A 30 yearold woman with hemoptysis

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A 30 year-old woman with hemoptysis

• Chest Conference
• November 19, 2002

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Case Presentation

• The patient is a 30 year-old Pakistani woman with
  CF who presents complaining of large-volume
  hemoptysis.
• The patient was relatively well until 1 month PTA
  when she developed an increasing productive
  cough. Her FEV1 was noted to be 1.4 (pts
  baseline 1.9). Her sputum grew Pseudomonas and
  she was treated for 2 weeks with IV
  Tobra/Timentin. She had scant hemoptysis during
  this episode that resolved with antibiotics.
• She was off antibiotics and without pulmonary
  symptoms until 1 day PTA when she awoke choking
  and coughing up large amounts of blood. She
  states she coughed up about 200cc of blood over
  15-20 minutes, then blood streaked sputum for
  several hours.

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Case Presentation

• On presentation to the ED, she endorsed
  orthostatic symptoms, but denied fever, chills,
  recent productive cough, SOB and chest pain.

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Case Presentation

• Past Medical History
• Cystic Fibrosis sweat test neg F508 mutation
  colonization with drug-resist Pseudomonas.
  Admitted for hemoptysis in 1998 resolved w/
  medical treatment.
• Iron deficiency anemia
• Medications
• Salmeterol
• Ipratropium/albuterol
• Fluticasone
• Social History lives in Morgan Hill, CA with
  partner no drugs, EtOH or tobacco

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Case Presentation

• Physical Examination
• 36.7 110/71 95 15 99 RA
• Gen well-appearing woman in NAD
• HEENT no oropharyngeal lesions no LAD
• Lungs few rales _at_ left mid-lung
• CV no R/M/G
• Abdomen soft, NT, ND
• Ext no edema

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Case Presentation

• Labs
• WBC 14
• Hct 35 (baseline Hct 35)
• Platelets 332
• Coags normal
• EKG sinus rhythm _at_ 85

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Hospital Course

• Pt was admitted treated with IV tobramycin
  Timentin
• Scant hemoptysis x 8 hours in the ED
• Hct 35 --gt 31.

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Hospital Course

• Pt underwent selective bronchial arteriography
• Aortogram demonstrates two large bronchial
  arteries. One bronchial artery supplies the mid
  and upper right lung. The other bronchial artery
  supplies the left mid and upper lung. These two
  vessels appear to have a common trunk origin.
• The bronchial arteries were successfully
  embolized with polyvinyl alcohol particles
  (350-500 and 500-710 microns).
• Follow-up angiographic run demonstrates some
  persistent flow of the right bronchial artery to
  the region along the medial apex.

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Hospital Course

• The patient developed severe R pleuritic CP, temp
  to 39.0C and mild dysphagia.
• Temperature and dysphagia resolved within 5
  hours and chest wall pain resolved with low doses
  of opiates.
• The patient had no further episodes of hemoptysis
  and was discharged on HD3 with a 14 day course
  of IV antibiotics.

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Bronchial Artery Embolization in CF
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Bronchial Artery Hypertrophy
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Bronchial Artery Anatomy

• Significant variability in origin of bronchial
  arteries.
• 70 arise from the thoracic aorta at T5-6.
• 45 have 2 right BA and a single left BA.
• Up to 15 have anomalous BA origins
  (thyrocervical trunk, internal mammary, inferior
  phrenic).
• 2-50 have a spinal artery branching off a
  bronchial artery.
• Bronchial arteries supply bronchi, middle third
  of the esophagus, diaphragmatic and visceral
  mediastinal pleura, aortic vasa vasorum, and
  spinal cord.

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Complications of Bronchial Artery Embolization

• Minor complications occur in 10-30 (fever, chest
  wall pain, dysphagia)
• Major complications in various case reports
• Bronchial necrosis
• Bowel ischemia
• Transverse myelitis (transient)
• Paraplegia related to spinal artery embolization
  (less of a concern with microcatheter
  technology).

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Spinal Artery Embolization
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Medical Management of Massive Hemoptysis in
Cystic Fibrosis

• 728 patients with CF at an academic center
• 38/728 (5) had massive hemoptysis (gt300ml/24hrs)
• All pts treated w/ antibiotics, vit K and fluids
• 5 pts required transfusions
• 4 had transient hypotension
• Hemoptysis stopped in all subjects without
  surgical intervention
• 34/38 had resolution of hemoptysis within 96hrs
• 10/38 died during follow-up (mean survival 2.5
  years) survival rate was similar to that of
  control group without massive hemoptysis.
• 17/38 had recurrent massive hemoptysis in
  follow-up.

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Medical Management of Massive Hemoptysis in
Cystic Fibrosis

• Conclusion
• Because patients with massive hemoptysis tend to
  stop bleeding without surgical intervention,
  future studies of therapies for massive
  hemoptysis must have appropriate control patients
  who receive only medical management.

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BAE to Control Hemoptysis in CF

• 20/425 CF patients developed hemoptysis from
  1982-86.
• Indications for BAE failure of med management
  and
• 1. An episode of massive hemoptysis w/
  persistent bleeding.
• 2. 3 or more 100mL hemorrhages within 1 week.
• 3. Chronic hemoptysis interfering with
  lifestyle.
• 4. Hemoptysis preventing effective postural
  drainage.

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BAE to Control Hemoptysis in CF

• Results 85 (19/20) had immediate control of
  bleeding with BAE
• 35 (7/20) had aberrant bronchial arteries.
• 55 (11/20) had a spinal artery coming off a
  bronchial artery.
• 90 17/19 developed post-procedure chest pain,
  fever, or dysphagia.
• No assessment of long term rate of re-bleed.
• No matched control group.

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BAE for Massive Hemoptysis in CF

• Case control study of 25 pts with CF and massive
  hemoptysis.
• Control group hemoptysis-free matched for
  disease severity, age and sex.
• 84 (21/25) had immediate control of hemoptysis
  with BAE.
• 6 died within 3 months of embolization.
• Reduced survival in embolized group vs control
  (plt0.02)
• 52 percent had recurrent massive hemoptysis
  (mean 20.5 months after first BAE).
• 52 had chest wall pain and fever after BAE. No
  serious complications.

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BAE for Massive Hemoptysis in CF

• Conclusions
• BAE effective in controlling massive hemoptysis.
• BAE has a low risk of serious adverse effects.
• BAE does not improve mortality, but may increase
  time to recurrent massive hemoptysis.

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Cystic Fibrosis Foundation Treatment Guidelines
for Major Hemoptysis

• There are almost no scientific data to support
  most of the therapeutic options listed for
  treatment of hemoptysis in CF.
• Discontinuation of drugs which could interfere
  with anticoagulation and reversal of coagulation
  abnormalities.
• Transfusions as clinically indicated.
• Treatment with appropriate antibiotics based on
  recent sputum cultures.
• Arterial embolization may be indicated for major
  hemoptysis or for minor hemoptysis when it
  interferes with patients lifestyle or medical
  management.