To the Editor:
Refractory hemoptysis can be a challenging clinical problem. We report herein 2 cases of effective treatment of hemoptysis via placement of endobronchial valves (EBVs). EBVs appear to be a valid addition to the armamentarium of the interventional pulmonologist faced with persistent hemoptysis.
A 57-year-old woman with right upper lobe (RUL) squamous cell lung cancer presented with a 3-day history of “blood when I spit.” Computed tomographic scan of the chest demonstrated a RUL mass with bulky adenopathy (Fig. 1A). Bronchoscopy demonstrated active bleeding from the RUL. Interventional radiology was consulted and felt that the anatomy was not amenable to embolization. Bleeding persisted, and 2 days later she was bronchoscoped and a 9-mm Spiration EBV (Redmond, Washington) was placed in the RUL bronchus. Bleeding stopped and did not recur. Blood did not spill into the airway after placement. Repeat bronchoscopy was not performed. A computed tomographic scan of the chest after the procedure (Fig. 1B) demonstrated valve placement, no pneumothorax, and complete atelectasis of the RUL.
A 61-year-old man with an enlarging right anterior mediastinal mass (Fig. 2A) thought to represent a primary esophageal cancer presented with 6 to 8 weeks of progressively increasing hemoptysis. Upon bronchoscopy, blood was seen to be oozing from RUL. A 9.0-mm Spiration EBV was deployed at the RUL takeoff (Fig. 2B). There was no spillage of blood into the airway at time of placement. Bleeding ceased and did not recur. The patient returned to bronchoscopy suite 3 days later for repeat bronchoscopic inspection. The EBV was in place in the RUL bronchus with some surrounding clot. There was no evidence of active bleeding. The patient was discharged to home for outpatient treatment of his cancer.
The evaluation and management of hemoptysis vary with clinical context and volume. When there is significant ongoing bleeding, management often involves an interplay between pulmonologist and interventional radiologist, with the initial step—bronchoscopy, intubation, or angiography—dependent upon availability and of the specifics of any individual case.1,2 EBV placement for refractory hemoptysis is a relatively novel approach.
EBVs were initially developed as a minimally invasive approach to lung volume reduction in severe emphysema. EBVs are unidirectional; they allow air to exit the isolated lung segment(s) during exhalation but do not allow refilling during inhalation. This principle was later extrapolated and applied to persistent bronchopleural fistula, with documented efficacy.3
The application of EBVs to the problem of persistent endobronchial bleeding is less intuitive. In theory, EBV deployment might not be effective; blood should be able to exit into the proximal airways after placement of a 1-way valve. On follow-up bronchoscopy case 2 demonstrated evidence of some spillage of blood after EBV placement, but in none of the cases reported to date has there been persistent bleeding into proximal airways.4,5 One can propose several mechanisms for the clinical efficacy illustrated in our cases. First, the valve is to some degree a physical impediment. Second, it is a nidus for coagulation. Third, atelectasis effected by an EBV can decrease blood flow to the bleeding area both via hypoxic vasoconstriction and via tamponade. One relatively unique aspect of the application of EBVs to hemoptysis is the potential for reversibility; if the etiology is benign and/or reversible, an EBV can be removed after treatment.4 In both of our cases, the EBVs were left in place with no attempt at removal given the clinical contexts with incurable malignancies.
Literature search revealed 2 prior case reports of the use of EBVs for hemoptysis;4,5 to our knowledge, the cases in this report are the third and fourth reported cases. The first case involved bilateral upper lobe deployment of EBVs in a 30-year-old man for persistent bleeding related to bilateral upper lobe aspergillomas,5 and the second involved massive hemoptysis in an HIV-positive 26-year-old man with active left upper lobe tuberculosis.4 Both had failed embolization. Our cases represent the first reported cases of the deployment of EBVs for hemoptysis caused by malignancy. The second case is unique in that EBV placement was the initial approach to hemoptysis rather than an option chosen after interventional radiology consideration or treatment; EBV placement is less invasive than embolization and may in some cases be an alternative treatment for hemoptysis.
In summary, when bronchoscopy is possible, EBVs represent another tool in the armamentarium of the interventional bronchoscopist participating in the treatment of intractable hemoptysis.
Bhavi Patel, MD*
Dina Abi-Fadel, MD*
Justin Rosenheck, MD*
Thaddeus Bartter, DO†
Ziad Boujaoude, MD*
Wissam Abouzgheib, MD*
*Division of Pulmonary and Critical Care Medicine, Cooper Medical School at Rowan University, Camden, NJ
†Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences and Central Arkansas Veterans Administration, Little Rock, AR
1. Larici AR, Franchi P, Occhipinti M, et al. Diagnosis and management of hemoptysis. Diagnostic Interv Radiol. 2014;20:299–309.
2. Ramírez Mejía AR, Méndez Montero JV, Vásquez-Caicedo ML, et al. Radiological evaluation and endovascular treatment of hemoptysis. Curr Probl Diagn Radiol. 2016;45:215–224.
3. Giddings O, Kuhn J, Akulian J. Endobronchial valve placement for the treatment of bronchopleural fistula: a review of the current literature. Curr Opin Pulm Med. 2014;20:347–351.
4. Lalla U, Allwood BW, Sinha Roy S, et al. Endobronchial valve used as salvage therapy in a mechanically ventilated patient with intractable life-threatening haemoptysis. Respiration. 2017;93:436–440.
5. Koegelenberg CFN, Bruwer JW, Bolliger CT. Endobronchial valves in the management of recurrent haemoptysis. Respiration. 2014;87:84–88.