Case Discussion <Brief History> C.C: Hemoptysis and dyspnea since Feb.10, 2001 P.I: This 39-year-old female patient had a history of pulmonary tuberculosis (TB) without regular control for 7-8 years. She began to took anti-TB drugs (Rifater and ethambutol) regularly since Sep. 15, 2000. The follow-up sputum examinations were negative for TB bacilli. Cough with bloody sputum and dyspnea developed on Feb.12, 2001. She consulted a local hospital where fever, leukocytosis, anemia and hypotension were noted. The CxR showed fibrotic lesions with reduction of right lung volume, deviation of the trachea to the right, and compensation hyperinflation of the left lung. (Figure 1). The hemoptysis improved after medical treatment. Unfortunately, severe cough with massive hemoptysis (about 500 ml) developed on Feb. 15, 2000, which lead to hypotension, tachycardia and tachypnea. She was intubated and was transferred to ICU. Her hemodynamics were stabilized after resuscitation with IV fluid, whole blood, and fresh frozen plasma (FFP) On examination, she was ill looking and the consciousness was clear. The body temperature was 37 C, pulse rate 95/min and blood pressure 120/764 mm Hg. The jugular veins were not distended. The breathing sounds were coarse over the right chest, with some crackles in the dependent area. There was no cardiac murmur. The abdomen was distended, tympanic but without tenderness. There was no edema over the extremities.  The follow-up CxR revealed increased infiltrates over the right side (Figure 2). The chest CT (Figure 3 and Figure 4) revealed severe destruction of the right lung parenchyma with consolidation and compensation hyperinflation of the left lung. IV Ciproxin and clindamycin were administered for suspicion of necrotizing pneumonia and lung abscess. Transamine and antitussives were also given. Because of persistent bleeding from Endotracheal tube, she underwent a bronchial angiography which revealed bleeding from right bronchial artery and inferior phrenic artery (Figure 5 ). Bronchial artery embolization (BAE) was performed smoothly and her hemoptysis subsided quickly. Her dyspnea also improved gradually and the arterial blood gases were within normal limits under T-piece weaning. Unfortunately, persistent hemoptysis recurred on Feb 19, 2001. A bedside bronchoscopy revealed active bleeding from right lower lobe bronchus. She underwent a second BAE. Unfortunately, another episode of hemoptysis with hypotension recurred on Feb. 24, 2001, requiring large amount of blood component therapy to maintain her hemodynamics. Pitreesin was also administered on Feb. 24, 2001 and her hemoptysis improved. Tachypnea, high minute ventilation, leukocytosis and moderate fever developed on Feb. 28, 2001. She underwent a right pneumonectomy on Mar. 1, 2001. The post-op course was complicated by pneumonia and hypercapnic respiratory failure. She was eventually weaned off ventilatory support and was discharged in a stable condition in late June 2001. 病例解說: 本病例為一年輕女性產生大量咳血而致休克。胸部X光及CT顯示右肺因肺結核感染而嚴重破壞。臨床上處理大量咳血最重要的是先穩定V ital signs。如經大量輸血及藥物治療仍未改善﹐比較常見之處理方式為經支氣管動脈(bronchial artery)栓塞術(BAE)。此法相當有效﹐但仍有其併發症。如果BAE效果不佳或再度大量咳血﹐手術切除為僅存之處理方式之一。經由支氣管鏡阻斷出血之方法並不容易﹐需有充分之臨床經驗者始得為之。臨床上大量咳血的病例不多見﹐以支氣管擴張症及嚴重肺結核病患居多。   繼續教育考題 1. (B) Which of the following is the most common used definition of massive hemoptysis? A Hemoptysis more than 300 cc within 24-48 hours B Hemoptysis more than 600 cc within 24-48 hours C Hemoptysis more than 1000 cc within 24-48 hours D None of the above 2. (D) Which of the following blood components are most appropriate in the transfusion therapy for massive hemoptysis with hemorrhage shock? A Packed RBC and fresh frozen plasma (FFP) B Whole blood and cryoprecipitate C Packed RBC and platelets D Whole blood and fresh frozen plasma (FFP) 3. (A) Which of the following descriptions of massive hemoptysis is WRONG? A Massive hemoptysis accounts for only 25% of all cases of hemoptysis B Bronchogenic carcinoma should be high in the list among smokers >40 yrs of age C Febrile conditions with pulmonary infections (lung abscess, necrotizing pneumonia) may be complicated by massive hemoptysis D Bronchial adenoma, vascular anomalies, and aspiration of foreign bodies are very common causes of hemoptysis among children 4. (B) For the source of bleeding, the great majority of hemoptysis originates from: A Pulmonary arteries B Bronchial arteries C Intercostal arteries D Internal thoracic arteries 5. (D) About TB-associated massive hemoptysis, which statement below is true? A TB remains the most frequent among the infectious etiologies of massive hemoptysis B Aspergilloma should be included in the differential diagnostic work-up in patients with prior diagnosis of cavitary or bullous diseases C Patients with pulmonary TB may bleed from Rasmussen's aneurysm caused by erosion of blood vessels deprived of lateral support or by bronchopulmonary anastomosis within the wall of old cavities D All of the above 6. (D) Which of the following descriptions about the management of massive hemoptysis is true? A All patients should be monitored in the ICU B Worsening hypoxemia should be corrected by high-flow oxygen C The indications of intubation include refractory hypoxemia, hypovolemic shock, CO2 retention D All of the above 7. (D) Which of the following descriptions is true for the medical therapy of hemoptysis? A IV Transamine and pitressin can be useful B The patient should be placed on lateral decubitus toward the site of bleeding to prevent aspiration into the contralateral lung C Cough-suppressing drugs can be added as an adjunct therapeutic measure D All of the above 8. (D) Which of the following descriptions about the bronchoscopy for massive hemoptysis is true? A The ideal timing is still controversial, but the consensus is to perform urgent bronchoscopy in patients with rapid clinical deterioration B Delayed bronchoscopy (within 24-48 hrs of admission) is preferred in stable patients C The oxygen flow should be adjusted to maintain adequate oxygen saturation during the procedure D All of the above 9. (C) Which description is WRONG regarding the bronchial artery embolization (BAE) for the management of massive hemoptysis? A Is now considered the most effective non-surgical treatment in massive hemoptysis B The success rate within 24 hrs was high; but about 16% of patients may have recurrent bleeding within one year C No serious complications are associated with this procedure in patients without bleeding tendency D Failure of bronchial artery embolization is mainly attributable to non-bronchial collateral arteries from phrenic, intercostal, or subclavian arteries 10. (D) Which description is true regarding the surgical management of massive hemoptysis? A The surgical mortality rate, defined as death within 7 days of the operation, has varied between 1% and 50% B Surgery is contraindicated in patients with lung carcinoma invading trachea, the mediastinum, the heart, or great vessels C Surgery remains the procedure of choice for leaky aortic aneurysm, arteriovenous malformations, chest injuries, bronchial adenoma, and fungal ball D All of the above 答案解說 (B)Hemoptysis>= 600 ml within 24 hr is the most common used definition of massive hemoptysis? (D)For patients with massive hemoptysis, a minimum of 6 units of packed red cells should be ordered because of the potential blood loss from the bronchial arteries. If the patient presented initially with unstable vital signs, uncrossed O-positive blood type should be transfused immediately; O-negative blood type should be reserved for childbearing-age females (Reference: Crit Care Med 2000 May pp 1642-1647). (A)Massive hemoptysis accounts for only 1.5% of all cases of hemoptysis. All other descriptions are correct. (B)The great majority of hemoptysis prevalence originates from the bronchial arteries (90%) whereas the pulmonary arteries may be the cause in only 5%. Any bleeding originating from the bronchial arteries, even mild, has the propensity to cause life-threatening hemoptysis because of the high pressure in the bronchial arteries. (D)All descriptions are correct (D)All patients with massive hemoptysis should be monitored in the intensive care unit. Worsening hypoxemia is an indication of an expanded alveolar territory affected by the bleeding and should be corrected with high-flow oxygen. When intubation becomes necessary (life-threatening hemoptysis, hypovolemic shock, worsening of the hypoxemia in spite of supplemental oxygen, or elevated CO2 concentration), a large bore endotracheal tube of>= 8 mm internal diameter is preferred to allow the fiberoptic exploration of the lungs. (D)The patient should be placed on lateral decubitus toward the site of bleeding in the prospect of sparing the contralateral lung from aspiration. This belief is rather theoretical and has not been challenged in controlled studies. Cough-suppressing drugs can be added as an adjunct therapeutic measure, but they may favor the hazard of blood retention into the lungs. (D)All descriptions are correct. (C)The most serious complication of BAE is the accidental embolization of the spinal artery either by contrast material or the embolizing particles causing ischemic injury to the spinal cord. The reported prevalence is extremely low (<1%) and it occurs when the spinal artery arises from the bronchial artery (D)All descriptions are correct.