To the Editor:
Airway obstruction from a large blood clot can occur in a variety of clinical settings; however, it is not always preceded by hemoptysis.1 Occasionally, endobronchial blood clot (EBBC) may cause life-threatening large airway obstruction and respiratory failure. The management of a large airway clot might initially include intubation, rigid bronchoscopy, mechanical ventilation, and supportive care.2
We report a case of a massive hemoptysis in which we removed a large, life-threatening EBBC simply using a flexible bronchoscope (FB).
A 49-year-old woman, life-long nonsmoker with chronic renal failure from urinary infection and requiring hemodialysis presented with hemoptysis. She had no prior pulmonary or bleeding history. She had expectorated approximately 500mL of blood preceding 24 hours. On physical examination, her vital signs were stable; crackles were heard in both the lower lung fields. A laboratory analysis revealed normal coagulation parameters and platelet count. Chest x-ray revealed a bilateral infiltrate involving the lower zones.
A computed tomography scan of the chest revealed interlobular septal thickening and reticulonodular densities involving both the lower lobes of the lung. There was evidence of bilateral hilar and subcarinal lymphadenopathy. Despite a course of antibiotics, her hemoptysis continued. The patient underwent FB under local anesthesia, which revealed a large blood clot totally occluding the left lobe lower bronchus (Fig. 1). Extraction of the clot was attempted and was successful simply using continuous suction through the working channel of the scope. The entire clot, in a shape of bronchial cast, was removed along with FB (Piggyback). No active bleeding was visualized. Bronchoalveolar lavage and transbronchial needle aspiration of the mediastinal lymph node was performed. The cytologic, pathologic, and microbiological specimens demonstrated macrophages with ingested erythrocytic debris and organized blood clot; however, studies for mycobacterial, fungal, and malignant disease were negative. The patient was discharged home with a course of antibiotics and tapering steroids. She continues to do well without recurrent hemoptysis.
Uremia can cause hemoptysis without any other identifiable etiology. In a retrospective review of 34 uremic patients, etiology of hemoptysis was undetermined in 41%.3
Hemoptysis, or the expectoration of blood, can range from blood streaking of sputum to the presence of gross blood in the absence of any accompanying sputum.4 A massive hemoptysis is variably defined as expectoration of blood in an amount ranging from 100 mL within 24 hours to over 1 L over several days.5 The most common causes of massive hemoptysis are tuberculosis, bronchiectasis, aspergilloma, lung abscess, and neoplasm. Less common causes are mitral stenosis or congenital heart diseases, autoimmune diseases, cystic fibrosis, vascular malformation, and iatrogenic events. In 8% to 15% of cases of massive hemoptysis, however, the cause remains obscured despite a thorough workup (cryptogenic or idiopathic hemoptysis).5 Our patient had expectoration of blood with cough 500 mL in a day and had no cardiac or, autoimmune diseases, tuberculosis, or neoplasm. In our patient, the bleeding was thought to be related to platelet dysfunction from chronic renal failure.
The presence of EBBC is suggested by the clinical and radiographic findings of local airway obstruction.1 The diagnosis is established by direct endoscopic evaluation. Management of airway obstruction from blood clots is not standardized, and various techniques have been used.2 Initial efforts at removal of the airway clot, if warranted, involve lavage and suctioning by means of an FB. The use of flexible forceps is usually unsuccessful in removing large clots. If unsuccessful, further management options include cryoadhesion, rigid bronchoscopy, Fogarty catheter dislodgment of the clot, and topical thrombolytic agents.1 The use of cryo has been reported to have 100% success in removing large clots (R).2 Rigid bronchoscopy is another method of choice in the setting of massive hemoptysis, especially in critically ill patients; however, in most, it requires general anesthesia. We recommend initial attempt to remove the blood clot with a flexible scope.
Gülcan Çetin, MD
Ruhsel Cörüt, MD
Pulmonary Diseases Department, Başkent University School of Medicine, Ankara, Turkey
1. Arney KL, Judson MA, Sahn SA. Airway obstruction from blood clot: three reports and review of the literature. Chest. 1999;115:293–300
2. Michael N, Solomon, Charles A, et al. Urologic tools in the extraction of endobronchial blood clot. J Bronchol. 2003;10:133–138
3. Kalay N, Dunagan D, Adair N, et al. Hemoptysis in patients with renal insufficiency: the role of flexible bronchoscopy. Chest. 2001;119:788–794
4. Thompson AB, Teschler H, Rennard SI. Pathogenesis, evaluation, and therapy for massive hemoptysis. Clin Chest. 1992;13:69–82
5. Cahil B, Ingbar D. Massive hemoptysis: assessment and management. Clin Chest Med. 1994;15:147–168