Hemoptysis: Clinicians’ Perspectives RESULTS part 3

17 Apr
2011

Hemoptysis: Clinicians' Perspectives RESULTS part 3

Massive Hemoptysis

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)

Favored by

Option

Respondents,
%

Insertion of
Carlens or Robertshaw tube

7

Selective
endotracheal intubation

19

Nonselective
endotracheal intubation

33

Bronchoscopic
intubation

25

Consult
anesthesiologist for intubation

16

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

Respondents
(%)

Timing of
procedure (n
= 106)

Immediate

50

Initial
24
hours

34

Later, after
bleeding subsides

16

Favored approach
(n
= 108)

Rigid instrument

17

Fiberoptic (via
endotracheal tube)

41

Fiberoptic (without
endotracheal tube)

7

Consult surgeon

35

Adjunctive
measures (n
= 92)

Endobronchial
balloon tamponade

38

Iced saline
lavage

5

Topical
epinephrine

21

Vasopressin

4

None of the
above useful

32

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)

Indication

Respondents,
%

Inoperable
patients only

45

Initial therapy,
all patients

2

Initial therapy,
most patients

21

Undecided

31

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