D. P. Laporta MD D. P. Laporta MD Departments of Adult Critical Care and Medicine, Sir MB Davis Jewish General Hospital McGill University presented to McGill Residents presented to McGill Residents Critical Care (January 2000) Pulmonary (July July 2000
Massive Hemoptysis. D. P. Laporta MD Departments of Adult Critical Care and Medicine, Sir MB Davis Jewish General Hospital McGill University presented to McGill Residents Critical Care (January 2000) Pulmonary (July July 2000. MASSIVE HEMOPTYSIS REFERENCES. - PowerPoint PPT Presentation
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D. P. Laporta MDD. P. Laporta MD
Departments of Adult Critical Care and Medicine, Sir MB Davis Jewish General Hospital
McGill University
presented to McGill Residentspresented to McGill ResidentsCritical Care (January 2000)Pulmonary (July July 2000
A right-sided bleeding : B left-sided bleedingL lung selectively intubated trachea intubated over bronchoscope firstOver the bronchoscope. with the patient in the left lateral position to
minimize aspiration14Fr 100 cm Fogarty catheter passed through thevocal cords beside the endotracheal tube to a levelseveral centimeters below the cuff.
DOUBLE LUMEN ETT FOR ENDOBRONCHIAL TAMPONADE.
bronchial lumen: placed in L main bronchus to ventilate L lung
tracheal lumen: remains supracarinal to ventilate R lungand prevents occlusion of the RUL orifice.
external lumina connected to ventilator using a "Y" connector device.
Left and right-sided double lumen tubes are currently available.
DOUBLE-LUMEN ETT IN DOUBLE-LUMEN ETT IN MASSIVE HEMOPTYSISMASSIVE HEMOPTYSIS
Size 4 to 7 French catheter, J-wire(through nostril), bronchus blocker
Laserphotocoagulation
For endobronchial lesions
Pharmacologic Rxs Vasopressin
Tranexamic acid
Systemic steroids In cases of alveolar hemorrhage
GnRH/danazol In catamenial hemoptysis
Antibiotics/anti-TB/anti-fungals
In cases of suspected or known infection
Angiography andembolization
Standard/superselective
Semidefinitive therapy, or bridge tosurgery
Radiation therapy In aspergillomas and vascular tumors
Surgical resection(ifpulmonary functionallows)
CavernostomySegmentectomyLobectomy2Pneumonectomy
If embolization not feasible (unavailable,technically impossible, or did not stopbleeding), patient too unstable to wait forangiogram, or cause of hemoptysis notlikely to benefit from embolization (PAperforation, ruptured mycetoma)
Role of bronchoscopy is presented in bold typeface.
most difficult : identify the vessel(s) responsible for bleeding.
injection in the descending aorta just below the left subclavian artery
may require a full-arch aortogram in some LL bleeding w/no apparent bronchial supply: UL bleeding: unilateral subclavian artery injection
to exclude nonbronchial systemic collateral arteries.
formal bronchial arteriogram blush,abnormal vessels, ensures that no
communication to the anterior spinal artery
Intervention in MH: Medical or Surgical ?Intervention in MH: Medical or Surgical ?
Observational studies no RCTs… selection bias none used bae as part of medical therapy wide range of mortality rates :
• surgical (1-50%) and medical (1.6-85%) results are mixed …lower surgical
mortality rates
Intervention in MH: Medical or Surgical ?Intervention in MH: Medical or Surgical ?Current recommendationsCurrent recommendations : surgical resection preferred if:
BAE unavailable or failed imminent survival threatened by transport to radiology (ABCs) surgically operable patient with a localized (ie resectable) lesion as
cause of MH which is deemed unlikely to be controlled by BAE:
– Thoracic vascular injury/trauma
– mycetoma +profuse collateral arterial supply,
– hydatid cyst
– bronchial adenoma
– AVM
PA RUPTURE PA RUPTURE (1) Epidemiology Prevalence .06-.2% Rebleed: 90 % within 3 days Mechanism:
Pseudoaneurysm (Psan) Mortality:
all comers 45-65%
if rebleed: 40-70%
26% if abnormal CXR is only manifest'n of PA rupture