid sequence induction of anesthesia.20,33,34


Massive hemoptysis, usually accompanied with the patient’s agitation, might preclude the use of awake fiberoptic intubation.30


The use of video laryngoscopes might offer new merits for awake endotracheal intubation in patients with massive hemoptysis.31,35,36 Moreover, the video laryngoscopes could allow awake endobronchial intubation using the DLT although it maybe more difficult than intubation with an SLT.37



Rapid Sequence Induction


Rapid sequence induction of anesthesia might be considered in nonlife-threatening situations with ensuring the accessibility of rescue equipment and medications. Short active muscle relaxants should be used only if the airway is reassuring. Any concern regarding control of the airway should be managed with awake intubation. The practitioner should never burn his bridges.33,34 Etomidate or ketamine are appropriate for induction of general anesthesia in patients with unstable hemodynamic status.31



Isolation of the Bleeding Lung/Lobar (see Chapter 16)


There is no consensus on the best method of lung isolation for patients with hemoptysis (Case Studies shown in Fig 48.4).


image
• Fig. 48.4 Case studies—a systematic approach to the management of massive hemoptysis. A,B, A 59-year-old female with massive hemoptysis and bilateral bronchiectasis. Bronchoscopy revealed right lower lobe as a source of hemorrhage. C, A 47-year-old male with bilateral cavitation and mycetoma. Right upper lobe was identified as source of bleeding by FOB. D, Both subjects were stabilized by ETT intubation and right-sided bronchial blockade prior to bronchial artery embolization. (From Radchenko C, Alraiyes AH, Shojaee S. A systematic approach to the management of massive hemoptysis. Journal of Thoracic Disease (2017): S1069-S86. jtd.amegroups.com/article/view/15576.)


  1. 1. Bronchial Blockers

    Bronchial blockers can be used for isolating the main bronchus or selective lobar bronchus blockade to allow control of the bleeding lung or lobe, respectively by tamponade. The bronchial blockers are usually available in 7.0 F or 9.0 F for adult patients who require tracheal intubation with a SLT with a minimum size of 7.5 or 8.0 mm inner diameter, respectively. That allows the insertion of the flexible bronchoscopes with a size of 3.8 to 4.0 mm outer diameter.38 The use of video laryngoscopes allows effective suctioning of blood and direct visualization of tracheal intubation with the bronchial blocker before placement of the SLT. Bronchial blockers could be placed through tracheostomy tube in patients with tracheostomies.39


    Bronchial blockers are more expensive than DLTs may take longer time to placement, and could be associated with more frequent dislodgement.40,41 The use of bronchial blockers limits the effective suctioning of blood because of their narrow inner lumens. In addition, blood stagnation in the lung distal to the blocker’s inflated cuff has long-term side effects.42 However, if the patient is bleeding with the SLT in place and there is a concern regarding control of airways while converting to a DLT, it is best to use a bronchial blocker to tamponade the main bronchus of the bleeding side.


    There are several types of blockers as summarized subsequently and in Table 48.2.



    Table 48.2






















































































    Author’s Recommended Choices for Selective Lung/Lobar Blockade Based on the Current Evidences Available
    Lung/Lobe Double-Lumen Tube Side Fuji Uniblocker Torque Control Arndt Wired Tip Cohen Deflecting Tip EZ Blocker Coopdech Angled Tip
    Right lung Left or right          
    Right upper lobe Left          
    Tracheal bronchus Left          
    Right middle lobe Left or right          
    Right lower lobe Left or right          
    Left lung Left or right          
    Left upper lobe Left or right          
    Left lower lobe Left or right          
    References 42 40,115 45,46 13,42 48,49 50–54

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