70	A. Bansal and V. Kantroo

•Surgical resection of the bleeding site is possible if the lesion can be localized and the patient is fit for surgery.

•Surgery is also preferable when the acuity (rate and amount of bleeding) of hemoptysis precludes safe BAE.

•More specific indications for surgery in massive hemoptysis include persistent bleeding from a mycetoma resistant to medical management, bronchial adenoma, iatrogenic pulmonary artery rupture, leaking aortic aneurysm, hydatid cysts, and selected AV malformations.

Step 9: Endobronchial brachytherapy

This therapy serves well in treating residual or recurrent carcinoma. It can be effective for the patients who have been treated with maximal doses of external beam radiation. However, it can be potentially dangerous. Massive hemoptysis and mediastinal fistulae are the most common complications. A brief summary of management is described (Fig. 8.1).

Suggested Reading

1.MacDonald JA, Fraser JF, Foot CL, Tran K. Successful use of recombinant factor VII in massive hemoptysis due to community-acquired pneumonia. Chest. 2006;130:577–9.

Recombinant factor VII may be a useful temporizing measure in the unstable patient with pulmonary hemorrhage without coagulopathic bleeding when conventional treatment is not immediately available.

2.Ong TH, Eng P. Massive hemoptysis requiring intensive care. Intensive Care Med. 2003; 29:317–20.

Embolization is a suitable first-line treatment for massive hemoptysis not responding to conservative treatment, reserving emergency surgery for cases in which the above measures are insufficient to control bleeding.

3.De Gracia J, de la Rosa D, Catalán E, Alvarez A, Bravo C, Morell F. Use of endoscopic fibrinogen-thrombin in the treatment of severe hemoptysis. Respir Med. 2003;97:790–5.

The topical treatment with fibrinogen-thrombin could be considered in the initial endoscopic evaluation of the patients with severe hemoptysis while awaiting BAE or surgery, or as alternative treatment to arterial embolization when the latter is not available, has proved ineffective.

4.Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics. 2002;22:1395–409.

BAE is a safe and effective nonsurgical treatment for the patients with massive hemoptysis. However, nonbronchial systemic arteries can be a significant source of massive hemoptysis and a cause of recurrence after successful BAE.

5.Abal AT, Nair PC, Cherian J. Haemoptysis: aetiology, evaluation and outcome—a prospective study in a third world country. Respir Med. 2001;95:548–52.

This article gives a comprehensive review of the assessment and management of hemoptysis.

6.Dupree HJ, Lewejohann JC, Gleiss J, Muhl E, Bruch HP. Fiberoptic bronchoscopy of intubated patients with life-threatening hemoptysis. World J Surg. 2001;25:104–7.

Widespread use of flexible bronchoscopy makes this procedure immediately applicable in critical situations. Intubated and mechanically ventilated patients with life-threatening hemoptysis especially benefit from this rapidly feasible procedure.

7.Jean–Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med. 2000;28:1642–7.

This article gives comprehensive review of assessment and management of hemoptysis.