This has reduced enthusiasm for lung resection as a primary treatment modality for active massive hemoptysis. 15 of the 20 patients tempered with BAE (75%) had recurrent hemoptysis, whereas 1 of the 41 patients (2.44%) who underwent lung resection without BAE developed recurrent hemoptysis (p-value < 0.0001). There were no deaths or surgical complications other than recurrent hemoptysis in patients who underwent BAE before lung resection.
Although there were no deaths in patients who underwent lung resection alone, 2 patients developed a bronchopleural fistula after resection and 1 patient developed a post-resection empyema thoracis (6.82% morbidity). These preliminary data suggest that patients with radiologically localized disease and massive hemoptysis who are considered suitable for surgery should undergo urgent lung resection. These data also suggest that BAE is probably best used as a temporary measure in patients unsuitable for acute lung resection.
INTRODUCTION
When BAE is used as a temporary measure followed by non-urgent lung resection (in appropriately selected patients), it is assumed that there is sufficient time for adequate resuscitation of the patient and removal of blood from the bronchial tree. However, selection criteria for lung resection were unclear and lung isolation techniques may have been inadequate. In addition, 31 of the 68 patients who underwent lung resection did not have a lung function assessment.
Andrejak et al demonstrated a postoperative morbidity of 71% and mortality of 35% in patients undergoing lung resection who were actively bleeding and in whom BAE was not performed or failed. It is believed that lung resection in the presence of active tuberculosis is associated with a higher complication rate, especially in bronchopleural fistulas and post-resectional empyema thoraces. Therefore, BAE is believed to be the best therapeutic modality in patients with massive hemoptysis with active tuberculosis, despite being suitable candidates for lung resection.
OVERVIEW AND LITERATURE REVIEW
SURGERY
This improves the pulmonary reserve and allows adequate resuscitation of the patient before the operation [Knott-Craig, CJ., et al.], which is then usually undertaken 48-72 hours later. The bronchial cuff of the double-lumen endotracheal tube should be proximal to the upper lobe bronchus to avoid Two of the most important post-operative complications after lung resection are bronchial stump secretion and a post-resection empyema thoracis.
Arteries other than the bronchial arteries that may be the source of the hemotysis include: the intercosto-brachial trunk, subclavian artery, axillary artery, and the internal mammary artery [Wong, ML., et al]. Spinal arteries may arise from the intercostal branch of the right ICBT in 5%–10% of cases. The number and origin of the bronchial arteries are carefully assessed to determine the optimal approach for embolization.
This allows safe placement of the catheter into the bronchial circulation, beyond the origin of the bronchial circulation. After catheterization of the bronchial artery, bronchial angiography is performed with manual injection of a contrast agent. 25 early recurrence of hemoptysis due to recanalization of an embolized artery [Wong, ML., et al].
Nonbronchial systemic arteries can be a significant source of massive hemoptysis, particularly in patients with pleural disease due to extension of the underlying lung disease. Missing the non-bronchial systemic arteries during initial angiography can lead to early recurrent bleeding after successful embolization of the bronchial arteries [Mal, H., et al]. Life-threatening active massive hemoptysis can be treated by endobronchial therapies aimed at causing vasoconstriction of the bronchial arteries.
A double-lumen endotracheal tube may be used in severe cases of massive hemoptysis where emergency airway control is critical to prevent asphyxiation. 34 complications include a post-stenotic pneumonia due to atelectasis of the closed lung [Hankanson, E., et al]. This is most likely due to effusion and contamination of the normal bronchial tree resulting in inadequate ventilation.
AIMS
HYPOTHESIS
MATERIALS AND METHODS
39 A detailed history and examination was undertaken on all patients as a preliminary assessment to determine not only the possible etiology of the hemoptysis, but also the feasibility of lung resection. It has been used in conjunction with more accurate methods of assessing lung function to determine the feasibility of lung resection. The timing of examinations depends on the severity of the hemoptysis and the patient's hemodynamics.
42 A PaO2 >60mmHg and PaCO2<45mmHg were usually the lower limits for lung resection. Blood gas analysis has also been useful in assessing the risk of mechanical ventilation after lung resection. ii) Whole blood count. BAE requires contrast that is nephrotoxic and lung resection. undertaken in patients with renal failure is associated with a higher risk of post-operative morbidity and mortality. v) HIV.
HIV status was generally only considered when lung resection due to hemoptysis was elective and not lifesaving (such as in cases of active massive hemoptysis). 43 Currently, UKZN Department of Cardiothoracic Surgery policy regarding surgery for HIV-positive patients states that patients with a CD4 cell count >200 cells/ul or an undetectable viral load in patients receiving antiretroviral therapy are suitable for surgery, provided other criteria for lung resection are satisfactory. vi). Lung resection was usually performed when the ppoFEV1>40% and, if necessary, a ppoDLCO>40% (ppo: predicted postoperative FEV1: forced expiratory volume in the first second; DLCO: diffusion capacity for carbon monoxide). vii) Radiology.
These radiological examinations allow assessment of the extent of the disease, possible etiology and feasibility of lung resection. Lung resection was undertaken in the presence of localized disease and if surgery was deemed appropriate after detailed evaluation. BAE was undertaken as a temporary measure in those patients suitable for lung resection or as definitive therapy in patients refusing surgery or deemed unfit for surgery.
Patients who underwent lung resection were followed up for at least 1 month from their discharge date.
RESULTS
MASSIVE HAEMOPTYSIS a) SURGERY
- Recurrent haemoptysis
- Morbidity and mortality
- All complications
- MASSIVE HAEMOPTYSIS a) SURGERY
An analysis comparing the incidence of recurrent hemoptysis after treatment, morbidity, mortality, and all complications (including recurrent hemoptysis, morbidity, and mortality) between patients temporized with BAE before surgery and those treated with surgery alone using the Fischer exact test, showed the following: association between the 2 groups: . 1) Recurrent hemoptysis. Therefore, patients who undergo BAE prior to surgery have a statistically significant risk of recurrent hemoptysis compared with patients who undergo immediate surgery without temporizing with BAE. Complications were observed in 18 patients (90%) in the BAE group prior to lung resection, compared with 5 patients (12.20%) who developed complications in the surgery alone group (p-value<0.0001 ).
There is a statistically significant risk of complications if BAE is performed before lung resection. There was active hemoptysis prior to and during surgery and surgery was performed as life-saving therapy. He was ventilated overnight, resuscitated after lung resection and died on day 2 in the high care unit awaiting transfer to the general ward.
BAE was undertaken as a temporary measure and there was no recurrence of hemoptysis during the period before lung resection. Another patient, who presented after a year with recurrent minor hemoptysis, after previous “successful BAE,” was ineligible for BAE because of HIV-related nephropathy and subsequently died of poor health. An analysis comparing the occurrence of post-treatment recurrent haemoptysis, morbidity, mortality and all complications (including recurrent haemoptysis, morbidity and mortality) between those patients treated with preoperative BAE and those treated with surgery alone using the exact test Fischer, showed the following Connection between 2 groups: . 1) Recurrent hemoptysis.
Therefore, patients undergoing preoperative BAE were shown to have a statistically significant risk of recurrent hemoptysis after BAE, compared to patients who only had emergency surgery. Complications were observed in 7 patients (87.50%) in the group that was temporary with BAE before surgery, compared to 3 patients (6.82%) that were complicated in the group that underwent surgery alone (p-value<0.0001). There is therefore a statistically significant risk of complications if BAE is undertaken before lung resection.
Recurrent hemoptysis occurred in 7 patients (7.45%), all of which were due to active or recurrent TB.
DISCUSSION
This carries an increased risk of contamination of the normal lung leading to an increased mortality even if lung resection is not undertaken. In this review, 15 patients (75%) presenting with massive hemoptysis tempered with BAE before lung resection had recurrent hemoptysis after BAE, despite being suitable surgical candidates on admission. Furthermore, of the 8 patients in this review who underwent BAE for minor hemoptysis and who were considered feasible for lung resection before BAE, 5 had recurrent hemoptysis (62.5%).
Recurrent hemoptysis after surgery for massive hemoptysis can occur in up to 5% [Andrejak, C., et al]. This calls into question the previous belief that BAE undertaken before lung resection improves outcomes especially in those patients presenting with active massive hemoptysis and suggests the need for a future study to further analyze morbidity and mortality. In this series, complications of lung resection for massive hemoptysis after BAE included: 1 death due to respiratory failure due to a bronchopneumonia after lung resection and 2 patients who developed a post-.
There was no mortality in our series in patients undergoing lung resection for minor hemoptysis even in patients who had recurrent hemoptysis after BAE. However, these patients in this study were not suitable for lung resection and were discharged within 48 hours after BAE. Unfortunately, lung resection is rarely undertaken urgently in this case, as the diagnosis is difficult and often not considered as the etiology of hemoptysis.
Medical treatment (which may include antibiotics or radiotherapy based on the likely etiology) for hemoptysis is undertaken only if BAE has failed (usually technical) or if lung resection is not considered feasible. However, the primary focus of this study was on patients presenting with hemoptysis who underwent lung resection with and without preoperative BAE. However, other studies have extensively evaluated BAE and medical therapy alone, and the superiority of adding lung resection is undisputed.
This is despite the fact that the risk of a potentially fatal attack of recurrent hemoptysis after BAE is significantly higher than when lung resection is undertaken.
CONCLUSION
