Hemoptysis, Empyema

Key Points

• Severe hemoptysis is a life-threatening medical emergency.

• Careful systematic workup is needed to identify the origin and reason for hemoptysis.

• The anesthesiologist should play an important role in identifying the severity and origin of hemoptysis, initiation first-aid management, and follow a systematic therapeutic plan according to the severity of hemoptysis.

• The anesthesiologist should select the best option for securing airway and sealing the source of bleeding from lung.

• There is no consensus on the best lung isolation tool in patients with hemoptysis, and it should depend upon the clinical scenario.

Introduction

Hemoptysis may present as mild or as a life-threatening condition. Massive hemoptysis, a major medical emergency associated with a high mortality, has been defined in the literature by several different criteria, ranging from 100 to 600 mL of blood over wide-ranging periods of time. ^, These variations in definition are impacted by the difficulty in quantifying the amount of blood expectorated, which may be overestimated by patients. In general, any hemoptysis that jeopardizes respiratory function should be considered a life-threatening medical emergency.

Case Presentation

A 22-year-old male sustained several stab wounds to the back which penetrated into the right chest. He presented to the emergency department agitated and confused with severe hemoptysis, tachycardia, tachypnoea, and dyspnea. Physical examination revealed cyanosis, signs of respiratory distress, and absent breath sounds on the right chest. The arterial oxygen saturation was 83%, with a nonrebreather mask supplying oxygen at 15 L/min. Hemoglobin concentration was 7.5 g/dL and lactic acid was 3.7 mmol/L. Point-of-care sonography and chest radiograph showed a right hemopneumothorax. Electrocardiogram and transthoracic echocardiography showed no abnormalities.

Case Management

A chest tube was inserted to the right chest and a total of 1.2 L of blood was drained. Lactated Ringer’s solution 2.0 L and 2 units of type-crossmatched packed red blood cells were administered and was followed with improved blood pressure and the level of consciousness. Chest radiography and computed tomography (CT) confirmed the presence of right hemopneumothorax. Cervical and abdominal CT scanning showed no abnormalities. The patient was brought to the operating room (OR) for emergency exploration via right posterolateral thoracotomy.

Problem A: How Can We Reduce Risk by Intraoperative Monitoring?

Routine monitors included five-lead electrocardiograph with ST segment analysis, processed electroencephalographic-based control the depth of anesthesia, and train-of-four stimulation of the ulnar nerve. Transcutaneous multifunction pads for monitoring, defibrillation, and pacing were connected to the chest wall. The radial artery was cannulated and connected to a fluid responsiveness monitoring system to guide hemodynamic parameters. An 8.0-F cordis was placed in the right internal jugular vein, and a urethral Foley’s catheter was placed.

Rapid sequence induction was considered, a left-side double-lumen tube (DLT) was placed, and the proper DLT position was confirmed using a flexible 4.0-mm bronchoscope in both supine and lateral decubitus positions. Bronchoscopic examination showed significant bleeding from the right lower lobe, and the presence of major trachea-bronchial injury was ruled out. Surgery consisted of right thoracotomy and repair of the right lower lobe bronchial injury. The patient was extubated at the end of the procedure and postoperative course were uneventful.

Cause of Hemoptysis

Several causes for hemoptysis are presented in Table 48.1 .

Preoperative Assessment

Suspected hemoptysis must be confirmed, its severity established, the origin of bleeding located, and the cause determined.

The diagnostic workup and management of severe hemoptysis is often challenging and includes chest x-ray (CXR), lung sonography, CT scanning, angiography, and importantly, bronchoscopy to identify the origin of bleeding. ^,

Detailed clinical history and physical examination should be emphasized on the initial causes and severity of hemoptysis to guide the diagnostic and therapeutic measures. ^,

Confirmation of hemoptysis is based on the direct observation of bleeding or as they are reported by the patient. Hemoptysis should be differentiated from hematemesis or bleeding from the oral cavity and nasal fossa. Endoscopic examinations, such as rhinolaryngoscopy, gastroscopy, and bronchoscopy, may be needed to confirm the origin of the bleeding.

Location of origin and etiology can be identified and quantified during the initial efforts to control bleeding or when the patient condition has been stabilized.

Diagnostic tests should include ^,

• 1

  Clinical laboratory tests including complete blood count, coagulation parameters, and biochemistry.

• 2

  Pulse oximetry and arterial blood gases to determine the impact of hemoptysis on oxygenation and ventilation.

• 3

  If indicated once bleeding is controlled, spirometry can be done to determine the patient’s pulmonary function. Spirometry should not be used in patients with active hemoptysis.

• 4

  Electrocardiogram to rule out pulmonary thromboembolism.

• 5

  Transthoracic echocardiogram to detect endocarditis, mitral valve stenosis, congenital heart diseases, pulmonary hypertension, aortic aneurysm, or the presence of shunts because of arteriovenous malformations.

• 6

  Cytologic study and sputum microbiology (e.g., Gram and Ziehl-Neelsen usual cultures and Lowëstein-Jensen). Mantoux in patients with suspected tuberculosis.

• 7

  Blood cultures or serologies if infectious disease is suspected.

• 8

  Anterior-posterior and lateral CXR are the usual initial imaging tests performed in patients with hemoptysis. ^, CXR determines the site of bleeding in 45% to 65% of the cases and the cause in 25% to 35%. ^{, ,} However, as much as 10% of pulmonary malignancies are occult on CXR, whereas 96% of which will be detected by CT.

• 9

  Chest multidetector CT must be performed in all patients with gross hemoptysis. It is useful to locate the origin of bleeding and give an idea about the proper isolation tool used (e.g., type of bronchial blocker [particularly in case of early takeoff origin of the right main bronchus] and proper size and side of double lumen tube [e.g., using the right-sided DLT in case of obstructed passage of the left main bronchus with a mass]).

• 10

  Angiomultidetector CT is useful for identifying arteries which are the source of bleeding in hemoptysis and determining whether bronchial artery embolization is indicated or whether conservative treatment is sufficient. ^, Performing a CT requires the patient to be transported into a remote setting where it may be challenging to manage a massive bleed. In certain situations, it is preferable to prophylactically secure the patient’s airway before transportation to the radiology suite, particularly for patients with life-threatening conditions ( Fig. 48.1 ).

  

• 11

  Flexible bronchoscopy has an important role in identifying the severity (from blood-streaked sputum to gross hemoptysis), cause, and origin of hemoptysis. It can be performed rapidly at the patient’s bedside in the intensive care unit (ICU) or in the OR. ^, It can also be used for collecting samples for cytology and microbiologic studies, bronchial aspirate, or bronchoalveolar lavage.

• 12

  Rigid bronchoscopy obviously provides better scope for suctioning but does not generally allow visualization of upper lobes and peripheral lesions. ^, It allows localization of bleeding and provide a wide conduit for the instruments and catheters or materials instilled into the airways through the bronchoscope. ^, However, rigid bronchoscopy is performed in the OR and ventilation is best with intermittent jet ventilation.

Box 48.1