Hemoptysis: Clinicians’ Perspectives DISCUSSION part 2

19 Apr
2011

Massive Hemoptysis

The initial approaches to airway support during life- threatening hemoptysis reflected practical con­cerns in the resuscitation of a drowning patient (Table 4). While either the insertion of specialized tubes and blockers or selective endotracheal intubation of the nonbleeding lung are theoretically attractive and con­sistently recommended in major reviews, the difficulty and/or impracticality of these measures in acute situ­ations often precludes their initial use. Less experi­enced individuals, in particular, should take note of the cautious approach to airway support that was advo­cated. Bronchoscopic intubation or nonselective in­sertion of a large endotracheal tube was preferred by most. During discussions which followed this session, experienced clinicians volunteered potentially useful caveats which have not been emphasized in the literature. A small number had successfully managed patients with life-threatening bleeding without intu­bation, with the view that these carefully selected, alert individuals could cough more effectively than they could be suctioned. (All specified, however, that such patients were managed in the intensive care unit, with all equipment necessary for immediate intuba­tion available in the event of any clinical deterioration.) In addition, they described their successful use of a polyvinyl chloride double-lumen endotracheal tube which has been used for single lung ventilation in other clinical settings. Publication of such experiences by practitioners would be important to more widely communicate (and prospectively evaluate) these strat­egies.

Approaches to bronchoscopy in patients with mas­sive bleeding also reflected a caution essential to safe management (Table 5). The considerably more urgent timing of bronchoscopy reflects the priority of locali­zation of the bleeding site, protection of the nonbleed­ing lung, and the immediate impacts of these maneu­vers upon treatment. Despite reports of successful fiberoptic bronchoscopy without endotracheal intu­bation in this setting, only a minority of individuals selected this option. Approximately half either performed rigid bronchoscopy themselves or, much more commonly, referred the patient to a surgeon for this procedure. This strategy is consistent with the well- established superiority of the open tube instrument in this situation and with conventional recommenda­tions in the literature. Nearly half of respondents evaluated their patients with the fiberoptic instrument (usually with protection of an endotracheal tube), probably reflecting that most current pulmonologists are trained nearly exclusively with this instrument. Endobronchial balloon tamponade, which can be a technically difficult procedure performed with the fiberoptic instrument, had been used successfully by 38 percent of the participants. However, nearly one third had not found this or other adjunctive, tempo­rizing maneuvers to be successful in the control of bleeding.
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Interventional angiography is increasingly available for treatment of massive hemoptysis, and may obviate the need for resectional surgery. Practitioners’ per­spectives of the roles of this technologic innovation are important, but have not been documented previ­ously. Increasing cumulative experience has demon­strated the efficacy of bronchial arterial embolization, with the cessation of bleeding in approximately 80 percent of patients treated during acute hemor­rhage. Despite these encouraging observations, nearly half of the participants at this session reserved interventional angiography for inoperable patients only (Table 6), consistent with the historic view that resectional surgery is the definitive therapy which should be offered to operable individuals with massive hemoptysis. One fifth of those polled selected inter­ventional angiography as an initial option, perhaps because of their more recent training and/or increasing availability of this option within their communities. Importantly, nearly one third of individuals overall, and nearly half of those practicing for more than ten years, were undecided about the role of this therapy, reflecting a caution that seems appropriate for what would be a fundamental shift in management. Further long-term experience with interventional angiography is needed to resolve this issue. Future prospective investigations should include comprehensive descrip­tions of patient selection criteria, the etiology and characteristics of bleeding, technical approaches, and timing of the procedure in order to distinguish which persons with massive or recurrent hemoptysis benefit the most from this modality.

Comments

Because of a number of possible limitations and biases inherent to any survey, these results should not be overemphasized. The framework in which the questions were asked might have influenced the respondents. Since not every physician responded to every question, and only a predetermined number of optional answers could be selected, the data are somewhat incomplete. Errors might also have related to the brevity of time periods used to consider and answer questions, erroneous recording of answers, and imprecise recollection of previous clinical experiences.
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Nevertheless, the characteristics of this self-selected group of highly motivated physicians, experienced in the management of patients with hemoptysis, make their views especially informative. Important, unre­solved issues in the management of patients with hemoptysis require further study. The investigations designed to address these problems must relate to the real-world experiences of the practitioners who most often encounter them.

 

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