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Management of Hemoptysis

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Management of Hemoptysis

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Hemoptysis is a serious medical problem requiring urgent or emergency management. This presentation discuss this in a lucid way

Hemoptysis is a serious medical problem requiring urgent or emergency management. This presentation discuss this in a lucid way

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Management of Hemoptysis

  1. 1. MANAGEMENT OF HEMOPTYSIS Dr R.S Dhaliwal MBBS,MS,DNB(Surg),M.Ch,DNB(CTV Surg) FACS,FCCP,FNCCP,FICA,FIACS Prof & HOD , Cardiovascular & Thoracic Surgery, P.G.I.M.E.R, Chandigarh,India
  2. 2. INTRODUCTION • Hemoptysis - Expectoration of blood originating from the tracheobronchial tree or pulmonary parenchyma • Massive Hemoptysis – Expectoration Of >600 ml blood in 24 hrs • Very important symptom which brings the patient to the doctor quickly • Can occur directly or indirectally due to any chest disease
  3. 3. Etiology • Pulmonary tuberculosis – active or its late sequallae • Bronchiectasis • Bronchial carcinoma • Lung abcess • Aspergilloma • Pulmonary infarct • Necrotizing Pneumonia • Chest trauma –airways injury • Pulmonary AV malformation and telangiectasis • Iatrogenic –PA catheter Bronchoscopic biopsy • Cardiac Disorders –MS, Eisenmenger, Cyanotic CHD • Diffuse parenchymal disease-SLE,Wegner’s granuloma • Idiopathic
  4. 4. Investigations • Sputum Cytology • X-Ray Chest • CT Scan • Bronchoscopy • Angiography • Tuberculin test or ELISA tests
  5. 5. Management Objects of Management - Prevent asphyxiation Localize site of bleeding Arrest the bleeding Determine cause of hemoptysis Treat the patient definitively
  6. 6. Medical Management • Head low with bleeding side dependent • Sedation- Non narcotics • Volume Replacement - IV fluids -Blood transfusion • Clear airways of blood and secretions • Cough Suppressants • ATT- Use in active T.B. with hemoptysis -broad spectrum antibiotics
  7. 7. Methods to control hemoptysis • Endobronchial Measures Ice cold saline Lavage Ballon Tamponade Pulmonary Isolation • Arterial Embolization • Mechanical Ventilation with PEEP • Vasoactive Drugs • Radiotherapy • Intracavitary Treatment
  8. 8. Surgical Therapy • Surgical rather than medical methods reduce mortality.Lung resections is most effective method to control massive hemoptysis and prevent recurrance of hemoptysis • Higher mortality in emergency surgery • Ongoing bleeding at time of surgery – most imp. factor for mortality. • Spillage of blood,pus and infected secretions in dependent normal lung–main cause of problems • Poor PFT –Very imp. cause of mortality & morbidity
  9. 9. Criteria for Surgical Therapy • Localized site of bleeding • Adequate pulmonary functions • No medical contrindications • Resectable Br. carcinoma without distant metastases • No mitral valve disease ( requiring cardiac surgery)
  10. 10. Indications for Urgent surgery • Fungus ball (almost all cases will rebleed after any control method) • Lung abcess ( erosion of a large vessel) • Failure of control methods • Cavity - with a movable mass, emptying and quick refilling, persistent radiodensity • Obstruction of the main or lobar bronchus due to a clot - can not be removed during rigid bronchoscopy • Endobronchial methods and arterial embolization can control hemoptysis In majority of patients temporarily
  11. 11. Surgical Techniques • Pulmonary Resections - Segmentectomy Lobectomy, or Pneumonectomy • Physiological Lung Exclusion • Collapse Therapy - Thoracoplasty or plombage • Cavernostomy and packing • Bronchial arteries ligation & ligation of chest wall collateral vessels • Anesthesia-Isolation of bleeding lung essential Single lung ventilation with Double lumen tubes Standard endotracheal tube in normal bronchus Endobronchial blocking catheters or gauze packing of bleeding bronchus also tried.
  12. 12. Pulmonary Resections • Standard treatment for massive / recurrent hemoptysis of any etiology.Removal of bleeding diseased lobe or lung is ideal. Postolateral thoracotmy is usual incision. Vascular adhesions present between lung and chest wall in T.B &infective diseases – makes it time consuming,more blood loss and difficult . May need pleuro pneumon-ectomy with higher mortality and complications like BPF, Empyema and space problems
  13. 13. Physiological Lung Exclusion • Life saving Alternative/Adjunct to a difficult or hazardous lung resection due to dense vascular adhesions,fibrosis and calcification between chest wall and lung • PHYSIOLOGICAL BASIS INVOLVED PART OF LUNG ISOLATED BY DIVISION OF * PULMONARY ARTERY * BRONCHUS & BRONCHIAL ARTERIES * VIABILITY OF ISOLATED LUNG MAINTAINED BY * VASCULAR ADHESIONS WITH CHEST WALL * INTACT PULMONARY VEINS FOR DRAINAGE
  14. 14. SURGICAL TECHNIQUE • ANTERO LATERAL THORACOTOMY • J STERNOTOMY • MINIMUM LUNG MOBILISATION- NEAR HILUM • PULMONARY ARTERY LIGATION DONE EXTRA OR INTRAPERICARDIALLY * INVOLVED BRONCHUS DIVIDED AND CLOSED * PULMONARY VEINS PRESERVED
  15. 15. RESULTS • Hospital mortality Nil • Post Operative Empyema Nil • Residual Space Nil • Recurrance of Hemoptysis 1 (FOB - other side Bleeding ) • Follow up up to 18 yrs No Problem No BPF or Empyema
  16. 16. CONCLUSIONS PHYSIOLOGICAL LUNG EXCLUSION IS AN EFFECTIVE ALTERNATIVE OPERATION FOR CONTROL OF MASSIVE OR RECURRENT HEMOPTYSIS WHERE LUNG RESECTION IS DIFFICULT/HAZARDOUS DUE TO DENSE FIBROSIS, VASCULAR ADHESIONS & CALCIFICATION
  17. 17. Other Surgical techniques • Collapse Therapy - Thoracoplasty or plombage • Cavernostomy and packing • Bronchial arteries ligation & ligation of chest wall collateral vessels

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