Massive or persistent hemoptysis can be a life-threatening condition and poses a major challenge for acute and long-term treatment.1,2 The main priorities are to maintain the airway, optimize oxygenation, and stabilize the hemodynamic status. Endobronchial balloon tamponade has been used to control life-threatening hemoptysis.3–5
The successful use of a Fogarty balloon catheter for endobronchial tamponade was first described in 1974.6 With the classical balloon tamponade technique, the bleeding airway is occluded by inflating a balloon catheter, which is passed through either a flexible or a rigid bronchoscope.
We present 3 clinical cases of patients with persistent or massive hemoptysis successfully treated by a modified bronchoscopic balloon tamponade technique. A snare inserted through a bronchoscope was used to grasp a balloon catheter, outside the bronchoscope, allowing the adequate placement of the balloon at the bleeding bronchus (Fig. 1).
A 76-year-old man was admitted with small-volume hemoptysis for 24 hours. He had a history of chronic lymphocytic leukemia (B-cell) and had undergone chemotherapy.
Flexible bronchoscopy was performed under local anesthesia (Fig. 2) using an Olympus EVIS IT180 scope inserted through the nasal route. A large floating clot occluded the right main bronchus. After the suction removal of the clot and irrigation with cold saline solution and topical aminocaproic acid, a continuous active bleeding from right B3 was observed (Fig. 2A).
A balloon catheter (Olympus B7-2C) was inserted through the working channel of the bronchoscope and inflated inside the right main bronchus to stop bleeding, but it was ineffective. The bronchoscope was rapidly withdrawn from the airway up to the larynx. A snare catheter was introduced through the bronchoscope and the balloon was inserting through the other nostril. To navigate the balloon catheter to the bleeding site, the snare was protruded outside the working channel of the bronchoscope (Fig. 1). The distal end of the balloon catheter was held in place with the wire snare. Together, the balloon catheter and the bronchoscope were pushed forward to the trachea and the B3 right segmental bronchus (Fig. 2B). The balloon was placed proximal to the bleeding bronchus and inflated transiently (Fig. 2C). After confirming the adequate blockade, the balloon was deflated and gently withdrawn to allow the snare to be removed (Fig. 2D), and then the balloon was reinflated. The bronchoscope was withdrawn and the balloon was left in place in the right B3 and secured at the proximal end. Seventy-two hours later, the balloon was deflated under bronchoscopic guidance; no bleeding was present. The patient was discharged 5 days later without further hemoptysis for further evaluation as an outpatient.
A 45-year-old woman, nonsmoker, with a history of a right pleural fibrous tumor had undergone several surgeries for tumor resection, phrenectomy, and diaphragm reconstruction due to the tumor relapse. Three days after the last surgery she was admitted with small-volume hemoptysis for 24 hours duration.
Flexible bronchoscopy revealed continuous bleeding from the right B6 segment. The bleeding could not be controlled neither by repeated instillation of cold saline nor by aminocaproic acid solution. A balloon tamponade was then performed according to the procedure described above (Fig. 3). The balloon was removed at 72 hours after insertion without complications or recurrence of bleeding. The patient was discharged 5 days after the catheter removal with no further hemoptysis.
A 62-year-old woman, active smoker, underwent a right upper lobectomy and right lower lobe segmentectomy for a primary lung adenocarcinoma. Twenty-five days after the surgery she developed an acute episode of massive hemoptysis requiring intubation, mechanical ventilation, and red blood cell transfusion.
A flexible bronchoscopy revealed that the right main stem bronchus was occluded by a large clot; the clot was successfully removed using a suction (Fig. 4). The bleeding originated from the posterior wall of the trunchus intermedius bronchus. Instillation of cold saline and aminocaproic acid solution were ineffective in controlling the bleeding. Bronchoscopic balloon tamponade was performed through the endotracheal tube with immediate bleeding control. The bronchoscope was then withdrawn and the balloon catheter was secured proximally. The balloon was kept in the intermediate bronchus for 9 hours until she was submitted to a right pneumonectomy with no further hemoptysis.
Bronchoscopic tamponade has been widely used for the treatment of acute airway bleeding because it allows an immediate control of the bleeding, simultaneously maintaining airway patency and lung function. The usual technique consists in inflating a balloon catheter passed through the working channel of the bronchoscope.
However, bronchoscopic vision is lost if bleeding persists, as suction capacity is almost abolished and the balloon catheter cannot be left in place as the bronchoscope needs to be removed after the procedure.
Our modified technique, using a therapeutic 2.8 mm working channel bronchoscope and a 1.6-mm-diameter steering snare for guidance of balloon catheter, provides a greater suction capacity because of the smaller gauge of the catheter snare allowing continuous blood aspiration and a better field of view. Once bronchial blocking and adequate bleeding control has been achieved, the balloon is transiently deflated to free the snare tip, and the inflated balloon is left in place. The snare is then withdrawn from the working channel of the bronchoscope, and a final cleaning of the airway is performed before finishing the procedure. The inflated balloon can be left in place for longer periods and a surveillance bronchoscopy can be repeated on demand.
The technique is easy to perform and no contraindications were observed. Moreover, no special catheter is required as it can be performed with a Swan-Ganz catheter, Fogarty catheter, or any other commonly available balloon catheter, such as the Olympus B7-2C with a diameter of 2.3 mm.
The bronchial blocking technique was described for selective lung ventilation using the Arndt endobronchial blocker and has also been found useful in the control of localized airway hemorrhage. However, difficult placement of the catheter and dislodgement of the inflated balloon in smaller bronchi have been reported.7 The device is also not universally available.
In the first 2 cases, sustained tamponade resolved the hemoptysis and no further invasive treatments were needed. Furthermore, successful blocking of the bleeding bronchi allowed for adequate hemodynamic stabilization and ventilatory improvement in the third patient, reducing the risks and complications from the required more invasive procedure. In conclusion, this modified technique, using ancillary devices, has the potential for a longer and more efficient control of persistent hemoptysis, either as a simple yet definitive solution or as a bridging step to more invasive and curative solutions.
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