Departments: Interventional Pulmonology in Other Journals
Use of Endoscopic Fibrinogen-Thrombin in the Treatment of Severe Hemoptysis
Respir Med. 2003; 97:790–795 de Gracia J, de la Rosa D, Catalán E, Alvarez A, Bravo C, Morell F. Servei de Pneumologia, Hospital Universitari Vall d'Hebron, Barcelona.
This prospective study evaluated the usefulness of bronchoscopic instillation of fibrinogen–thrombin (FT) to control severe hemoptysis in eleven of 101 patients (11%) with severe hemoptysis (>150 mL/12 h) in whom bronchial artery embolization (BAE) was not possible or proved ineffective. The procedure involved identification of the bleeding site followed by local hemostasis measures such as bronchoscopic instillation of cold sterile 0.9% saline solution, epinephrine solution (diluted at 1:20,000 in cold sterile 0.9% saline solution), or collapse of the bleeding bronchial orifice by applying continuous aspiration with the tip of the flexible bronchoscope. Then the airway was dried by using oxygen administered directly through the flexible bronchoscopic channel (by connecting an O2 probe directly to the suction channel at a flow of 3–4 L/min and a pressure of 5 bar). Following this, the FT solution was instilled and bronchoscopic visualization of the bronchial tree was undertaken to assure hemostasis. The FT solution was made up of 2 separate solutions of fibrinogen (fibronectin, factor XIII, plasminogen, and aprotin) and human thrombin. The 2 components were instilled simultaneously into the bleeding bronchial orifice using syringes connected to a double-syringe system and a double-channel, 180-cm long, 0.17-cm external diameter catheter, which was passed through the bronchoscope channel and placed inside the bleeding bronchial segment or subsegment. Mean procedure duration was 3 min. The severe hemoptysis was controlled immediately in all cases. During the follow-up period (mean, 39.4 mo), early relapse of the severe hemoptysis occurred in 2 patients (18%) and a long-term relapse in one. Short- and long-term control of hemoptysis was noted in 82% and 70% of patients, respectively. No complications attributed to FT instillation were observed. The authors conclude that these results suggest that bronchoscopic topical treatment with FT could be considered in the initial endoscopic evaluation of 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, or is contraindicated. The majority of patients who develop severe or massive hemoptysis that cannot be controlled by simple bronchoscopic techniques could require BAE as one of the initial steps or a stopgap measure to control the bleeding. However, BAE is not always available or feasible in all patients and in all medical centers. Moreover, BAE has a failure rate of up to 15%. Many publications have reported bronchoscopic use of various agents to control severe hemoptysis. The paper by de Gracia and colleagues describes their experience with instillation of FT, a technique that has been used by others with varying success. One difference was the airway drying with direct oxygen administration through the flexible bronchoscope's channel. The authors infer that this step could have permitted better adhesion of the fibrin glue to the bleeding bronchial wall.