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Respiratory emergencies
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Respiratory emergencies
Respiratory emergencies
Respiratory emergencies
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Respiratory emergencies

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  • 1. Respiratory Emergencies Stepwise management of Hemoptysis Tarek Mohsen MD, FRCS Cardiothoracic Surgeon Cairo University
  • 2. Definitions
    • Hemoptysis is the expectoration of blood or of blood-stained sputum.
    • Massive hemoptysis, the amount varies from 200 – 1L / 24 hrs, but is usually defined as 600 / 24 hrs.
    • Any amount that causes respiratory compromise and/or hemodynamic instability is life threatening and constitutes a medical emergency.
    • The mortality ranges 7–30% for non-massive, and up to 80% for massive hemoptysis.
  • 3. Questions and Answers
    • Is it Hemoptysis?
    • What is the Cause?
    • What is the source?
    • When massive hemoptysis is the case
    • Resuscitation + search for the cause + active treatment are held hand in hand
  • 4. Is it Hemoptysis?
    • Hemoptysis
    • History
    • Lung disease
    • Asphyxia is possible
    • Sputum examination
    • Frothy, bright red.
    • Lab
    • Alkaline pH
    • Mixed with macrophages and neutrophils
    • Hematemesis
    • History
    • Nausea and vomiting
    • Gastric or hepatic disease
    • Sputum examination
    • Coffee ground, black or brown
    • Lab
    • Acidic pH
    • Mixed with food particles
  • 5. What is the cause?
    • Neoplastic
    • Bronchogenic carcinoma
    • Bronchial adenoma
    • Pulmonary metastasis
    • Infectious
    • Tuberculosis #
    • Fungal infections
    • Necrotising pneumonia
    • Lung abscess
    • Hydatid cyst
    • Pulmonary
    • Bronchiectasis #
    • Cystic fibrosis
    • LAM
    • Vascular
    • Pulmonary thrombo-embolism
    • AV malformation
    • Mitral stenosis
    • Thoracic aorta aneurysm
    • Systemic diseases
    • Behcet’s disease
    • Wegener’s granulomatosis
    • Goodpasture’s syndrome
    • SLE
    • Coagulopathies
    • DIC, Thrombocytopenia, Haemophilia
    • Anticoagulant therapy
    • Misc.
    • Catamenial and brocholith
  • 6. Source of blood
    • In 90% of cases, hemoptysis originates from the bronchial arteries, in 5% from the pulmonary arteries, and in the remainder from non bronchial collaterals.
    • Bronchial hemoptysis is usually profuse while pulmonary hemoptysis is not.
  • 7. Most common cause in Egypt
    • In adults exclude TB, bronchiactesis and bronchogenic and DON’T forget RTI.
    • In children exclude FB and RTI.
    • Put in mind AV malformation and vasculitis
  • 8. Steps towards diagnosis
    • History and clinical examinations
    • Labs
    • Radiography (HRCT) + contrast.
    • Bronchoscopy
    • Bronchial angio
    • CT pulmonary angio
    • Echo heart.
  • 9. Diagnostic Clues in Hemoptysis: Physical History
    • Clinical clues
    • Association with menses
    • Anticoagulant use
    • Dyspnea on exertion, fatigue, orthopnea, PND, frothy pink sputum
    • Fever, productive cough
    • History of chronic lung disease, recurrent lower RTI, cough with copious purulent sputum
    • Pleuritic chest pain, calf tenderness
    • Suggested diagnosis
    • Catamenial hemoptysis
    • Medication effect, coagulation disorder
    • Congestive heart failure, left ventricular dysfunction, mitral valve stenosis
    • Upper RTI, acute sinusitis, acute bronchitis, pneumonia, lung abscess
    • Bronchiectasis, lung abscess
    • Pulmonary embolism or infarction
  • 10. Diagnostic Clues in Hemoptysis: Physical History II
    • Clinical clues
    • Tobacco use
    • Weight loss
    • History of breast, colon, or renal cancers
    • Immunosuppression
    • Suggested diagnosis
    • Acute bronchitis, chronic bronchitis, lung cancer, pneumonia
    • Emphysema, lung cancer, tuberculosis, bronchiectasis, lung abscess, HIV
    • Endobronchial metastatic disease of lungs
    • Neoplasia, tuberculosis, Kaposi's sarcoma
  • 11. Diagnostic Clues in Hemoptysis: Laboratory Tests
    • Test
    • CBC
    • INR and PTT
    • ESR and Tuberculin test
    • ABG
    • Sputum for Gram stain, culture and sensitivity and cytology.
    • D- dimer
    • Diagnostic finding
  • 12. Diagnostic Clues in Hemoptysis: Chest Radiograph
    • Radiological findings
    • Normal or no change from base line
    • Cavitary lesion
    • Hilar adenopathy or mass lesion
    • Nodules or granulomas
    • Diffuse alveolar infiltrate
    • Patchy alveolar infiltrate
    • Lobar or segmental infiltrate
    • Hyperinflation
    • Suggested diagnosis
    • Sinusitis, bronchitis, PE
    • TB, lung abscess, necrotizing ca.
    • Sarcoid, lung ca., infectious process
    • Carcinoma, mets, Wegener's granulomatosis, septic embolism, vasculitides
    • Chronic heart failure, pul. edema, aspiration, toxic injury.
    • Bleeding disorders, idiopathic pulmonary hemosiderosis, Goodpasture's syndrome
    • Pneumonia, thromboembolism, obstructing carcinoma
  • 13. Cavitary lesions
  • 14. Hilar adenopathy and mass
  • 15. Nodule or granuloma
  • 16. Lobar or segmental infiltrates
  • 17. Alveolar infiltrate
  • 18. Bronchiactesis
  • 19. Hydatid cyst
  • 20. Role of bronchoscopy
    • Bronchoscopy is useful in both the diagnostic work-up as well as a therapeutic modality.
    • The timing of performing bronchoscopy is controversial. One suggestion is to perform urgent bronchoscopy when there is rapid deterioration and elective bronchoscopy within 24–48 h in stable patients.
    • In patients with massive hemoptysis, rigid bronchoscopy is the method of choice due to its better suction ability. The major limitation of rigid bronchoscopy is that it is difficult or even impossible to visualize the upper lobes or peripheral lesions
  • 21. Initial management steps
    • 1) Resuscitation and airway protection are the first priority.
    • 2) Localization of the site and establishing the cause of bleeding is the next step.
    • 3) The final step is directed at specific and definitive treatments to stop the haemoptysis and to prevent rebleeding
  • 22. Resuscitation
    • Admit to ICU with full monitoring.
    • Position the patient with the bleeding site down.
    • Estimate of blood Loss (Hb, Hct and CVP).
    • Stable patient are investigated.
    • Unstable patients are intubated and ventilated.
  • 23. Airway protection
    • Selective intubation of one lung can be performed by a rotational technique. After intubating the trachea, the tube is rotated through 90 in the direction of the desired placement until resistance is felt. The tube placement should be confirmed both clinically and radiologically.
    • Alternatively, a double-lumen endotracheal tube can be passed to protect the unaffected lung.
  • 24. Localization of the site
    • Localization of the bleeding site directs
    • definitive treatment. This can be achieved by combining the various imaging techniques with bronchoscopy.
  • 25. Definitive and specific treatments.
    • Bronchoscopic treatment.
    • Bronchial Embolization.
    • Surgery.
    • Disease specific approach.
  • 26. Bronchoscopic management
    • When bleeding is mild to moderate instillation of cold saline, adrenaline (1: 20.000). I.V or local ornipressin 5 IU in 20 ml normal saline.
    • If massive bleeding, rigid bronchoscopy or combined bronchoscopy is needed.
    • Bronchial tamponade may be needed in some cases, Fogarty size 4 – 6, 170 cm can be placed via bronchoscopy. Up to 7 days until definitive treatment is established
  • 27. Bronchoscopic intervention
    • The use of laser, electrocautery
  • 28.
    • Coagulation
      • laser
      • electrocautery
      • cryotherapy
    Mechanical debulking twist & push
  • 29. Bronchoscopic intervention
  • 30. Bronchoscopic intervention
  • 31. Bronchial artery embolisation.
    • BAE is a technically demanding procedure and should always be performed by skilled
    • interventional radiologists.
    • Multi-detector row helical CT angiography could be used as a road map guiding the interventional radiologist.
    • The most commonly used agent is polyvinyl alcohol (PVA) with particles sized 350–500 mm in diameter.
    • Immediate response rates after BAE range 73–98%.
    • Complications are chest pain and is transient, Spinal cord injury in 1 %.
  • 32. Surgery
    • Currently, surgery represents one of a few treatment options, but still represents the only definitive one.
    • Surgical mortality ranges 1–50%.
    • Surgery remains the procedure of choice in patients with localised bronchiectasis, trauma, hydatid cyst, arteriovenous malformations, thoracic aneurysm and aspergilloma, because it is curative for these underlying diseases.
  • 33. Disease-specific approaches.
    • Aspergilloma.
    • A patient with an aspergilloma should undergo surgical resection. Unfortunately, such patients often have significant concomitant bronchiectasis that may preclude them from surgery due to insufficient pulmonary reserves. In these patients intracavitary Na of K iodide is curative. In some series external beam irradiation was used .
    • Immunological diseases.
    • Some of the immunological diseases, such as Goodpasture’s
    • disease, can present with massive haemoptysis. These diseases do not need invasive procedures and are usually treated with high-dose corticosteroids, cytotoxic agents or plasmapheresis.
  • 34. In practice tailored management for hemoptysis is needed
  • 35. Case I
    • 58 yrs old male presented with frank hemoptysis and heart failure.
    • History of old TB, asthmatic bronchitis, previous cardiac catheterization and Marevan
    • Examination revealed features of heart failure, and murmur of AS.
  • 36. Investigation
    • Hb 7gm%, CT scan, Echocardiography, PFTs.
    • CT scan revealed bilateral epical fibrotic lesions, pulm edema and bilateral pl effusion. Calcified Ao. Valve
    • Echo revealed AS with a gradient of 60 mmHg and ejection fraction of 38 %
  • 37.  
  • 38. Management
    • Resuscitation with Blood to restore Hb
    • Upright position
    • Coagulants
    • Anti failure measures
    • No bronchodilators or cough sedatives
    • Hemoptysis decreased in amount but did not stop on the 3 rd day of admission.
    • Bronchoscopy was done revealing right upper lobe a source of bleeding.
  • 39. What Next
    • Consider RUL followed by AVR
    • Consider AVR followed by RUL
    • Combined procedure
    • Embolization followed by AVR
    • What Valve is suitable for this patient?
  • 40. Final management
    • Because we considered the patient for valve replacement his marginal pulmonary functions and bilateral lesion we decided to do bronchial angiography and possible embolization.
    • Four weeks later the patient had dobutamine stress echo and cardiac catheterization.
    • Ao. Valve replacement with a tissue valve was then done.
  • 41. Bronchial embolization
  • 42.  
  • 43. Case II
    • 72 yrs old female presented with repeated attacks of hemoptysis
    • History of CAD, hypertension, DM, left mastectomy for Ca breast 10 yrs ago with post resection chemo and radiotherapy.
    • Angina class III
  • 44. Investigation
    • Routine investigations were normal
    • CT scan showed a Rt lower lobe mass, adenoca. was confirmed by TBLB. Patient was staged as stage IIB
    • Coronary angio revealing 3 Vs disease with critical proximal LAD.
  • 45.  
  • 46. Problem List
    • CAD + other co-morbidity.
    • Hemoptysis due to operable malignant mass.
    • High mortality if resection is done in CAD.
    • So what next?
  • 47. Management
    • In our patient hemoptysis didn’t respond to conservative therapy.
    • Options left were
    • Lobectomy followed by CABG
    • CABG followed by lobectomy
    • Combined procedure
    • Stenting followed by RLL
  • 48. Definitive management
    • A drug eluding stent to LAD and mid RCA were done.
    • Patient developed left hemiparesis few hours after the procedure.
    • On the 3 rd day significant attack of hemoptysis.
  • 49. Options
    • Urgent RLL.
    • Urgent wedge resection of the mass (not oncologically radical).
    • Rigid bronchoscopy and packing.
  • 50. Rigid bronchoscopy and tamponade
    • Urgent rigid bronchoscopy with packing of the Rt intermediate bronchus, using Fogarty size 6 hemoptysis was then controlled.
  • 51.
    • Two weeks later uneventful RLL was done.
  • 52. Case III
    • Male 48 yrs old chronic heavy cigarette smoker
    • Hemoptysis responded to conservative management
    • All investigations were normal
  • 53. Multi slice Pulmonary angio
  • 54. Bronchoscopy
    • White light bronchoscopy revealed bleeding middle lobe but no lesion.
    • EBUS revealed distraction of cartilage and biopsy revealed grade II dysplasia
    • Patient was diagnosed as stage 0 ca
    • He underwent middle lobectomy
  • 55. EBUS
  • 56. Thank You

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