Views differed about the most common cause of fatal hemoptysis: lung cancer (29 percent), bronchiectasis (28 percent), tuberculosis (23 percent), mycetoma (11 percent), or lung abscess (9 percent) were each considered. Opinions about the mortality associated with the nonsurgical management of massive hemoptysis also varied greatly. Of the approaches to airway support in patients with life-threatening bleeding (Table 4), only 7 percent advocated initial placement of a Carlens or Robertshaw tube. Either nonselective insertion of a large endotracheal tube (33 percent) or more selective intubation using the fiberoptic bronchoscopy as a stylet (25 percent) was preferred.
Table 4—Massive Hemoptysis: Approaches to Airway Support (n=105)
Issues related to bronchoscopy in this setting are summarized in Table 5. Most physicians favored fiberoptic bronchoscopy performed via an endotracheal tube (41 percent), or surgical consultation for bronchoscopy (35 percent). Less than one fifth performed rigid endoscopy initially. Only 7 percent advocated fiberoptic bronchoscopy without protection of an endotracheal tube. In contrast to their more elective approach to nonmassive hemoptysis, 84 percent of respondents performed bronchoscopy during the first 24 hours of massive bleeding (p<0.01). Of adjunctive measures reported to be useful temporizing maneuvers in the control of life-threatening hemorrhage, endobronchial balloon tamponade was employed successfully by 38 percent of respondents. Nearly one third, however, found that neither this technique, iced saline lavage, topical epinephrine, nor systemic or topical vasopressin had been worthwhile in their experiences.
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Table 5—Massive Hemoptysis: Approaches to Bronchoscopy
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When asked about which patients they would refer for interventional angiography (bronchial or pulmonary arterial embolization), nearly one half reserved this modality for inoperable patients only (Table 6). Twenty-one percent selected embolization as initial therapy for most patients, and only 2 percent as the initial treatment for all; 31 percent were undecided about its optimum role. The level of clinicians experience might have influenced attitudes about embolization procedures: those having <=10 years in practice more often favored it as an option (56.3 vs 33.3 percent) than individuals practicing >10 years. More senior clinicians tended to be undecided about the role of interventional angiography than their less experienced counterparts (44.4 vs 21.9 percent). These differences, however, were not statistically significant.
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Table 6—Massive Hemoptysis: Indications for Interventional Angiography, (n=99)