Bronchial embolisation to treat bleeding caused by chronic pulmonary aspergillosis

LED BY GRAHAM ATHERTON SUPPORTED BY GEORGINA POWELL, MARIE KIRWAN & DEBBIE KENNEDY NAC CENTRE MANAGER CHRIS HARRIS TALK GIVEN BY RAY ASHLEIGH RADIOLOGY CONSULTANAT AT THE NATIONAL ASPERGILLOSIS CENTRE NATIONAL ASPERGILLOSIS CENTRE UHSM MANCHESTER Support Meeting for Aspergillosis Patients Fungal Research Trust

Programme
1pm Introduction
1:05 Ray Ashleigh - Embolisation
1:45 Questions
2:00 Tea & Coffee
2:15 Discussions:
What do you want to hear about in the next 12 months?
Any Other Business
3:00 Close

Definitions
Haemoptysis = coughing up blood
Embolisation = therapeutic blocking of blood
vessel

The Problem
Distressing
May be life threatening
Surgery difficult
Poor lung function
Technically challenging
Significant morbidity/mortality
1-6% mortality; 25-30% post op morbidity

Haemoptysis - Classification
Massive haemoptysis
>300ml blood/24 hours
Moderate
>3 episodes of 100ml/day/week
Mild
<100ml/day

Massive Haemoptysis
Emergency
Death from asphyxiation

Mild to moderate haemoptysis
Life interfering
Debilitating
May worsen lung function
Infective exacerbations
May be prequel to massive bleed

Pathophysiology
Chronic Inflammation
Arterial hypertrophy Acute infection
New blood vessel formation
HAEMOPTYSIS

Treatment
Conservative
Radiological
Embolisation
Intracavitary antifungal therapy
Surgery

Anatomy –Dual blood supply
Pulmonary arteries
Low pressure circulation
Gas exchange
Rarely bleed
Bronchial arteries
Systemic pressure
Usual cause of bleeding
Can be blocked

Bronchial Arterial Anatomy
Variable origin
Most arise from thoracic aorta
Aberrant origins/ transpleural collaterals common
CT scanning can be helpful to identify aberrant vessels

Collateral Supply
Subclavian
Internal mammary
Thyrocervical
Costocervical
Intercostal
Lateral thoracic
Inferior phrenic

Bronchial arterial supply
Constant
Lung
Oesophagus
Pericardium
Rare
Coronary
Spinal cord

Technique
X-Ray guided procedure
Femoral (groin) access
“ Pinhole” surgery
Position catheter in target artery
Inject plastic beads to block artery
Continue until all feeding arteries occluded

What you will feel
Routine monitoring
Heartbeat (ECG)
Blood oxygen (pulse oximetry)
Blood pressure
Sedation optional
Nurse present
Doctor doing the procedure is “scrubbed”

What you will feel
Groin cleaned with antiaseptic
Injection of local anaesthetic
Stinging
Pushing when “gate” (vascular sheath) is put in artery
Warm feeling from contrast (X-Ray dye)

What you will NOT feel
Catheter moving inside
Pain on injection of particles

After procedure
Hole in artery sealed with manual pressure or dissolvable plug
Variable time of bed rest
Usually home following day
Some bruising common
Bleeding after leaving hospital very rare
Avoid strenuous activity/heavy lifting 5-7 days

Bronchial Embolisation - Complications
Minor - common
fever
chest pain
Pain on swallowing
Major – very rare
Damage to bronchus
Broncho oesophageal fistula (short circuit)
Leg paralysis
Chemotoxic
embolic
TIA/stroke

Results
50% patients have multiple blood supply
Control of haemorrhage in >90% patients
30-50% rebleed rate at 3 years
Mean rebleed free interval 9 months
Serisli et al Int Angio 2008;27:319-28

Potential for research
Use of newer embolic agents
No benefit in other anatomical areas
Uterine fibroids
Drug coated embolic agents
Anti-fungals
Proteins to prevent blood vessel growth
Research is expensive
Takes up to 10 years to come to market

Conclusions
Bronchial artery embolisation
Good at controlling bleeding
Rebleed rate is high
Major complication rate low

Discussion – part 1
Vitamin D
Q & A from a clinician – send in questions
Virtual clinic
Presentation for carers ( Carers Association )?
Skin/visual sensitivity – January 2012
Fatigue & muscle pain
Cardiothoracic surgery
Help at home /everyday life (Used to be FALLS service at Manchester) – have moved
Weight loss – Xmas Party Debbie/Marie?
Cleaning & freshening products – breathing problems
Tips for travel insurance
Carers – coping, impact on their lives

Discussion – part 2
Anxiety/panic attacks – psycological methods to improve
Practical help with preparing for end of life
Vaccines

Expert Patients Programme
Several of the requests we have had for information and advice are covered in detail in the Expert Patients Programme
Everyday life- practical problems
Carer support & advice
Practical help with end of life
Help at home
Psychological support
EPP is intended to act in a similar way to our support group on these issues and others, but will also show you how to use your NHS to get this support on a regular basis and provides contacts who can help.
Highly recommended for patients & carers

AOB
New patients information leaflets (nearly) ready to go
Complications of ABPA
SAFS
Aspergillus bronchitis – coming soon
Funguide Cook book – keep sending in recipes
Calendar – have got help on a ‘mushroom’ calendar
Colourful
Can insert informative text on each page
Downside – although attractive they don’t really have direct relevance to much of what we are trying to put across
Donate by mobile phone – now in operation, automatically gift aided
Send ASPR44 2 to 70070 to donate £2,
can also donate £3, 4, 5 or 10 by substituting the 2
Discussing emergency out of hours number – 12345 text
,

Nursing Times Award – wish us luck!

Next Month - Speaker
Livingstone Chisimba: Q & A session for any medical issues you want to bring up
We need questions!!
3rd November 2011 in Seminar room 4

Thank You
“ The best chance we have of beating this illness is to work together”
Living with it, Working with it, Treating it
Fungal Research Trust

Bronchial embolisation to treat bleeding caused by chronic pulmonary aspergillosis

by Graham Atherton on Oct 13, 2011

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Bronchial embolisation to treat bleeding caused by chronic pulmonary aspergillosis — Webinar Transcript